Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts.

INTRODUCTION: Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals. METHODS: Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development. RESULTS: The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination. CONCLUSION: Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.

Changes in Racial and Ethnic Inequities in Pregnancy-Associated Death in the United States During the COVID-19 Pandemic.

Objectives. To examine changes in cause-specific pregnancy-associated deaths during the COVID-19 pandemic by race and ethnicity and assess changes in racial and ethnic inequities in pregnancy-associated deaths. Methods. We used US vital statistics mortality data from 2018 to 2021 to identify pregnancy-associated deaths among females aged 15 to 44 years. We calculated crude pregnancy-associated death rates (deaths per 100 000 live births) by year, cause, and race/ethnicity, percent change in death rate, and the inequity (difference) in rate for each racial or ethnic group compared with non-Hispanic White people. Results. The pregnancy-associated death rate for obstetric, drug-related, homicide, and other causes of death increased during 2020, and obstetric deaths continued to increase in 2021. Overall estimates mask 2021 increases in drug-related deaths among Hispanic, non-Hispanic American Indian and Alaska Native (AI/AN), and non-Hispanic Asian people; increases in homicide among most racial and ethnic groups; and increases in suicide among Hispanic, non-Hispanic AI/AN, and non-Hispanic Asian people. Conclusions. We found disproportionate increases in pregnancy-associated deaths from nonobstetric causes among minoritized racial and ethnic groups during the COVID-19 pandemic. (Am J Public Health. 2024;114(7):733-742. https://doi.org/10.2105/AJPH.2024.307651).

Neighborhood eviction trajectories and odds of moderate and serious psychological distress during pregnancy among African American women.

African American mothers are unjustly burdened by both residential evictions and psychological distress. We quantified associations between trajectories of neighborhood evictions over time and the odds of moderate and serious psychological distress (MPD and SPD, respectively) during pregnancy among African American women. We linked publicly available data on neighborhood eviction filing and judgment rates to preconception and during-pregnancy addresses from the Life-course Influences on Fetal Environments (LIFE) Study (2009-2011; n = 808). Multinomial logistic regression-estimated odds of MPD and SPD during pregnancy that were associated with eviction filing and judgment rate trajectories incorporating preconception and during-pregnancy addresses (each categorized as low, medium, or high, with two 9-category trajectory measures). Psychological distress was measured with the Kessler Psychological Distress Scale (K6) (K6 scores 5-12 = MPD, and K6 scores ≥13 = SPD). MPD was reported in 60% of the sample and SPD in 8%. In adjusted models, higher neighborhood eviction filing and judgment rates, as compared with low/low rates, during the preconception and pregnancy periods were associated with 2- to 4-fold higher odds of both MPD and SPD during pregnancy among African American women. In future studies, researchers should identify mechanisms of these findings to inform timely community-based interventions and effective policy solutions to ensure the basic human right to housing for all. This article is part of a Special Collection on Mental Health.

Trends and disparities in perinatal health outcomes among women from refugee backgrounds in Victoria, Australia: A population-based study.

BACKGROUND: Women from refugee backgrounds generally experience poorer pregnancy-related outcomes compared to host populations. AIM: To examine the trend and disparities in adverse perinatal outcomes among women of refugee background using population-based data from 2003 to 2017. METHODS: A population-based cross-sectional study of 754,270 singleton births in Victoria compared mothers of refugee backgrounds with Australian-born mothers. Inferential statistics, including Pearson chi-square and binary logistic regression, were conducted. Multiple logistic regression was conducted to explore the relationship between adverse perinatal outcomes and the women's refugee status. FINDINGS: Women of refugee background had higher odds of adverse neonatal and maternal outcomes, including stillbirth, neonatal death, low APGAR score, small for gestational age, postpartum haemorrhage, abnormal labour, perineal tear, and maternal admission to intensive care compared to Australian-born women. However, they had lower odds of neonatal admission to intensive care, pre-eclampsia, and maternal postnatal depression. The trend analysis showed limited signs of gaps closing over time in adverse perinatal outcomes. DISCUSSION AND CONCLUSION: Refugee background was associated with unfavourable perinatal outcomes, highlighting the negative influence of refugee status on perinatal health. This evidences the need to address the unique healthcare requirements of this vulnerable population to enhance the well-being of mothers and newborns. Implementing targeted interventions and policies is crucial to meet the healthcare requirements of women of refugee backgrounds. Collaborative efforts between healthcare organisations, government agencies and non-governmental organisations are essential in establishing comprehensive support systems to assist refugee women throughout their perinatal journey.

