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.

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.

The unique contribution of gendered racial stress to depressive symptoms among pregnant Black women.

INTRODUCTION: Pregnant Black women are at disproportionate risk for adverse birth outcomes, in part associated with higher prevalence of stress. Stress increases risk of depression, a known risk factor for preterm birth. In addition, multiple dimensions of stress, including perceived stress and stressful life events, are associated with adverse birth outcomes, independent of their association with prenatal depression. We use an intersectional and contextualized measure of gendered racial stress to assess whether gendered racial stress constitutes an additional dimension to prenatal depression, independent of stressful life events and perceived stress. METHODS: In this cross-sectional study of 428 Black women, we assessed gendered racial stress (using the 39-item Jackson Hogue Phillips Reduced Common Contextualized Stress Measure), perceived stress (using the Perceived Stress Scale), and stressful life events (using a Stressful Life Event Index) as psychosocial predictors of depressive symptoms (measured by the Edinburgh Depression Scale). We used bivariate analyses and multivariable regression to assess the association between the measures of stress and prenatal depression. RESULTS: Results revealed significant bivariate associations between participant scores on the full Jackson Hogue Phillips Reduced Common Contextualized Stress Measure and its 5 subscales, and the Edinburgh Depression Scale. In multivariable models that included participant Perceived Stress Scale and/or Stressful Life Event Index scores, the Jackson Hogue Phillips Reduced Common Contextualized Stress Measure contributed uniquely and significantly to Edinburgh Depression Scale score, with the burden subscale being the strongest contributor among all variables. No sociodemographic characteristics were found to be significant in multivariable models. CONCLUSION: For Black women in early pregnancy, gendered racial stress is a distinct dimension of stress associated with increased depressive symptoms. Intersectional stress measures may best uncover nuances within Black women's complex social environment.

DLK1: A Novel Biomarker of Placental Insufficiency in Stillbirth and Live Birth.

OBJECTIVE: Delta-like homolog 1 (DLK1) is a growth factor that is reduced in maternal sera in pregnancies with small for gestational age neonates. We sought to determine if DLK1 is associated with stillbirth (SB), with and without placental insufficiency. STUDY DESIGN: A nested case-control study was performed using maternal sera from a multicenter case-control study of SB and live birth (LB). SB and LB were stratified as placental insufficiency cases (small for gestational age <5% or circulatory lesions on placental histopathology) or normal placenta controls (appropriate for gestational age and no circulatory lesions). Enzyme-linked immunosorbent assay (ELISA) was used to measure DLK1. The mean difference in DLK1 was compared on the log scale in an adjusted linear regression model with pairwise differences, stratified by term/preterm deliveries among DLK1 results in the quantifiable range. In exploratory analysis, geometric means were compared among all data and the proportion of "low DLK1" (less than the median value for gestational age) was compared between groups and modeled using linear and logistic regression, respectively. RESULTS: Overall, 234 SB and 234 LB were analyzed; 246 DLK1 values were quantifiable within the standard curve. Pairwise comparisons of case and control DLK1 geometric means showed no significant differences between groups. In exploratory analysis of all data, adjusted analysis revealed a significant difference for the LB comparison only (SB: 71.9 vs. 99.1 pg/mL, p = 0.097; LB: 37.6 vs. 98.1 pg/mL, p = 0.005). In exploratory analysis of "low DLK1," there was a significant difference between the odds ratio of having "low DLK1" between preterm cases and controls for both SB and LB. There were no significant differences in geometric means nor "low DLK1" between SB and LB. CONCLUSION: In exploratory analysis, more placental insufficiency cases in preterm SB and LB had "low DLK1." However, low DLK1 levels were not associated with SB. KEY POINTS: · Maternally circulating DLK1 is correlated with placental insufficiency.. · Maternally circulating DLK1 is not correlated with SB.. · DLK1 is a promising marker for placental insufficiency..

