Influenza and Tetanus, Diphtheria, and Acellular Pertussis Vaccination Coverage During Pregnancy: Pregnancy Risk Assessment Monitoring System, 2020.

OBJECTIVES: Estimates of vaccination coverage during pregnancy and identification of disparities in vaccination coverage can inform vaccination campaigns and programs. We reported the prevalence of being offered or told to get the influenza vaccine by a health care provider (hereinafter, provider); influenza vaccination coverage during the 12 months before delivery; and tetanus, diphtheria, and acellular pertussis (Tdap) vaccination coverage during pregnancy among women with a recent live birth in the United States. METHODS: We analyzed 2020 data from the Pregnancy Risk Assessment Monitoring System from 42 US jurisdictions (n = 41 673). We estimated the overall prevalence of being offered or told to get the influenza vaccine by a provider and influenza vaccination coverage during the 12 months before delivery. We estimated Tdap vaccination coverage during pregnancy from 21 jurisdictions with available data (n = 22 020) by jurisdiction and select characteristics. RESULTS: In 2020, 84.9% of women reported being offered or told to get the influenza vaccine, and 60.9% received it, ranging from 35.0% in Puerto Rico to 79.7% in Massachusetts. Influenza vaccination coverage was lower among women who were not offered or told to get the influenza vaccine (21.4%) than among women who were offered or told to get the vaccine (68.1%). Overall, 72.7% of women received the Tdap vaccine, ranging from 52.8% in Mississippi to 86.7% in New Hampshire. Influenza and Tdap vaccination coverage varied by all characteristics examined. CONCLUSIONS: These results can inform vaccination programs and strategies to address disparities in vaccination coverage during pregnancy and may inform vaccination efforts for other infectious diseases among pregnant women.

Increasing access to quality care for pregnant and postpartum people with opioid use disorder: Coordination of services, provider awareness and training, extended postpartum coverage, and perinatal quality collaboratives.

INTRODUCTION: Fifteen states participating in the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community (OMNI LC) developed action plan goals and activities to address the rise in opioid use disorder (OUD) among birthing persons. In a separate initiative, Perinatal Quality Collaboratives (PQCs) from 12 states participating in Centers for Disease Control and Prevention (CDC)-supported activities hosted trainings to improve the provision of OUD services and implement protocols for screening and treatment in delivery facilities. METHODS: This descriptive study synthesizes qualitative data extracted from 15 OMNI LC state action plans, excerpts from qualitative interviews conducted with OMNI LC state teams, and quantitative data from quarterly project performance monitoring reports from 12 CDC-funded PQCs implementing quality improvement activities to address clinical service gaps for pregnant and postpartum people with OUD. Qualitative data were deidentified, coded as barriers or facilitators, then aggregated into emergent themes. Count data are presented for quantitative results. RESULTS: The OMNI LC states identified a lack of coordinated care among providers, stigma toward people with OUD, discontinued insurance coverage, and inconsistencies in screening and treating birthing people with OUD as barriers to accessing quality care. State-identified facilitators for access to quality care included: 1) improving engagement and communication between providers and other partners to integrate medical and behavioral health services post-discharge, and facilitate improved patient care postpartum; 2) training providers to prescribe medications for OUD, and to address bias and reduce patient stigma; 3) extending Medicaid coverage up to one year postpartum to increase access to and continuity of services; and 4) implementing screening, brief intervention, and referral to treatment (SBIRT) in clinical practice. PQCs demonstrated that increased provider trainings to treat OUD, improvements in implementation of standardized protocols, and use of evidence-based tools can facilitate access to and coordination of services in delivery facilities. CONCLUSION: State-identified facilitators for increasing access to care include coordinating integrated services, extending postpartum coverage, and provider trainings to improve screening and treatment. PQCs provide a platform for identifying emerging areas for quality improvement initiatives and implementing clinical best practices to provide comprehensive, quality perinatal care for birthing populations.

U.S. stillbirth surveillance: The national fetal death file and other data sources.