Recent Immigrants With Inflammatory Bowel Disease Have Significant Healthcare Utilization From Preconception to Postpartum: A Population Cohort Study.

INTRODUCTION: Immigrants with inflammatory bowel disease (IBD) may have increased healthcare utilization during pregnancy compared with non-immigrants, although this remains to be confirmed. We aimed to characterize this between these groups. METHODS: We accessed administrative databases to identify women (aged 18-55 years) with IBD with a singleton pregnancy between 2003 and 2018. Immigration status was defined as recent (<5 years of the date of conception), remote (≥5 years since the date of conception), and none. Differences in ambulatory, emergency department, hospitalization, endoscopic, and prenatal visits during 12 months preconception, pregnancy, and 12 months postpartum were characterized. Region of immigration origin was ascertained. Multivariable negative binomial regression was performed for adjusted incidence rate ratios (aIRRs) with 95% confidence intervals (CIs). RESULTS: A total of 8,880 pregnancies were included, 8,304 in non-immigrants, 96 in recent immigrants, 480 in remote immigrants. Compared with non-immigrants, recent immigrants had the highest rates of IBD-specific ambulatory visits during preconception (aIRR 3.06, 95% CI 1.93-4.85), pregnancy (aIRR 2.15, 95% CI 1.35-3.42), and postpartum (aIRR 2.21, 1.37-3.57) and the highest rates of endoscopy visits during preconception (aIRR 2.69, 95% CI 1.64-4.41) and postpartum (aIRR 2.01, 95% CI 1.09-3.70). There were no differences in emergency department and hospitalization visits between groups, although those arriving from the Americas were the most likely to be hospitalized for any reason. All immigrants with IBD were less likely to have a first trimester prenatal visit. DISCUSSION: Recent immigrants were more likely to have IBD-specific ambulatory care but less likely to receive adequate prenatal care during pregnancy.

Community-Level Factors are Predictors of Severe Maternal Morbidity Among American Indian and Alaska Native Pregnant People in the Pacific Northwest in a Multilevel Logistic Regression.

INTRODUCTION: American Indian/Alaska Native (AI/AN) pregnant people face barriers to health and healthcare that put them at risk of pregnancy complications. Rates of severe maternal morbidity (SMM) among Indigenous pregnant people are estimated to be twice that of non-Hispanic White (NHW) pregnant people. METHODS: Race-corrected Oregon Hospital Discharge and Washington Comprehensive Hospital Abstract Reporting System data were combined to create a joint dataset of births between 2012 and 2016. The analytic sample was composed of 12,535 AI/AN records and 313,046 NHW records. A multilevel logistic regression was used to assess the relationship between community-level, individual and pregnancy risk factors on SMM for AI/AN pregnant people. RESULTS: At the community level, AI/AN pregnant people were more likely than NHW to live in mostly or completely rural counties with low median household income and high uninsured rates. They were more likely to use Medicaid, be in a high-risk age category, and have diabetes or obesity. During pregnancy, AI/AN pregnant people were more likely to have insufficient prenatal care (PNC), gestational diabetes, and pre-eclampsia. In the multilevel model, county accounted for 6% of model variance. Hypertension pre-eclampsia, and county rurality were significant predictors of SMM among AI/AN pregnant people. High-risk age, insufficient PNC and a low county insured rate were near-significant at p < 0.10. DISCUSSION: Community-level factors are significant contributors to SMM risk for AI/AN pregnant people in addition to hypertension and pre-eclampsia. These findings demonstrate the need for targeted support in pregnancy to AI/AN pregnant people, particularly those who live in rural and underserved communities.

What is already known on this subject? American Indian and Alaska Native pregnant people face higher rates of severe maternal morbidity and mortality, and the risk is exacerbated for rural Indigenous pregnant people.What this study adds? This publication uses a multilevel model to assess the contribution of community-level factors in severe maternal morbidity risk for American Indian and Alaska Native pregnant people. This analysis highlights the important role that rurality, prenatal care adequacy and access to insurance play in maternal morbidity risk and discusses how those risks are disproportionately felt by American Indian and Alaska Native pregnant people in the Pacific Northwest.

The impact of diabetes during pregnancy on neonatal outcomes among the Aboriginal population in Western Australia: a whole-population study.

