Dolutegravir in Pregnancy as Compared with Current HIV Regimens in the United States.

BACKGROUND: Data on the effectiveness and safety of dolutegravir-based antiretroviral therapy (ART) for human immunodeficiency virus type 1 (HIV-1) infection in pregnancy as compared with other ART regimens commonly used in the United States and Europe, particularly when initiated before conception, are limited. METHODS: We conducted a study involving pregnancies in persons with HIV-1 infection in the Pediatric HIV/AIDS Cohort Study whose initial ART in pregnancy included dolutegravir, atazanavir-ritonavir, darunavir-ritonavir, oral rilpivirine, raltegravir, or elvitegravir-cobicistat. Viral suppression at delivery and the risks of infants being born preterm, having low birth weight, and being small for gestational age were compared between each non-dolutegravir-based ART regimen and dolutegravir-based ART. Supplementary analyses that included participants in the Swiss Mother and Child HIV Cohort Study were conducted to improve the precision of our results. RESULTS: Of the pregnancies in the study, 120 were in participants who received dolutegravir, 464 in those who received atazanavir-ritonavir, 185 in those who received darunavir-ritonavir, 243 in those who received rilpivirine, 86 in those who received raltegravir, and 159 in those who received elvitegravir-cobicistat. The median age at conception was 29 years; 51% of the pregnancies were in participants who started ART before conception. Viral suppression was present at delivery in 96.7% of the pregnancies in participants who received dolutegravir; corresponding percentages were 84.0% for atazanavir-ritonavir, 89.2% for raltegravir, and 89.8% for elvitegravir-cobicistat (adjusted risk differences vs. dolutegravir, -13.0 percentage points [95% confidence interval {CI}, -17.0 to -6.1], -17.0 percentage points [95% CI, -27.0 to -2.4], and -7.0 percentage points [95% CI, -13.3 to -0.0], respectively). The observed risks of preterm birth were 13.6 to 17.6%. Adjusted risks of infants being born preterm, having low birth weight, or being small for gestational age did not differ substantially between non-dolutegravir-based ART and dolutegravir. Results of supplementary analyses were similar. CONCLUSIONS: Atazanavir-ritonavir and raltegravir were associated with less frequent viral suppression at delivery than dolutegravir. No clear differences in adverse birth outcomes were observed with dolutegravir-based ART as compared with non-dolutegravir-based ART, although samples were small. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others.).

Body Mass Index, Adverse Pregnancy Outcomes, and Cardiovascular Disease Risk.

BACKGROUND: Obesity is a well-established risk factor for both adverse pregnancy outcomes (APOs) and cardiovascular disease (CVD). However, it is not known whether APOs are mediators or markers of the obesity-CVD relationship. This study examined the association between body mass index, APOs, and postpartum CVD risk factors. METHODS: The sample included adults from the nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be) Heart Health Study who were enrolled in their first trimester (6 weeks-13 weeks 6 days gestation) from 8 United States sites. Participants had a follow-up visit at 3.7 years postpartum. APOs, which included hypertensive disorders of pregnancy, preterm birth, small-for-gestational-age birth, and gestational diabetes, were centrally adjudicated. Mediation analyses estimated the association between early pregnancy body mass index and postpartum CVD risk factors (hypertension, hyperlipidemia, and diabetes) and the proportion mediated by each APO adjusted for demographics and baseline health behaviors, psychosocial stressors, and CVD risk factor levels. RESULTS: Among 4216 participants enrolled, mean±SD maternal age was 27±6 years. Early pregnancy prevalence of overweight was 25%, and obesity was 22%. Hypertensive disorders of pregnancy occurred in 15%, preterm birth in 8%, small-for-gestational-age birth in 11%, and gestational diabetes in 4%. Early pregnancy obesity, compared with normal body mass index, was associated with significantly higher incidence of postpartum hypertension (adjusted odds ratio, 1.14 [95% CI, 1.10-1.18]), hyperlipidemia (1.11 [95% CI, 1.08-1.14]), and diabetes (1.03 [95% CI, 1.01-1.04]) even after adjustment for baseline CVD risk factor levels. APOs were associated with higher incidence of postpartum hypertension (1.97 [95% CI, 1.61-2.40]) and hyperlipidemia (1.31 [95% CI, 1.03-1.67]). Hypertensive disorders of pregnancy mediated a small proportion of the association between obesity and incident hypertension (13% [11%-15%]) and did not mediate associations with incident hyperlipidemia or diabetes. There was no significant mediation by preterm birth or small-for-gestational-age birth. CONCLUSIONS: There was heterogeneity across APO subtypes in their association with postpartum CVD risk factors and mediation of the association between early pregnancy obesity and postpartum CVD risk factors. However, only a small or nonsignificant proportion of the association between obesity and CVD risk factors was mediated by any of the APOs, suggesting APOs are a marker of prepregnancy CVD risk and not a predominant cause of postpartum CVD risk.