The National Vital Statistics System is the primary source of information on fetal deaths of 20 weeks of gestation or more in the United States. Data are cooperatively produced by jurisdiction vital statistics offices and the National Center for Health Statistics. In order to promote the uniformity of data, the National Center for Health Statistics issues The Model State Vital Statistics Act and Regulations, and produces standard certificates and reports, developed in collaboration with the states, to inform the development of jurisdictional vital records laws and regulations and data collection. While there are challenges in collecting national fetal death data, there are ongoing data quality improvement efforts to address them. Improved national fetal death data and data from other sources will continue to add insights into the risks, causes and prevention of fetal death.

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.

Assessing Sustainability of State-Led Action Plans for the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community, 2018-2021.

Objective(s): The opioid crisis affects the health and health care of pregnant and postpartum people and infants prenatally exposed to substances. A Learning Community (LC) among 15 states was implemented to improve services for these populations. States drafted action plans with goals, strategies, and activities. Materials and Methods: Qualitative data from action plans were analyzed to assess how reported activities aligned with focus areas each year. Year 2 focus areas were compared with year 1 to identify shifts or expansion of activities. States self-assessed progress at the LC closing meeting, reported goal completion, barriers and facilitators affecting goal completion, and sustainment strategies. Results: In year 2, many states included activities focused on access to and coordination of quality services (13 of 15 states) and provider awareness and training (11 of 15). Among 12 states participating in both years of the LC, 11 expanded activities to include at least one additional focus area, adding activities in financing and coverage of services (n = 6); consumer awareness and education (n = 5); or ethical, legal, and social considerations (n = 4). Of the 39 goals developed by states, 54% were completed, and of those not completed, 94% had ongoing activities. Barriers to goal completion included competing priorities and pandemic-related constraints, whereas facilitators involving use of the LC as a forum for information-sharing and leadership-supported goal completion. Sustainability strategies were continued provider training and partnership with Perinatal Quality Collaboratives. Conclusion: State LC participation supported sustainment of activities to improve health and health care for pregnant and postpartum people with opioid use disorder and infants prenatally exposed to substances.

Sudden Unexpected Infant Deaths: 2015-2020.

OBJECTIVE: Although the US infant mortality rate reached a record low in 2020, the sudden infant death syndrome (SIDS) rate increased from 2019. To understand if the increase was related to changing death certification practices or the coronavirus disease 2019 (COVID-19) pandemic, we examined sudden unexpected infant death (SUID) rates as a group, by cause, and by race and ethnicity. METHODS: We estimated SUID rates during 2015 to 2020 using US period-linked birth and death data. SUID included SIDS, unknown cause, and accidental suffocation and strangulation in bed. We examined changes in rates from 2019 to 2020 and assessed linear trends during prepandemic (2015-2019) using weighted least squares regression. We also assessed race and ethnicity trends and quantified COVID-19-related SUID. RESULTS: Although the SIDS rate increased significantly from 2019 to 2020 (P < .001), the overall SUID rate did not (P = .24). The increased SIDS rate followed a declining linear trend in SIDS during 2015 to 2019 (P < .001). Other SUID causes did not change significantly. Our race and ethnicity analysis showed SUID rates increased significantly for non-Hispanic Black infants from 2019 to 2020, widening the disparities between these two groups during 2017 to 2019. In 2020, <10 of the 3328 SUID had a COVID-19 code. CONCLUSIONS: Diagnositic shifting likely explained the increased SIDS rate in 2020. Why the SUID rate increased for non-Hispanic Black infants is unknown, but warrants continued monitoring. Interventions are needed to address persistent racial and ethnic disparities in SUID.

Maternal and neonatal risk-appropriate care: gaps, strategies, and areas for further research.

Risk-appropriate care is a strategy to improve perinatal health outcomes by providing care to pregnant persons and infants in facilities with the personnel and services capable of meeting their health needs. The Association of State and Territorial Health Officials hosted discussions among state health officials, health agency staff, and clinicians to advance risk-appropriate care. The discussions focused on neonatal levels of care, levels of maternal care, ancillary services utilized for care of both populations including transport and telemedicine, and issues affecting provision of care such as standardization of state policies or approaches, reimbursement for services, gaps in risk-appropriate care, and equity. State-identified implementation strategies for improvement were presented. In this Perspective, we summarize current studies describing provision of risk-appropriate care in the United States, identify gaps in research, and highlight ongoing and proposed activities to address research gaps and support state health officials and clinicians.