BACKGROUND: Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have a high prevalence of diabetes in pregnancy (DIP), which includes pre-gestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM). We aimed to characterize the impact of DIP in babies born to Aboriginal mothers. METHODS: A retrospective cohort study, using routinely collected linked health data that included all singleton births (N = 510 761) in Western Australia between 1998 and 2015. Stratified by Aboriginal status, generalized linear mixed models quantified the impact of DIP on neonatal outcomes, estimating relative risks (RRs) with 95% CIs. Ratio of RRs (RRRs) examined whether RRs differed between Aboriginal and non-Aboriginal populations. RESULTS: Exposure to DIP increased the risk of adverse outcomes to a greater extent in Aboriginal babies. PGDM heightened the risk of large for gestational age (LGA) (RR: 4.10, 95% CI: 3.56-4.72; RRR: 1.25, 95% CI: 1.09-1.43), macrosomia (RR: 2.03, 95% CI: 1.67-2.48; RRR: 1.39, 95% CI: 1.14-1.69), shoulder dystocia (RR: 4.51, 95% CI: 3.14-6.49; RRR: 2.19, 95% CI: 1.44-3.33) and major congenital anomalies (RR: 2.14, 95% CI: 1.68-2.74; RRR: 1.62, 95% CI: 1.24-2.10). GDM increased the risk of LGA (RR: 2.63, 95% CI: 2.36-2.94; RRR: 2.00, 95% CI: 1.80-2.22), macrosomia (RR: 1.95, 95% CI: 1.72-2.21; RRR: 2.27, 95% CI: 2.01-2.56) and shoulder dystocia (RR: 2.78, 95% CI: 2.12-3.63; RRR: 2.11, 95% CI: 1.61-2.77). Birthweight mediated about half of the DIP effect on shoulder dystocia only in the Aboriginal babies. CONCLUSIONS: DIP differentially increased the risks of fetal overgrowth, shoulder dystocia and congenital anomalies in Aboriginal babies. Improving care for Aboriginal women with diabetes and further research on preventing shoulder dystocia among these women can reduce the disparities.

Postpartum navigation decreases severe maternal morbidity most among Black women.

BACKGROUND: Postpartum care is crucial for addressing conditions associated with severe maternal morbidity and mortality. Examination of programs that affect these outcomes for women at high risk, including disparate populations, is needed. OBJECTIVE: This study aimed to examine whether a postpartum navigation program decreases all-cause 30-day postpartum hospitalizations and hospitalizations because of severe maternal morbidity identified using the US Centers for Disease Control and Prevention guidelines. The effect of this program was explored across patient demographics, including race and ethnicity. STUDY DESIGN: This was a retrospective cohort study that used health records of women who delivered at 3 large hospitals in the New York metropolitan area (Queens and Long Island) between April 2020 and November 2021 and who were at high risk of severe maternal morbidity. The incidence rates of 30-day postpartum all-cause hospitalization and hospitalization because of severe maternal morbidity were compared between women who were and were not enrolled in a novel postpartum transitional care management program. Navigation included standardized assessments, development of care plans, clinical management, and connection to clinical and social services that would extend beyond the postpartum period. Because the program prioritized enrolling women of the greatest risk, the risk-adjusted incidence was estimated using multivariate Poisson regression and stratified across patient demographics. RESULTS: Patient health records of 5819 women were included for analysis. Of note, 5819 of 19,258 deliveries (30.2%) during the study period were identified as having a higher risk of severe maternal morbidity. This was consistent with the incidence of high-risk pregnancies for tertiary hospitals in the New York metropolitan area. The condition most identified for risk of severe maternal morbidity at the time of delivery was hypertension (3171/5819 [54.5%]). The adjusted incidence of all-cause rehospitalization was 20% lower in enrollees than in nonenrollees (incident rate ratio, 0.80; 95% confidence interval, 0.67-0.95). Rehospitalization was decreased the most among Black women (incident rate ratio, 0.57; 95% confidence interval, 0.42-0.80). The adjusted incidence of rehospitalization because of indicators of severe maternal morbidity was 56% lower in enrollees than in nonenrollees (incident rate ratio, 0.44; 95% confidence interval, 0.24-0.77). Furthermore, it decreased most among Black women (incident rate ratio, 0.23; 95% confidence interval, 0.07-0.73). CONCLUSION: High-risk medical conditions at the time of delivery increased the risk of postpartum hospitalization, including hospitalizations because of severe maternal morbidity. A postpartum navigation program designed to identify and resolve clinical and social needs reduced postpartum hospitalizations and racial disparities with hospitalizations. Hospitals and healthcare systems should adopt this type of care model for women at high risk of severe maternal morbidity. Cost analyses are needed to evaluate the financial effect of postpartum navigation programs for women at high risk of severe maternal morbidity or mortality, which could influence reimbursement for these types of services. Further evidence and details of novel postpartum interventional models are needed for future studies.