Social determinants of health and obstetric outcomes: A report and recommendations of the workshop of the Society for Maternal-Fetal Medicine.

This article is a report of a 2-day workshop, entitled "Social determinants of health and obstetric outcomes," held during the Society for Maternal-Fetal Medicine 2022 Annual Pregnancy Meeting. Participants' fields of expertise included obstetrics, pediatrics, epidemiology, health services, health equity, community-based research, and systems biology. The Commonwealth Foundation and the Alliance of Innovation on Maternal Health cosponsored the workshop and the Society for Women's Health Research provided additional support. The workshop included presentations and small group discussions, and its goals were to accomplish the following.

Socioeconomic disadvantage in pregnancy and postpartum risk of cardiovascular disease.

BACKGROUND: Pregnancy is an educable and actionable life stage to address social determinants of health (SDOH) and lifelong cardiovascular disease (CVD) prevention. However, the link between a risk score that combines multiple neighborhood-level social determinants in pregnancy and the risk of long-term CVD remains to be evaluated. OBJECTIVE: To examine whether neighborhood-level socioeconomic disadvantage measured by the Area Deprivation Index (ADI) in early pregnancy is associated with a higher 30-year predicted risk of CVD postpartum, as measured by the Framingham Risk Score. STUDY DESIGN: An analysis of data from the prospective Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be Heart Health Study longitudinal cohort. Participant home addresses during early pregnancy were geocoded at the Census-block level. The exposure was neighborhood-level socioeconomic disadvantage using the 2015 ADI by tertile (least deprived [T1], reference; most deprived [T3]) measured in the first trimester. Outcomes were the predicted 30-year risks of atherosclerotic cardiovascular disease (ASCVD, composite of fatal and nonfatal coronary heart disease and stroke) and total CVD (composite of ASCVD plus coronary insufficiency, angina pectoris, transient ischemic attack, intermittent claudication, and heart failure) using the Framingham Risk Score measured 2 to 7 years after delivery. These outcomes were assessed as continuous measures of absolute estimated risk in increments of 1%, and, secondarily, as categorical measures with high-risk defined as an estimated probability of CVD ≥10%. Multivariable linear regression and modified Poisson regression models adjusted for baseline age and individual-level social determinants, including health insurance, educational attainment, and household poverty. RESULTS: Among 4309 nulliparous individuals at baseline, the median age was 27 years (interquartile range [IQR]: 23-31) and the median ADI was 43 (IQR: 22-74). At 2 to 7 years postpartum (median: 3.1 years, IQR: 2.5, 3.7), the median 30-year risk of ASCVD was 2.3% (IQR: 1.5, 3.5) and of total CVD was 5.5% (IQR: 3.7, 7.9); 2.2% and 14.3% of individuals had predicted 30-year risk ≥10%, respectively. Individuals living in the highest ADI tertile had a higher predicted risk of 30-year ASCVD % (adjusted ß: 0.41; 95% confidence interval [CI]: 0.19, 0.63) compared with those in the lowest tertile; and those living in the top 2 ADI tertiles had higher absolute risks of 30-year total CVD % (T2: adj. ß: 0.37; 95% CI: 0.03, 0.72; T3: adj. ß: 0.74; 95% CI: 0.36, 1.13). Similarly, individuals living in neighborhoods in the highest ADI tertile were more likely to have a high 30-year predicted risk of ASCVD (adjusted risk ratio [aRR]: 2.21; 95% CI: 1.21, 4.02) and total CVD ≥10% (aRR: 1.35; 95% CI: 1.08, 1.69). CONCLUSION: Neighborhood-level socioeconomic disadvantage in early pregnancy was associated with a higher estimated long-term risk of CVD postpartum. Incorporating aggregated SDOH into existing clinical workflows and future research in pregnancy could reduce disparities in maternal cardiovascular health across the lifespan, and requires further study.