Preeclampsia at delivery is associated with lower serum vitamin D and higher antiangiogenic factors: a case control study.

BACKGROUND: Preeclampsia is characterized by decreased trophoblastic angiogenesis leading to abnormal invasion of spiral arteries, shallow implantation and resulting in compromised placentation with poor uteroplacental perfusion. Vitamin D plays an important role in pregnancy influencing implantation, angiogenesis and placental development. The objective of this study was to determine whether there is an association between serum vitamin D levels, and anti-angiogenic factors at the time of delivery and the occurrence of preeclampsia. METHODS: This nested case control study analyzed frozen serum samples at the time of delivery and related clinical data from women with singleton liveborn pregnancies who had participated in studies of the NICHD Stillbirth Collaborative Research Network. Women with a recorded finding of preeclampsia and who had received magnesium sulfate treatment prior to delivery were considered index cases (N = 56). Women without a finding of preeclampsia were controls (N = 341). RESULTS: Women with preeclampsia had 14.5% lower serum vitamin D levels than women in the control group (16.5 ng/ml vs. 19 ng/ml, p = 0.014) with 64.5% higher sFlt-1 levels (11,600 pg/ml vs. 7050 pg/ml, p < 0.001) and greater than 2 times higher endoglin levels (18.6 ng/ml vs. 8.7 ng/ml, < 0.001). After controlling for gestational age at delivery and maternal BMI, vitamin D levels were 0.88 times lower (P = 0.051), while endoglin levels were 2.5 times higher and sFlt-1 levels were 2.1 times higher than in control pregnancies (P < 0.001). CONCLUSIONS: Women with preeclampsia at time of delivery have higher maternal antiangiogenetic factors and may have lower maternal serum vitamin D levels. These findings may lead to a better understanding of the underlying etiology of preeclampsia as well as possible modifiable treatment options which could include assuring adequate levels of maternal serum vitamin D prior to pregnancy.

Elementary School-Based Health Centers and Access to Preventive and Asthma-Related Care Among Publicly Insured Children With Asthma in Georgia.

OBJECTIVES: We assessed the effects of 3 new elementary school-based health centers (SBHCs) in disparate Georgia communities-predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural-on asthma case management among children insured by Medicaid/Children's Health Insurance Program (CHIP). METHODS: We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child-school year. RESULTS: We found an increase of about 19 (P = .01) to 33 (P < .001) percentage points in the probability of having ≥3 asthma-related visits per child-school year and an increase of about 22 (P = .003) to 24 (P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 (P = .01) to 29 (P < .001) percentage-point increase in receipt of asthma-control medication and a 15 (P = .03) to 30 (P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC. CONCLUSION: Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

The confounder matrix: A tool to assess confounding bias in systematic reviews of observational studies of etiology.

Systematic reviews and meta-analyses are essential for drawing conclusions regarding etiologic associations between exposures or interventions and health outcomes. Observational studies comprise a substantive source of the evidence base. One major threat to their validity is residual confounding, which may occur when component studies adjust for different sets of confounders, fail to control for important confounders, or have classification errors resulting in only partial control of measured confounders. We present the confounder matrix-an approach for defining and summarizing adequate confounding control in systematic reviews of observational studies and incorporating this assessment into meta-analyses. First, an expert group reaches consensus regarding the core confounders that should be controlled and the best available method for their measurement. Second, a matrix graphically depicts how each component study accounted for each confounder. Third, the assessment of control adequacy informs quantitative synthesis. We illustrate the approach with studies of the association between short interpregnancy intervals and preterm birth. Our findings suggest that uncontrolled confounding, notably by reproductive history and sociodemographics, resulted in exaggerated estimates. Moreover, no studies adequately controlled for all core confounders, so we suspect residual confounding is present, even among studies with better control. The confounder matrix serves as an extension of previously published methodological guidance for observational research synthesis, enabling transparent reporting of confounding control and directly informing meta-analysis so that conclusions are drawn from the best available evidence. Widespread application could raise awareness about gaps across a body of work and allow for more valid inference with respect to confounder control.