Ancestry-Matched and Cross-Ancestry Genetic Risk Scores of Type 2 Diabetes in Pregnant Women and Fetal Growth: A Study in an Ancestrally Diverse Cohort.

Maternal genetic variants associated with offspring birth weight and adult type 2 diabetes (T2D) risk loci show some overlap. Whether T2D genetic risk influences longitudinal fetal weight and the gestational timing when these relationships begin is unknown. We investigated the associations of T2D genetic risk scores (GRS) with longitudinal fetal weight and birth weight among 1,513 pregnant women from four ancestral groups. Women had up to five ultrasonography examinations. Ancestry-matched GRS were constructed separately using 380 European- (GRSeur), 104 African- (GRSafr), and 189 East Asian- (GRSeas) related T2D loci discovered in different population groups. Among European Americans, the highest quartile GRSeur was significantly associated with 53.8 g higher fetal weight (95% CI 19.2-88.5) over the pregnancy. The associations began at gestational week 24 and continued through week 40, with a 106.8 g (95% CI 6.5-207.1) increase in birth weight. The findings were similar in analysis further adjusted for maternal glucose challenge test results. No consistent association was found using ancestry-matched or cross-ancestry GRS in non-Europeans. In conclusion, T2D genetic susceptibility may influence fetal growth starting at midsecond trimester among Europeans. Absence of similar associations in non-Europeans urges the need for further genetic T2D studies in diverse ancestries.

Disparities in Obstetric Readmissions: A Multistate Analysis, 2007-2014.

OBJECTIVE: Hospital readmissions are generally higher among racial-ethnic minorities and patients of lower socioeconomic status. However, this has not been widely studied in obstetrics. The aim of the study is to determine 30-day postpartum readmission rates by patient-level social determinants of health: race ethnicity, primary insurance payer, and median income, independently and as effect modifiers. STUDY DESIGN: Using state inpatient databases from the health care cost and utilization project from 2007 to 2014, we queried all deliveries. To produce accurate estimates of the effects of parturients' social determinants of health on readmission odds while controlling for confounders, generalized linear mixed models (GLMMs) were used. Additional models were generated with interaction terms to highlight any associations and their effect on the outcome. Adjusted odds ratios (aOR) with 95% confidence intervals are reported. RESULTS: There were 5,129,867 deliveries with 79,260 (1.5%) 30-day readmissions. Of these, 947 (1.2%) were missing race ethnicity. Black and Hispanic patients were more likely to be readmitted within 30 days of delivery, as compared with White patients (p < 0.001 and p < 0.05, respectively). Patients with government insurance were more likely to be readmitted than those with private insurance (p < 0.001). Patients living in the second quartile of median income were also more likely to be readmitted than those living in other quartiles (p < 0.05). Using GLMMs, we observed that Black patients with Medicare were significantly more likely to get readmitted as compared with White patients with private insurance (aOR 2.78, 95% CI 2.50-3.09, p < 0.001). Similarly, Black patients living in the fourth (richest) quartile of median income were more likely to get readmitted, even when compared with White patients living in the first (poorest) quartile of median income (aOR 1.48, 95% CI 1.40-1.57, p < 0.001). CONCLUSION: Significant racial-ethnic disparities in obstetric readmissions were observed, particularly in Black patients with government insurance and even in Black patients living in the richest quartile of median income. KEY POINTS: · Using generalized linear mixed models, we observed significant interactions.. · Government-insured Black patients were 2.78X more likely to be readmitted.. · The wealthiest Black patients were still 1.48X more likely to be readmitted..

Understanding racial disparities in severe maternal morbidity using Bayesian network analysis.