Post-Dobbs Abortion Restrictions and the Families They Leave Behind.

The June 24, 2022 US Supreme Court decision in Dobbs v Jackson Women's Health Organization resulted in an expansive restriction on abortion access that had been constitutionally guaranteed for nearly half a century. Currently, 14 states have implemented complete bans on abortion with very limited exceptions, and an additional 7 states have implemented abortion bans at 6 to 18 weeks' gestation. It has been well demonstrated that restrictive policies disproportionately limit abortion access for minoritized people and people of low socioeconomic status; the financial and geographic barriers of these post-Dobbs restrictions will only exacerbate this disparity. Proponents of abortion restrictions, who identify as pro-life, assert that these policies are essential to protect children, women, and families. We examine whether the protection of these groups extends past conception by evaluating the association between state abortion legislation and state-based policies and programs designed to provide medical and social support for children, women, and families. We found that states with the most restrictive post-Dobbs abortion policies in fact have the least comprehensive and inclusive public infrastructure to support these groups. We suggest further opportunities for advocacy. (Am J Public Health. 2024;114(10):1043-1050. https://doi.org/10.2105/AJPH.2024.307792).

Second-Trimester Ultrasound Receipt Mediates the Relationship Between Public Insurance and Prenatal Diagnosis of a Congenital Heart Defect.

OBJECTIVE: To delineate the mechanism behind insurance-related disparities in the prenatal diagnosis of a congenital heart defect (CHD). METHODS: This was a retrospective analysis of electronic health records of pregnant individuals whose infants received CHD surgery between 2019 and 2020 in the third-largest United States metropolitan area. The outcome was whether a prenatal diagnosis was received. The exposure was the pregnant individual's insurance status. The mediator was second-trimester ultrasound receipt. Control variables included sociodemographic and clinical characteristics of the pregnant individual and infant. The relationships between exposure, mediator, and outcome were quantified using mediation analysis with multivariable fixed-effects regression. RESULTS: In total, 496 pregnant individuals met inclusion criteria; 215 (43.3%) were publicly insured and 305 (61.5%) had prenatal diagnosis. In bivariate regressions, public insurance was associated with a 12.6% lower probability (CI 3%-21%) of prenatal diagnosis. In multivariable models, public insurance was associated with 13.2% lower probability (CI 2%-25%) of second-trimester ultrasound receipt but was no longer associated with prenatal diagnosis after adjusting for second-trimester ultrasound receipt, suggesting a possible mediation effect. Mediation analysis confirmed that second-trimester ultrasound receipt mediated 39% of the relationship between public insurance and prenatal diagnosis. CONCLUSION: An appreciable portion of insurance-related differences in prenatal CHD diagnosis is due to the lower frequency of second-trimester ultrasound receipt among those with public insurance.

Patient-reported barriers to prenatal diagnosis of congenital heart defects: A mixed-methods study.

OBJECTIVE: To ascertain patient-reported, modifiable barriers to prenatal diagnosis of congenital heart defects (CHDs). METHODS: This was a mixed-methods study among caretakers of infants who received congenital heart surgery from 2019 to 2020 in the Chicagoland area. Quantitative variables measuring sociodemographic characteristics and prenatal care utilization, and qualitative data pertaining to patient-reported barriers to prenatal diagnosis were collected from electronic health records and semi-structured phone surveys. Thematic analysis was performed using a convergent parallel approach. RESULTS: In total, 160 caretakers completed the survey, 438 were eligible for survey, and 49 (31%) received prenatal care during the COVID-19 pandemic. When comparing respondents and non-respondents, there was a lower prevalence of maternal Hispanic ethnicity and a higher prevalence of non-English/Spanish-speaking households. Of all respondents, 34% reported an undetected CHD on ultrasound or echocardiogram, while 79% reported at least one barrier to prenatal diagnosis related to social determinants of health. Among those social barriers, the most common were difficulty with appointment scheduling (n = 12, 9.5%), far distance to care/lack of access to transportation (n = 12, 9.5%) and difficulty getting time off work to attend appointments (n = 6, 4.8%). The latter two barriers were correlated. CONCLUSION: While technical improvements in the detection of CHDs remain an important area of research, it is equally critical to produce evidence for interventions that mitigate barriers to prenatal diagnosis due to social determinants of health.