Assisted Reproductive Technology and Perinatal Mortality: Selected States (2006-2011).

OBJECTIVE: This study aimed to compare trends and characteristics of assisted reproductive technology (ART) and non-ART perinatal deaths and to evaluate the association of perinatal mortality and method of conception (ART vs. non-ART) among ART and non-ART deliveries in Florida, Massachusetts, and Michigan from 2006 to 2011. STUDY DESIGN: Retrospective cohort study using linked ART surveillance and vital records data from Florida, Massachusetts, and Michigan. RESULTS: During 2006 to 2011, a total of 570 ART-conceived perinatal deaths and 25,158 non-ART conceived perinatal deaths were identified from the participating states. Overall, ART perinatal mortality rates were lower than non-ART perinatal mortality rates for both singletons (7.0/1,000 births vs. 10.2/1,000 births) and multiples (22.8/1,000 births vs. 41.2/1,000 births). At <28 weeks of gestation, the risk of perinatal death among ART singletons was significantly lower than non-ART singletons (adjusted risk ratio [aRR] = 0.46, 95% confidence interval [CI]: 0.26-0.85). Similar results were observed among multiples at <28 weeks of gestation (aRR = 0.64, 95% CI: 0.45-0.89). CONCLUSION: Our findings suggest that ART use is associated with a decreased risk of perinatal deaths prior to 28 weeks of gestation, which may be explained by earlier detection and management of fetal and maternal conditions among ART-conceived pregnancies. These findings provide valuable information for health care providers, including infertility specialists, obstetricians, and pediatricians when counseling ART users on risk of treatment. KEY POINTS: · ART use is associated with a decreased risk of perinatal deaths prior to 28 weeks of gestation.. · ART perinatal mortality rates were lower than that for non-ART perinatal mortality.. · This study used linked data to examine associations between use of ART and perinatal deaths..

COVID-19 Vaccination and Intent Among Pregnant Women, United States, April 2021.

OBJECTIVES: National data on COVID-19 vaccination coverage among pregnant women are limited. We assessed COVID-19 vaccination coverage and intent, factors associated with COVID-19 vaccination, reasons for nonvaccination, and knowledge, attitudes, and beliefs related to COVID-19 illness and vaccination among pregnant women in the United States. METHODS: Data from an opt-in internet panel survey of pregnant women conducted March 31-April 16, 2021, assessed receipt of ≥1 dose of any COVID-19 vaccine during pregnancy. The sample included 1516 women pregnant any time during December 1, 2020-April 16, 2021, who were not fully vaccinated before pregnancy. We used multivariable logistic regression to determine variables independently associated with receipt of COVID-19 vaccine. RESULTS: As of April 16, 2021, 21.7% of pregnant women had received ≥1 dose of COVID-19 vaccine during pregnancy, 24.0% intended to receive a vaccine, 17.2% were unsure, and 37.1% did not intend to receive a vaccine. Pregnant women with (vs without) a health care provider recommendation (adjusted prevalence ratio [aPR] = 4.86), those who lived (vs not) with someone with a condition that could increase risk for serious medical complications of COVID-19 (aPR = 2.11), and those who had received (vs not) an influenza vaccination (aPR = 2.35) were more likely to receive a COVID-19 vaccine. Common reasons for nonvaccination included concerns about safety risk to baby (37.2%) or self (34.6%) and about rapid vaccine development (29.7%) and approval (30.9%). CONCLUSIONS: Our findings indicate a continued need to emphasize the benefits of COVID-19 vaccination during pregnancy and to widely disseminate the recommendations of the Centers for Disease Control and Prevention and other clinical professional societies for all pregnant women to be vaccinated.

US county-level estimation for maternal and infant health-related behavior indicators using pregnancy risk assessment monitoring system data, 2016-2018.