Previous studies have evaluated the marginal effect of various factors on the risk of severe maternal morbidity (SMM) using regression approaches. We add to this literature by utilizing a Bayesian network (BN) approach to understand the joint effects of clinical, demographic, and area-level factors. We conducted a retrospective observational study using linked birth certificate and insurance claims data from the Arkansas All-Payer Claims Database (APCD), for the years 2013 through 2017. We used various learning algorithms and measures of arc strength to choose the most robust network structure. We then performed various conditional probabilistic queries using Monte Carlo simulation to understand disparities in SMM. We found that anemia and hypertensive disorder of pregnancy may be important clinical comorbidities to target in order to reduce SMM overall as well as racial disparities in SMM.

Association of Health Literacy Among Nulliparous Individuals and Maternal and Neonatal Outcomes.

Importance: Health literacy is considered an important social determinant of health that may underlie many health disparities, but it is unclear whether inadequate health literacy among pregnant individuals is associated with adverse maternal and neonatal outcomes. Objective: To assess the association between maternal health literacy and maternal and neonatal outcomes among nulliparous individuals. Design, Setting, and Participants: This was a secondary analysis of a large, multicenter cohort study of 10 038 nulliparous individuals in the US (2010-2013). Participants underwent 3 antenatal study visits and had detailed maternal and neonatal data abstracted. Data analysis was performed from July to December 2019. Exposures: Between 16 and 21 weeks of gestation, health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine-Short Form, a validated 7-item word recognition test. In accordance with standard scoring, results were dichotomized as inadequate vs adequate health literacy. Main Outcomes and Measures: On the basis of theoretical causal pathways between health literacy and health outcomes, a priori maternal and neonatal outcomes (determined via medical records) were selected for this analysis. Multivariable Poisson regression models were constructed to estimate the associations between health literacy and outcomes. Sensitivity analyses in which education was removed from models and that excluded individuals who spoke English as a second language were performed. Results: Of 9341 participants who completed the Rapid Estimate of Adult Literacy in Medicine-Short Form, the mean (SD) age was 27.0 (5.6) years, and 2540 (27.4%) had publicly funded prenatal care. Overall, 1638 participants (17.5%) had scores indicative of inadequate health literacy. Participants with inadequate health literacy were more likely to be younger (mean [SD] age, 22.9 [5.0] vs 27.9 [5.3] years), have less educational attainment (some college education or greater, 1149 participants [73.9%] vs 5279 participants [94.5%]), have publicly funded insurance (1008 participants [62.2%] vs 1532 participants [20.0%]), and report they were a member of an underrepresented racial or ethnic group (non-Hispanic Black, 506 participants [30.9%] vs 780 participants [10.1%]; Hispanic, 516 participants [31.5%] vs 948 participants [12.3%]) compared with those with adequate health literacy. Participants who had inadequate health literacy had greater risk of cesarean delivery (adjusted risk ratio [aRR], 1.11; 95% CI, 1.01-1.23) and major perineal laceration (aRR, 1.44; 95% CI, 1.03-2.01). The adjusted risks of small-for-gestational-age status (aRR, 1.34; 95% CI, 1.14-1.58), low birth weight (aRR, 1.33; 95% CI, 1.07-1.65), and 5-minute Apgar score less than 4 (aRR, 2.78; 95% CI, 1.16-6.65) were greater for neonates born to participants with inadequate health literacy. Sensitivity analyses confirmed these findings. Conclusions and Relevance: These findings suggest that inadequate maternal health literacy is associated with a variety of adverse maternal and neonatal outcomes.

Relationship Between Maternal Economic Vulnerability and Childhood Neurodevelopment at 2 and 5 Years of Life.

OBJECTIVE: To assess the relationship between economic vulnerability during pregnancy and childhood neurodevelopment. METHODS: This is a secondary analysis of two parallel multicenter, randomized, controlled trials of administration of levothyroxine to pregnant individuals with subclinical hypothyroidism or hypothyroxinemia in the United States. All participants who delivered a live, nonanomalous neonate and completed the WPPSI-III (Weschler Preschool & Primary Scale of Intelligence) at 5 years of life and the Bayley-III (Bayley Scales of Infant Development) test at 2 years were included. The primary outcome is WPPSI-III score. Secondary outcome included Bayley-III subtest scores. Multivariable analyses were used to assess the relationships between economic vulnerability during the index pregnancy-defined as a household income less than 200% of the estimated federal poverty level, part-time or no employment, and use of government insurance-and the prespecified outcomes. Tests of interaction were performed to assess whether the magnitude of association differed according to whether participants were married or completed more than a high school education. A sensitivity analysis was performed to limit the income criteria for economic vulnerability to household income of less than 100% of the estimated federal poverty level. RESULTS: Of 955 participants who met inclusion criteria, 406 (42.5%) were considered economically vulnerable. In bivariate analysis, the WPPSI-III score and Bayley-III subtest scores were significantly lower among children of the economically vulnerable. For the WPPSI-III, Bayley-III cognitive subtest, and Bayley-III language subtest scores, the associations between economic vulnerability and lower childhood neurodevelopmental scores were primarily seen only among those who were married or completed more than a high school education (P for interaction<.05). A similar pattern was noted when restricting the income criteria for economic vulnerability to less than 100% of the federal poverty level. CONCLUSION: Economic vulnerability during pregnancy is associated with an increased risk of adverse neurodevelopmental outcomes in their children at 2 and 5 years of life, particularly among those who are married or completed more than a high school education.