The role of clinic-based breastfeeding peer counseling on breastfeeding rates among low-income patients.

BACKGROUND: Despite the benefits of breastfeeding (BF), rates remain lower than public health targets, particularly among low-income Black populations. Community-based breastfeeding peer counselor (BPC) programs have been shown to increase BF. We sought to examine whether implementation of a BPC program in an obstetric clinical setting serving low-income patients was associated with improved BF initiation and exclusivity. METHODS: This is a quasi-experimental time series study of pregnant and postpartum patients receiving care before and after implementation of a BPC program in a teaching hospital affiliated prenatal clinic. The role of the BPC staff included BF classes, prenatal counseling and postnatal support, including in-hospital assistance and phone triage after discharge. Records were reviewed at each of 3 time points: immediately before the hire of the BPC staff (2008), 1-year post-implementation (2009), and 5 years post-implementation (2014). The primary outcomes were rates of breastfeeding initiation and exclusivity prior to hospital discharge, secondary outcomes included whether infants received all or mostly breastmilk during inpatient admission and by 6 weeks post-delivery. Bivariable and multivariable analyses were utilized as appropriate. RESULTS: Of 302 patients included, 52.3% identified as non-Hispanic Black and 99% had Medicaid-funded prenatal care. While there was no improvement in rates of BF initiation, exclusive BF during the postpartum hospitalization improved during the 3 distinct time points examined, increasing from 13.7% in 2008 to 32% in 2014 (2009 aOR 2.48, 95%CI 1.13-5.43; 2014 aOR 1.82, 95%CI 1.24-2.65). This finding was driven by improved exclusive BF for patients who identified as Black (9.4% in 2008, 22.9% in 2009, and 37.9% in 2014, p = 0.01). CONCLUSION: Inpatient BF exclusivity significantly increased with the tenure of a BPC program in a low-income clinical setting. These findings demonstrate that a BPC program can be a particularly effective method to address BF disparities among low-income Black populations.

Clinical Trials That Have Changed Clinical Practice and Care of Pregnant People With HIV.

Over the last 4 decades, significant advances in the care of HIV during pregnancy have successfully reduced, and nearly eliminated, the risk of perinatal HIV transmission. The baseline risk of transmission without intervention (25% to 30%) is now <1% to 2% in the United States with contemporary antepartum, intrapartum, and postnatal interventions. In this review, we discuss 3 landmark clinical trials that substantially altered obstetric practice for pregnant individuals with HIV and contributed to this extraordinary achievement: 1) the Pediatric AIDS Clinical Trials Group 076 Trial determined that antepartum and intrapartum administration of antiretroviral drug zidovudine to the pregnant individual, and postnatally to the newborn, could reduce the risk of perinatal transmission by approximately two-thirds; 2) the European Mode of Delivery Collaboration Trial demonstrated performance of a prelabor cesarean birth before rupture of membranes among pregnant people with viremia reduced the risk of perinatal transmission compared with vaginal birth; and 3) the International Maternal Pediatric Adolescent AIDS Clinical Trials Network 2010 Trial identified that dolutegravir-containing, compared with efavirenz-containing, antiretroviral regimens during pregnancy achieved a significantly higher rate of viral suppression at delivery with shorter time to viral suppression, with fewer adverse pregnancy outcomes. Collectively, these trials not only advanced obstetric practice but also advanced scientific understanding of the timing, mechanisms, and determinants of perinatal HIV transmission. For each trial, we will describe key aspects of the study protocol and outcomes, insights gleaned about the dynamics of perinatal transmission, how each study changed clinical practice, and relevant updates to current practice since the trial's publication.

Perspectives of Challenges in Counseling for Congenital Heart Defects.