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.

Variation in self-identified most stressful life event by outcome of previous pregnancy in a population-based sample interviewed 6-36 months following delivery.

The majority of health research uses a deductive approach to measure stressful life events, despite evidence that perception of what is stressful varies. The goal of this project was to 1) describe the distribution of self-identified most stressful life events in a cohort of women who experienced a perinatal loss (stillbirth or neonatal death) or live birth in the previous three years and 2) test how childhood adversity influences participant selection of their most stressful life event. We used data from 987 women (282 with stillbirth, 657 without loss, and 48 with a neonatal death in the first 28 days) in the Stillbirth Collaborative Research Network - OASIS (Outcomes after Study Index Stillbirth) follow-up study, a population-based sample set in five U.S. states in 2009. We applied an inductive coding process to open-ended responses to a question about the most stressful event or major crisis that participants had ever experienced, resulting in a set of 15 categories. We compare psychologic wellbeing across self-identified most stressful life event, accounting for sampling and loss-to-follow-up weights. Overall, stillbirth was most commonly identified as the most stressful event (18.3% [95% CI: 15.6, 21.5]), followed by loss by death of someone other than a child (17.25% [95% CI: 13.9, 20.3]). For participants who experienced a perinatal loss, we fit multivariable logistic regression models to quantify the association between report of childhood maltreatment and identifying the perinatal loss as the most stressful life event, calculating risk ratios (RRs). Reporting any moderate or severe childhood maltreatment was associated with 24% lower risk of identifying the perinatal loss as the most stressful life event (adjusted RR: 0.76 [95% CI: 0.58, 1.01]), after adjusting for race/ethnicity, age, and education. These results demonstrate the value of combining standardized measures with open-ended, inductive approaches to measuring stress in large, population-based studies.

Spatial Variation in Very Preterm Birth to Hispanic Women Across the United States: The Role of Intensified Immigration Enforcement.

Introduction: Limited existing research suggests that immigration climate and enforcement practices represent a social determinant of health for immigrants, their families, and communities. However, national research on the impact of specific policies is limited. The goal of this article is to estimate the effect of county-level participation in a 287(g) immigration enforcement agreement on very preterm birth (VPTB, <32 weeks' gestation) rates between 2005-2016 among US-born and foreign-born Hispanic women across the United States. Methods: We fit spatial Bayesian models to estimate the effect of local participation in a 287(g) program on county VPTB rates, accounting for variation by maternal nativity, county ethnic density, and controlling for individual specific Hispanic background and nativity and county-level confounders. Results: While there was no global effect of county participation in a 287(g) program on county VPTB rates, rates were slightly increased in some counties, primarily in the Southeast (Virginia, North Carolina, South Carolina). Future Directions: Future research should consider the mechanisms through which immigration policies and enforcement may impact health of both immigrants and wider communities.

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.

Perceptions of stress and resilience among Latina women enrolled in prenatal care in Metro Atlanta through an ecosocial lens.

Stress across the life course is highly prevalent, particularly among immigrant and racial/ethnic minority women who face adversities associated with structural and interpersonal racism. Understanding how women perceive and describe stress and resilience can provide cultural context to inform interventions to improve health among pregnant women facing adversity. The goal of this project was to examine how external stressors and coping strategies prior to and during pregnancy are reflected in Latina women's narratives about their lives through an Ecosocial framework. This mixed methods research study explores pregnant Latina women's psychosocial well-being before and during pregnancy based on Ecosocial theory. We conducted 111 surveys with Latina women receiving prenatal care in Atlanta, Georgia in 2017-2018. We conducted 24 in-depth interviews, chosen purposively from survey respondents, collecting narratives of stress and resilience over the course of pregnancy. We purposively sampled equal numbers of women who did and did not report an ongoing stressor in the survey. The survey and interview guide were focused on domains of stress, psychosocial being, coping and resilience. The majority of survey participants spoke Spanish (86%) and were born in Mexico (42%) or Guatemala (27%). Less than half (37%) reported ongoing stress, most commonly from a loved one's illness or work-related problem. The majority of women felt they should control emotional responses to external stressors during pregnancy to protect their baby's health. Women described motherhood and previous challenges as sources of maturity and improved coping. Familial financial and emotional support were perceived as critical to women's successful coping.