Investigation of optimal gestational weight gain based on the occurrence of adverse pregnancy outcomes for Chinese women: a prospective cohort study.

OBJECTIVE: To investigate recommendations for appropriate gestational weight gain (GWG) of Chinese females. METHODS: In total of 3,172 eligible women in the first trimester were recruited into the Chinese Pregnant Women Cohort Study (CPWCS) project. Pregnancy complications and outcomes were collated using the hospital medical records system. The method of occurrence of participants with adverse pregnancy outcomes (Occurrence Method) was conducted to calculate the recommended total GWG for each participant's pre-pregnancy BMI. Occurrence Method data were judged against the Institute of Medicine (IOM) and Japanese recommended criteria in terms of the total occurrence of adverse pregnancy outcomes of pregnant women with appropriate weight gain. RESULTS: The most frequent GWG was ≥ 14 kg and < 16 kg (19.4%), followed by ≥ 10 kg and < 12 kg (15.5%) and ≥ 12 kg and < 14 kg (15.2%). The most frequently occurring adverse pregnancy outcomes were cesarean sections for underweight (30.0%), normal weight (40.4%), overweight (53.6%) and obese (53.7%) women. A large for gestational age (LGA) accounted for 18.0% of the overweight and 20.9% of the obesity group. Gestational diabetes mellitus (GDM) occurred in 16.9% of overweight and 23.1% of obese women. The recommended total GWG in a Chinese women population is ≥ 8 and < 12 kg if underweight, ≥ 12 and < 14 kg for normal weight, ≥ 8.0 and < 10.0 kg if overweight, and < 8 kg for women with obesity. CONCLUSIONS: Current Chinese recommendations provide the optimal ranges of GWG to minimize the occurrence of undesirable pregnancy outcomes for each group of pre-pregnancy BMIs in a Chinese population. TRIAL REGISTRATION: Registered with ClinicalTrials ( NCT03403543 ).

Cultural malpractices during labor/delivery and associated factors among women who had at least one history of delivery in selected Zones of Amhara region, North West Ethiopia: community based cross-sectional study.

BACKGROUND: Every day, at least 810 women die worldwide from the complications of pregnancy and childbirth, 86% of which occurring in Southern Asia and Sub-Saharan Africa. One of the contributing factors for these problems is cultural malpractices during pregnancy and childbirth. The actual incidence of cultural malpractices in developing countries accounts for about 5-15% of maternal deaths. Thus, understanding the link between cultural affairs and maternal health is critical to saving the lives of women and their babies. Therefore, this research was aimed to assess cultural malpractices during labor and delivery and associated factors among women who had at least one history of delivery in selected Zones of the Amhara region, North West Ethiopia. METHOD: Community based cross-sectional study was conducted on women who had at least one delivery history in Awi, West, and East Gojjam Zones from January 1 to May 30, 2020. The multistage cluster sampling technique was used to select 845 study participants. Data was collected through a pre-tested and structured interview questionnaire, entered and cleaned using EPI info version 7.2, and exported to SPSS version 23 for analysis. Bivariable and multivariable logistic regression was employed to assess the association of the variables and a P-value less than 0.05 was declared as statistically significant. RESULT: Out of 845 women 162(19.2%) practiced nutritional taboo, 77(9.1%) women practiced abdominal massage and 273(32.3%) delivered their babies at home. Educational status of the respondents being un able to read and write (AOR = 14.35,95% CI: 3.12,65.96), husband's educational status (AOR = 3.80,95% CI: 1.24,11.64), residence (AOR = 2.93,95% CI: 1.41: 6.06), ethnicity (AOR = 2.20,95% CI:1.32, 3.67), pregnancy complications (AOR = 1.61,95% CI:1.02, 2.53), gravidity (AOR = 3.54,95% CI:1.38,9.08) and antenatal care follow up (AOR = 2.24, 95% CI:1.18,4.25) had statistically significant association with cultural malpractices during labor and delivery. CONCLUSION: This study showed that cultural malpractices during childbirth were high in Awi, West, and East Gojjam Zones relative to the country's maternal health service utilization plan. Working on antenatal care follow-up and women and husband education in a culturally acceptable manner may reduce cultural malpractices during labor and delivery.