BACKGROUND: There is a critical need for maternal and child health data at the local level (for example, county), yet most counties lack sustainable resources or capabilities to collect local-level data. In such case, model-based small area estimation (SAE) could be a feasible approach. SAE for maternal or infant health-related behaviors at small areas has never been conducted or evaluated. METHODS: We applied multilevel regression with post-stratification approach to produce county-level estimates using Pregnancy Risk Assessment Monitoring System (PRAMS) data, 2016-2018 (n = 65,803 from 23 states) for 2 key outcomes, breastfeeding at 8 weeks and infant non-supine sleeping position. RESULTS: Among the 1,471 counties, the median model estimate of breastfeeding at 8 weeks was 59.8% (ranged from 34.9 to 87.4%), and the median of infant non-supine sleeping position was 16.6% (ranged from 10.3 to 39.0%). Strong correlations were found between model estimates and direct estimates for both indicators at the state level. Model estimates for both indicators were close to direct estimates in magnitude for Philadelphia County, Pennsylvania. CONCLUSION: Our findings support this approach being potentially applied to other maternal and infant health and behavioral indicators in PRAMS to facilitate public health decision-making at the local level.

Summary of neonatal and maternal transport and reimbursement policies-a 5-year update.

OBJECTIVE: To examine the number of states with neonatal and maternal transport and reimbursement policies in 2019, compared with 2014. STUDY DESIGN: We conducted a systematic review of web-based, publicly available information on neonatal and maternal transport policies for each state in 2019. Information was abstracted from rules, codes, licensure regulations, and planning and program documents, then summarized within two categories: transport and reimbursement policies. RESULT: In 2019, 42 states had a policy for neonatal transport and 37 states had a policy for maternal transport, increasing by 8 and 7 states respectively. Further, 31 states had a reimbursement policy for neonatal transport and 11 states for maternal transport, increases of 1 state per category. Overall, the number of states with policies increased from 2014 to 2019. CONCLUSION: The number of state neonatal and maternal transport policies increased; these policies may support provision of care at the most risk-appropriate facilities.

Participation in survey research among mothers with a recent live birth: A comparison of mothers with living versus deceased infants - Findings from the Pregnancy Risk Assessment Monitoring System, 2016-2019.

BACKGROUND: Despite high infant mortality rates in the United States relative to other developed countries, little is known about survey participation among mothers of deceased infants. OBJECTIVE: To assess differences in survey response, contact and cooperation rates for mothers of deceased versus. living infants at the time of survey mailing (approximately 2-6 months postpartum), overall and by select maternal and infant characteristics. METHODS: We analysed 2016-2019 data for 50 sites from the Pregnancy Risk Assessment Monitoring System (PRAMS), a site-specific, population-based surveillance system of mothers with a recent live birth. We assessed differences in survey participation between mothers of deceased and living infants. Using American Association for Public Opinion Research (AAPOR) standard definitions and terminology, we calculated proportions of mothers who participated and were successfully contacted among sampled mothers (weighted response and contact rates, respectively), and who participated among contacted mothers (weighted cooperation rate). We then constructed multivariable survey-weighted logistic regression models to examine the adjusted association between infant vital status and weighted response, contact and cooperation rates, within strata of maternal and infant characteristics. RESULTS: Among sampled mothers, 0.3% (weighted percentage, n = 2795) of infants had records indicating they were deceased at the time of survey mailing and 99.7% (weighted percentage, n = 344,379) did not. Mothers of deceased infants had lower unadjusted weighted response (48.3% vs. 56.2%), contact (67.9% vs. 74.3%) and cooperation rates (71.1% vs. 75.6%). However, after adjusting for covariates, differences in survey participation by infant vital status were reduced. CONCLUSIONS: After covariate adjustment, differences in PRAMS participation rates were attenuated. However, participation rates among mothers of deceased infants remain two to four percentage points lower compared with mothers of living infants. Strategies to increase PRAMS participation could inform knowledge about experiences and behaviours before, during and shortly after pregnancy to help reduce infant mortality.

Hypertensive Disorders in Pregnancy and Mortality at Delivery Hospitalization - United States, 2017-2019.