Characteristics of Stillbirths Associated With Diabetes in a Diverse U.S. Cohort.

OBJECTIVE: To characterize stillbirths associated with pregestational diabetes and gestational diabetes mellitus (GDM) in a large, prospective, U.S. case-control study. METHODS: A secondary analysis of stillbirths among patients enrolled in a prospective; multisite; geographically, racially, and ethnically diverse case-control study in the United States was performed. Singleton gestations with complete information regarding diabetes status and with a complete postmortem evaluation were included. A standard evaluation protocol for stillbirth cases included postmortem evaluation, placental pathology, clinical testing as performed at the discretion of the health care professional, and a recommended panel of tests. A potential cause of death was assigned to stillbirth cases using a standardized classification tool. Demographic and delivery characteristics among women with pregestational diabetes and GDM were compared with characteristics of women with no diabetes in pairwise comparisons using χ or two-sample t tests as appropriate. Sensitivity analysis was performed excluding pregnancies with genetic conditions or major fetal malformations. RESULTS: Of 455 stillbirth cases included in the primary analysis, women with stillbirth and diabetes were more likely to be older than 35 years and have a higher body mass index. They were also more likely to have a gestational hypertensive disorder than women without diabetes (28% vs 9.1%; P<.001). Women with pregestational diabetes had more large-for-gestational-age (LGA) neonates (26% vs 3.4%; P<.001). Stillbirths occurred more often at term in women with pregestational diabetes (36%) and those with GDM (52%). Maternal medical complications, including pregestational diabetes and others, were more often identified as a probable or possible cause of death among stillbirths with maternal diabetes (43% vs 4%, P<.001) as compared with stillbirths without diabetes. CONCLUSION: Compared with stillbirths in women with no diabetes, stillbirths among women with pregestational diabetes and GDM occur later in pregnancy and are associated with hypertensive disorders of pregnancy, maternal medical complications, and LGA.

Effect of Elementary School-Based Health Centers in Georgia on the Use of Preventive Services.

INTRODUCTION: This study measures effects on the receipt of preventive care among children enrolled in Georgia's Medicaid or Children's Health Insurance Program associated with the implementation of new elementary school-based health centers. The study sites differed by geographic environment and predominant race/ethnicity (rural white, non-Hispanic; black, small city; and suburban Hispanic). METHODS: A quasi-experimental treatment/control cohort study used Medicaid/Children's Health Insurance Program claims/enrollment data for children in school years before implementation (2011-2012 and 2012-2013) versus after implementation (2013-2014 to 2016-2017) of school-based health centers to estimate effects on preventive care among children with (treatment) and without (control) access to a school-based health center. Data analysis was performed in 2017-2019. There were 1,531 unique children in the treatment group with an average of 4.18 school years observed and 1,737 in the control group with 4.32 school years observed. A total of 1,243 Medicaid/Children's Health Insurance Program-insured children in the treatment group used their school-based health centers. RESULTS: Significant increases in well-child visits (5.9 percentage points, p<0.01) and influenza vaccination (6.9 percentage points, p<0.01) were found for children with versus without a new school-based health center. This represents a 15% increase from the pre-implementation percentage (38.8%) with a well-child visit and a 25% increase in influenza vaccinations. Increases were found only in the 2 school-based health centers with predominantly minority students. The 18.7 percentage point (p<0.01) increase in diet/counseling among obese/overweight Hispanic children represented a doubling from a 15.3% baseline. CONCLUSIONS: Implementation of elementary school-based health centers increased the receipt of key preventive care among young, publicly insured children in urban areas of Georgia, with potential reductions in racial and ethnic disparities.