Disproportionate Vitamin A Deficiency in Women of Specific Ethnicities Linked to Differences in Allele Frequencies of Vitamin A-Related Polymorphisms.

Background: While the current national prevalence rate of vitamin A deficiency (VAD) is estimated to be less than 1%, it is suggested that it varies between different ethnic groups and races within the U.S. We assessed the prevalence of VAD in pregnant women of different ethnic groups and tested these prevalence rates for associations with the vitamin A-related single nucleotide polymorphism (SNP) allele frequencies in each ethnic group. Methods: We analyzed two independent datasets of serum retinol levels with self-reported ethnicities and the differences of allele frequencies of the SNPs associated with vitamin A metabolism between groups in publicly available datasets. Results: Non-Hispanic Black and Hispanic pregnant women showed high VAD prevalence in both datasets. Interestingly, the VAD prevalence for Hispanic pregnant women significantly differed between datasets (p = 1.973 × 10-10, 95%CI 0.04-0.22). Alleles known to confer the risk of low serum retinol (rs10882272 C and rs738409 G) showed higher frequencies in the race/ethnicity groups with more VAD. Moreover, minor allele frequencies of a set of 39 previously reported SNPs associated with vitamin A metabolism were significantly different between the populations of different ancestries than those of randomly selected SNPs (p = 0.030). Conclusions: Our analysis confirmed that VAD prevalence varies between different ethnic groups/races and may be causally associated with genetic variants conferring risk for low retinol levels. Assessing genetic variant information prior to performing an effective nutrient supplementation program will help us plan more effective food-based interventions.

Pregnancy and birth characteristics of Aboriginal twins in two Australian states: a data linkage study.

INTRODUCTION: Perinatal outcomes for singleton pregnancies are poorer, on average, for Aboriginal people than non-Aboriginal people, but little is known about Aboriginal multifetal pregnancies. Yet multifetal pregnancies and births are often more complicated and have poorer outcomes than singleton pregnancies. We describe the pregnancies, births and perinatal outcomes for Aboriginal twins born in Western Australia (WA) and New South Wales (NSW) with comparisons to Aboriginal singletons in both states and to non-Aboriginal births in NSW. MATERIALS AND METHODS: Whole-population birth records and birth and death registrations were linked for all births during 2000-2013 (WA) and 2002-2008 (NSW). Hospital records and the WA Register of Developmental Anomalies - Cerebral Palsy were linked for all WA births and hospital records for a subset of NSW births. Descriptive statistics are reported for maternal and child demographics, maternal health, pregnancy complications, births and perinatal outcomes. RESULTS: Thirty-four thousand one hundred twenty-seven WA Aboriginal, 32,352 NSW Aboriginal and 601,233 NSW non-Aboriginal births were included. Pregnancy complications were more common among mothers of Aboriginal twins than Aboriginal singletons (e.g. 17% of mothers of WA twins had hypertension/pre-eclampsia/eclampsia vs 8% of mothers of singletons) but similar to mothers of NSW non-Aboriginal twins. Most Aboriginal twins were born in a principal referral, women's or large public hospital. The hospitals were often far from the mother's home (e.g. 31% of mothers of WA Aboriginal twins gave birth at hospitals located more than 3 h by road from their home). Outcomes were worse for Aboriginal liveborn twins than Aboriginal singletons and non-Aboriginal twins (e.g. 58% of NSW Aboriginal twins were preterm compared to 9% of Aboriginal singletons and 49% non-Aboriginal twins). CONCLUSIONS: Mothers of Aboriginal twins faced significant challenges during the pregnancy, birth and the postnatal period in hospital and, in addition to accessible specialist medical care, these mothers may need extra practical and psychosocial support throughout their journey.