Hypertensive disorders in pregnancy (HDPs), defined as prepregnancy (chronic) or pregnancy-associated hypertension, are common pregnancy complications in the United States.* HDPs are strongly associated with severe maternal complications, such as heart attack and stroke (1), and are a leading cause of pregnancy-related death in the United States.† CDC analyzed nationally representative data from the National Inpatient Sample to calculate the annual prevalence of HDP among delivery hospitalizations and by maternal characteristics, and the percentage of in-hospital deaths with an HDP diagnosis code documented. During 2017-2019, the prevalence of HDP among delivery hospitalizations increased from 13.3% to 15.9%. The prevalence of pregnancy-associated hypertension increased from 10.8% in 2017 to 13.0% in 2019, while the prevalence of chronic hypertension increased from 2.0% to 2.3%. Prevalence of HDP was highest among delivery hospitalizations of non-Hispanic Black or African American (Black) women, non-Hispanic American Indian and Alaska Native (AI/AN) women, and women aged ≥35 years, residing in zip codes in the lowest median household income quartile, or delivering in hospitals in the South or the Midwest Census regions. Among deaths that occurred during delivery hospitalization, 31.6% had any HDP documented. Clinical guidance for reducing complications from HDP focuses on prompt identification and preventing progression to severe maternal complications through timely treatment (1). Recommendations for identifying and monitoring pregnant persons with hypertension include measuring blood pressure throughout pregnancy,§ including self-monitoring. Severe complications and mortality from HDP are preventable with equitable implementation of strategies to identify and monitor persons with HDP (1) and quality improvement initiatives to improve prompt treatment and increase awareness of urgent maternal warning signs (2).

A Field Placement Approach to Enhance State and Local Capacity for Opioid-Related Issues Affecting Pregnant and Postpartum People and Infants Prenatally Exposed to Opioids and Other Substances.

Opioid use disorder (OUD) poses a significant public health concern impacting maternal and infant outcomes. In 2018, the Centers for Disease Control and Prevention (CDC) partnered with the Association of State and Territorial Health Officials (ASTHO) to develop the Opioid use disorder, Maternal outcomes, and Neonatal abstinence syndrome Initiative Learning Community (OMNI LC) to identify and disseminate best practices and strategies for implementing systems-level changes in state health departments to address OUD affecting pregnant and postpartum persons and infants prenatally exposed to opioids. In 2019, the OMNI LC incorporated a field placement approach that assigned temporary field placement staff in five select OMNI LC states to provide important linkages, facilitate information sharing, and strengthen capacity among state and local health departments and other partners supporting maternal and child health communities affected by the opioid crisis. Using an implementation science framework, the field placement approach was assessed using five implementation outcome measures: appropriateness, acceptability, implementation cost, sustainability, and feasibility. Written responses from the participating OMNI LC states on these implementation outcome measures were analyzed to (1) highlight key strategies used by field placement staff, (2) assess the implementation of the OMNI LC field placement approach within the context of implementation science, and (3) identify implementation barriers. This report describes the implementation of a temporary field placement approach and suggests that this approach could be replicated to enhance state and local capacity to respond to the opioid crisis or other high-consequence events.

Assisted Reproductive Technology Surveillance - United States, 2018.

PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to have multiple births because multiple embryos might be transferred. Multiple births can pose substantial risks for both mothers and infants, including obstetric complications, preterm birth (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2018 and compares birth outcomes that occurred in 2018 (resulting from ART procedures performed in 2017 and 2018) with outcomes for all infants born in the United States in 2018. PERIOD COVERED: 2018. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from the 50 U.S. states, the District of Columbia, and Puerto Rico. RESULTS: In 2018, a total of 203,119 ART procedures (range: 196 in Alaska to 26,028 in California) were performed in 456 U.S. fertility clinics and reported to CDC. These procedures resulted in 73,831 live-birth deliveries (range: 76 in Puerto Rico and Wyoming to 9,666 in California) and 81,478 infants born (range: 84 in Wyoming to 10,620 in California). Nationally, among women aged 15-44 years, the rate of ART procedures performed was 3,135 per 1 million women. ART use exceeded 1.5 times the national rate in seven states (Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island) and the District of Columbia. ART use rates exceeded the national rate in an additional seven states (California, Delaware, Hawaii, New Hampshire, Utah, Vermont, and Virginia). Nationally, among all ART transfer procedures, the average number of embryos transferred was similar across age groups (1.3 among women aged <35 years, 1.3 among women aged 35-37 years, and 1.4 among women aged >37 years). The national single-embryo transfer (SET) rate among all embryo-transfer procedures was 74.1% among women aged <35 years (range: 28.2% in Puerto Rico to 89.5% in Delaware), 72.8% among women aged 35-37 years (range: 30.6% in Puerto Rico to 93.7% in Delaware), and 66.4% among women aged >37 years (range: 27.1% in Puerto Rico to 85.3% in Delaware). In 2018, ART contributed to 2.0% of all infants born in the United States (range: 0.4% in Puerto Rico to 5.1% in Massachusetts) from procedures performed in 2017 and 2018. Approximately 78.6% of ART-conceived infants were singleton infants. Overall, ART contributed to 12.5% of all multiple births, including 12.5% of all twin births and 13.3% of all triplets and higher-order births. ART-conceived twins accounted for approximately 97.1% (15,532 of 16,001) of all ART-conceived multiple births. The percentage of multiple births was higher among infants conceived with ART (21.4%) than among all infants born in the total birth population (3.3%). Approximately 20.7% (15,532 of 74,926) of ART-conceived infants were twins, and 0.6% (469 of 74,926) were triplets and higher-order multiples. Nationally, infants conceived with ART contributed to 4.2% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 18.3% were low birthweight compared with 8.3% among all infants. ART-conceived infants contributed to 5.1% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (26.1%) than among all infants born in the total birth population (10.0%). The percentage of low birthweight among singletons was 8.3% among ART-conceived infants and 6.6% among all infants born. The percentage of preterm births among ART-conceived singleton infants was 14.9% compared with 8.3% among all singleton infants. The percentages of small for gestational age infants was 7.3% among ART-conceived infants compared with 9.4% among all infants. INTERPRETATION: Although singleton infants accounted for the majority of ART-conceived infants, multiple births from ART varied substantially among states and nationally, contributing to >12% of all twins, triplets, and higher-order multiple infants born in the United States. Because multiple births are associated with higher rates of prematurity than singleton births, the contribution of ART to poor birth outcomes continues to be noteworthy. Although SET rates increased among all age groups, variations in SET rates among states and territories remained, which might reflect variations in embryo-transfer practices among fertility clinics and might in part account for variations in multiple birth rates among states and territories. PUBLIC HEALTH ACTION: Reducing the number of embryos transferred and increasing use of SET, when clinically appropriate, can help reduce multiple births and related adverse health consequences for both mothers and infants. Whereas risks to mothers from multiple-birth pregnancy include higher rates of caesarean delivery, gestational hypertension, and gestational diabetes, infants from multiple births are at increased risk for numerous adverse sequelae such as preterm birth, birth defects, and developmental disabilities. Long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes on a population basis.

Seven years later: state neonatal risk-appropriate care policy consistency with the 2012 American Academy of Pediatrics Policy.

OBJECTIVE: To assess consistency of state neonatal risk-appropriate care policies with the 2012 AAP policy seven years post-publication. STUDY DESIGN: Systematic, web-based review of all publicly available 2019 state neonatal levels of care policies. Information on infant risk (gestational age, birth weight), technology and equipment capabilities, and availability of specialty staffing used to define neonatal levels of care was extracted for review. RESULT: Half of states (50%) had a neonatal risk-appropriate care policy. Of those states, 88% had language consistent with AAP-defined Level I criteria, 80% with Level II, 56% with Level III, and 55% with Level IV. Comparing policies (2014-2019), consistency increased in state policies among all levels of care with the greatest increase among level IV criteria. CONCLUSION: States improved consistency of policy language by each level of care, though half of states still lack policy to provide minimum standards of care to the most vulnerable infants.