Glucocorticoid receptor sensitivity in early pregnancy in an African American cohort.

PROBLEM: Disruption in homeostatic feedback loops between inflammatory mediators and the hypothalamic-pituitary-adrenal (HPA) axis is a key mechanism linking chronic stress to inflammation and adverse health outcomes, including those occurring during pregnancy. In particular, alterations in glucocorticoid sensitivity may occur as a result of chronic stress, including that due to racial discrimination, and may be implicated in the persistent adverse maternal and infant health outcomes experienced by African Americans. While there are a few large-scale studies in human pregnancy that measure both cytokines and HPA axis hormones, to our knowledge, none directly measure glucocorticoid sensitivity at the cellular level, especially in an African American population. METHOD OF STUDY: We measured the full range of the dexamethasone (DEX) dose-response suppression of TNF-α in first-trimester blood samples from 408 African American women and estimated leukocyte cell type contribution to the production of TNF-α. RESULTS: The mean (SD) DEX level needed to inhibit TNF-α production by 50% (ie, DEX IC50 ) was 9.8 (5.8) nmol/L. Monocytes appeared to be the main driver of Uninhibited TNF-α production, but monocyte counts explained only 14% of the variation. Monocyte counts were only weakly correlated with the DEX IC50 (r = -.11, P < .05). Moreover, there was no statistically significant correlation between the DEX IC50 and circulating pro-inflammatory (CRP, IL-6, IFN-γ) or anti-inflammatory (IL-10) mediators (P > .05). CONCLUSION: These findings challenge some prior assumptions and position this comprehensive study of glucocorticoid sensitivity as an important anchor point in the growing recognition of interindividual variation in maternal HPA axis regulation and inflammatory responses.

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.

Assessing Pregnancy, Gestational Complications, and Co-morbidities in Women With Congenital Heart Defects (Data from ICD-9-CM Codes in 3 US Surveillance Sites).

Improved treatment of congenital heart defects (CHDs) has resulted in women with CHDs living to childbearing age. However, no US population-based systems exist to estimate pregnancy frequency or complications among women with CHDs. Cases were identified in multiple data sources from 3 surveillance sites: Emory University (EU) whose catchment area included 5 metropolitan Atlanta counties; Massachusetts Department of Public Health (MA) whose catchment area was statewide; and New York State Department of Health (NY) whose catchment area included 11 counties. Cases were categorized into one of 5 mutually exclusive CHD severity groups collapsed to severe versus not severe; specific ICD-9-CM codes were used to capture pregnancy, gestational complications, and nongestational co-morbidities in women, age 11 to 50 years, with a CHD-related ICD-9-CM code. Pregnancy, CHD severity, demographics, gestational complications, co-morbidities, and insurance status were evaluated. ICD-9-CM codes identified 26,655 women with CHDs, of whom 5,672 (21.3%, range: 12.8% in NY to 22.5% in MA) had codes indicating a pregnancy. Over 3 years, age-adjusted proportion pregnancy rates among women with severe CHDs ranged from 10.0% to 24.6%, and 14.2% to 21.7% for women with nonsevere CHDs. Pregnant women with CHDs of any severity, compared with nonpregnant women with CHDs, reported more noncardiovascular co-morbidities. Insurance type varied by site and pregnancy status. These US population-based, multisite estimates of pregnancy among women with CHD indicate a substantial number of women with CHDs may be experiencing pregnancy and complications. In conclusion, given the growing adult population with CHDs, reproductive health of women with CHD is an important public health issue.

The association between gestational weight gain z-score and stillbirth: a case-control study.