Racial Discrimination and Stress Across the Life Course: Associations With Prenatal Inflammation, Perceived Stress, and Depressive Symptoms.

BACKGROUND: Among Black Americans, interpersonal racial discrimination is common. Stress, including following discrimination, contributes to pregnancy complications. In this secondary analysis, we provide data on associations among discrimination, stress, and their interaction across the life course and inflammation, perceived stress, and depressive symptoms during pregnancy. METHODS: During the early third trimester, Black American women (n = 93) completed the Experiences of Discrimination Scale, the Stress and Adversity Inventory, the Perceived Stress Scale, and the Center for Epidemiological Studies Depression Inventory. Plasma interleukin-6 (IL-6), IL-8, tumor necrosis factor-α (TNF-α), and IL-ß levels were quantified. Associations were examined by linear regression, controlling for demographic, behavioral, and clinical covariates. RESULTS: Associations among racial discrimination and plasma IL-8, TNF-α, and IL-ß levels depended upon average ratings of life course stress. When stress was low, discrimination in the mid tertile was associated with the highest levels of IL-8, TNF-α, and IL-ß. Subscale analyses suggested that findings related to IL-8 were driven by chronic stress whereas findings related to TNF-α and IL-ß were driven by acute stress. When examined together, greater discrimination but not greater life course stress was associated with higher prenatal perceived stress. In subscale analyses, the association between discrimination and prenatal perceived stress depended upon average ratings of life course acute stress. When acute stress was low, discrimination in the midtertile was associated with the highest levels of prenatal perceived stress. When acute stress was high, discrimination in the high tertile was associated with the highest levels of prenatal perceived stress. There were also direct associations among greater life course chronic stress, prenatal perceived stress, and prenatal depressive symptoms. Associations were attenuated when discrimination was included as a covariate. CONCLUSIONS: The current analyses suggest that, among Black Americans, prenatal inflammation, perceived stress, and depressive symptoms may be shaped by racial discrimination and stress across the life course. In many cases, associations among discrimination and prenatal parameters depended upon how stressful exposures to life course stressors had been rated. The data suggest the potential for adaptive plasticity under some stress and highlight the deleterious nature of compounding stress.

Challenges in migrant women's maternity care in a high-income country: A population-based cohort study of maternal and perinatal outcomes.

INTRODUCTION: This study aims to explore maternal and perinatal outcomes of migrant women in Iceland. MATERIAL AND METHODS: This prospective population-based cohort study included women who gave birth to a singleton in Iceland between 1997 and 2018, comprising a total of 92 403 births. Migrant women were defined as women with citizenship other than Icelandic, including refugees and asylum seekers, and categorized into three groups, based on their country of citizenship Human Development Index score. The effect of country of citizenship was estimated. The main outcome measures were onset of labor, augmentation, epidural, perineum support, episiotomy, mode of birth, obstetric anal sphincter injury, postpartum hemorrhage, preterm birth, a 5-minute Apgar <7, neonatal intensive care unit admission and perinatal mortality. Odds ratios (ORs) and 95% confidence intervals (CIs) for maternal and perinatal outcomes were calculated using logistic regression models. RESULTS: A total of 8158 migrant women gave birth during the study period: 4401 primiparous and 3757 multiparous. Overall, migrant women had higher adjusted ORs (aORs) for episiotomy (primiparas: aOR 1.43, 95% CI 1.26-1.61; multiparas: 1.39, 95% CI 1.21-1.60) and instrumental births (primiparas: 1.14, 95% CI 1.02-1.27, multiparas: 1.41, 95% CI 1.16-1.72) and lower aORs of induction of labor (primiparas: 0.88, 95% CI 0.79-0.98; multiparas: 0.74, 95% CI 0.66-0.83), compared with Icelandic women. Migrant women from countries with a high Human Development Index score (≥0.900) had similar or better outcomes compared with Icelandic women, whereas migrant women from countries with a lower Human Development Index score than that of Iceland (<0.900) had additionally increased odds of maternal and perinatal complications and interventions, such as emergency cesarean and postpartum hemorrhage. CONCLUSIONS: Women's citizenship and country of citizenship Human Development Index scores are significantly associated with a range of maternal and perinatal complications and interventions, such as episiotomy and instrumental birth. The results indicate the need for further exploration of whether Icelandic perinatal healthcare services meet the care needs of migrant women.