BACKGROUND: There is limited information on potentially modifiable risk factors for stillbirth, such as gestational weight gain (GWG). Our purpose was to explore the association between GWG and stillbirth using the GWG z-score. METHODS: We analyzed 479 stillbirths and 1601 live births from the Stillbirth Collaborative Research Network case-control study. Women with triplets or monochorionic twins were excluded from analysis. We evaluated the association between GWG z-score (modeled as a restricted cubic spline with knots at the 5th, 50th, and 95th percentiles) and stillbirth using multivariable logistic regression with generalized estimating equations, adjusting for pre - pregnancy body mass index (BMI) and other confounders. In addition, we conducted analyses stratified by pre - pregnancy BMI category (normal weight, overweight, obese). RESULTS: Mean GWG was 18.95 (SD 17.6) lb. among mothers of stillbirths and 30.89 (SD 13.3) lb. among mothers of live births; mean GWG z-score was - 0.39 (SD 1.5) among mothers of cases and - 0.17 (SD 0.9) among control mothers. In adjusted analyses, the odds of stillbirth were elevated for women with very low GWG z-scores (e.g., adjusted odds ratio (aOR) and 95% Confidence Interval (CI) for z-score - 1.5 SD versus 0 SD: 1.52 (1.30, 1.78); aOR (95% CI) for z-score - 2.5 SD versus 0 SD: 2.36 (1.74, 3.20)). Results differed slightly by pre - pregnancy BMI. The odds of stillbirth were slightly elevated among women with overweight BMI and GWG z-scores ≥1 SD (e.g., aOR (95% CI) for z-score of 1.5 SD versus 0 SD: 1.84 (0.97, 3.50)). CONCLUSIONS: GWG z-scores below - 1.5 SD are associated with increased odds of stillbirth.

Stillbirth Associated With Infection in a Diverse U.S. Cohort.

OBJECTIVE: To better characterize infection-related stillbirth in terms of pathogenesis and microbiology. METHODS: We conducted a secondary analysis of 512 stillbirths in a prospective, multisite, geographically, racially and ethnically diverse, population-based study of stillbirth in the United States. Cases underwent evaluation that included maternal interview, chart abstraction, biospecimen collection, fetal autopsy, and placental pathology. Recommended evaluations included syphilis and parvovirus serology. Each case was assigned probable and possible causes of death using the INCODE Stillbirth Classification System. Cases where infection was assigned as a probable or possible cause of death were reviewed. For these cases, clinical scenario, autopsy, maternal serology, culture results, and placental pathology were evaluated. RESULTS: For 66 (12.9%) cases of stillbirth, infection was identified as a probable or possible cause of death. Of these, 36% (95% CI 35-38%) were categorized as a probable and 64% (95% CI 62-65%) as a possible cause of death. Infection-related stillbirth occurred earlier than non-infection-related stillbirth (median gestational age 22 vs 28 weeks, P=.001). Fetal bacterial culture results were available in 47 cases (71%), of which 35 (53%) grew identifiable organisms. The predominant species were Escherichia coli (19, 29%), group B streptococcus (GBS) (8, 12%), and enterococcus species (8, 12%). Placental pathology revealed chorioamnionitis in 50 (76%), funisitis in 27 (41%), villitis in 11 (17%), deciduitis in 35 (53%), necrosis in 27 (41%), and viral staining in seven (11%) cases. Placental pathology found inflammation or evidence of infection in 65 (99%) cases and fetal autopsy in 26 (39%) cases. In infection-related stillbirth cases, the likely causative nonbacterial organisms identified were parvovirus in two (3%) cases, syphilis in one (2%) case, cytomegalovirus (CMV) in five (8%) cases, and herpes in one (2%) case. CONCLUSION: Of infection-related stillbirth cases in a large U.S. cohort, E coli, GBS, and enterococcus species were the most common bacterial pathogens and CMV the most common viral pathogen.