Prior work regarding counseling patients about congenital heart defects (CHD) has focused on their perceptions about accurate communication of cardiac anatomy, and the emotional support received from the provider. The objectives of this study were to identify the additional CHD counseling-specific challenges and areas for future intervention, using a practical communication framework. This is a secondary analysis of qualitative data provided by caretakers of infants who received congenital heart surgery from 2019 to 2020 in the Chicagoland area. While the survey in the primary study pertained to barriers in obtaining prenatal diagnosis, respondents with both prenatal and postnatal diagnosis reported challenges to effective counseling. Qualitative data measuring counseling challenges were collected from semi-structured phone interviews. Thematic analysis was performed using an inductive approach. Themes were organized into five domains using SPIKES (Setting, Perception, Invitation, Knowledge, Empathy, and Summarize/Strategy), a previously validated framework to help clinicians effectively break bad news. Among 160 survey respondents, 35 (21.9%) reported a challenge during CHD counseling that they received. In total, 12 challenges were identified and spanned all six SPIKES domains. The three most common challenges were as follows: perception of repeated imaging studies for accurate diagnosis or management (n = 19, Knowledge), the lack of cardiologist presence at the time of initial CHD detection (n = 8, Setting), and insufficient information provided about the CHD diagnosis (n = 7, Knowledge). Patients perceive counseling as a key component of prenatal diagnosis of CHD and identify the challenges that exist at all stages of the counseling process. These findings suggest that effective counseling extends beyond conveying information about anatomy and prognosis.

Characteristics Associated with Trial of Labor among Patients with Twin Pregnancies.

OBJECTIVE: This study aimed to identify patient and provider factors associated with undergoing trial of labor (TOL) among eligible patients with twin gestations. STUDY DESIGN: This retrospective cohort study of patients with twin gestations who received care at a large tertiary care center from 2000 to 2016 included individuals with live pregnancies greater than 23 weeks of gestation and cephalic-presenting twin. Patients with a prior uterine scar or contraindication to vaginal delivery were excluded from analyses. Maternal and clinical characteristics were compared among patients who did and did not undergo TOL. Multivariable logistic regression models included characteristics chosen a priori and those with bivariable associations with p < 0.1. Interactions between parity and other significant variables in the primary models were also investigated. RESULTS: Among 1,888 eligible patients, 80.7% (N = 1,524) underwent TOL. Those undergoing TOL were more likely to be younger, multiparous, and have a maternal-fetal medicine physician as the delivering provider (p < 0.01). Hypertensive disorders of pregnancy were less prevalent among patients undergoing TOL (20.2 vs. 27.8%, p < 0.01). In multivariable analysis, advanced maternal age (adjusted odds ratio [aOR]: 0.55, 95% confidence interval [CI]: 0.40-0.74) and nulliparity (aOR: 0.36, 95% CI: 0.25-0.52) conferred a lower odds of TOL, while having a maternal-fetal medicine provider (aOR: 2.74, 95% CI: 1.55-4.83) was associated with higher odds. Interaction analyses demonstrated no significant interaction effects between parity and other characteristics. Among those undergoing a TOL, 76.0% (1,158/1,524) had a successful vaginal delivery of both twins, with 48.1% (557/1,158) having breech extraction of the second twin. CONCLUSION: In this cohort of twin gestations with a high frequency of TOL, patient and provider characteristics are associated with attempting vaginal delivery. Variation in provider practices suggests differing skills and comfort with twin vaginal delivery may influence route of delivery decision-making in patients with twins. KEYPOINTS: · Most patients with twin pregnancies undergoing TOL had successful vaginal deliveries.. · Having an MFM delivering provider was associated with higher odds of attempting twin TOL.. · Nulliparity and advanced maternal age were associated with lower odds of twin TOL..

Statewide Implementation of Universal Third-Trimester Repeat HIV Testing in Illinois.

OBJECTIVE: This article aims to assess statewide uptake of HIV repeat testing in the first 2 years after the implementation of an amendment to the Illinois Perinatal HIV Prevention Act (IPHPA) mandating universal repeat HIV testing in the third trimester. STUDY DESIGN: This is a retrospective, population-based study of all birthing individuals in Illinois (2018-2019). Data were collected using the state-mandated closed system of perinatal HIV test reporting. We evaluated the incidence of mother-infant pairs with negative early tests and repeat third-trimester tests (RTTTs) performed in adherence with the law, as well as the timing of the performance of the RTTTs (outpatient vs. inpatient). Chi-square tests of trend by quarter were performed to ascertain sustainability. RESULTS: Of 138,805 individuals delivered in 2018, 80.6% presented with early test and RTTTs. In 2018, outpatient RTTTs improved from 71.8% (quarter 1) to 85.1% (quarter 4; p < 0.001). In 2018, the proportion of mother-infant dyads who received testing that was adherent to the IPHPA Amendment was 92.1, 95.5, 96.7, and 96.4% in quarters 1 through 4, respectively (p < 0.001). In 2019, outpatient RTTTs performance remained high (87.4%) and stable (p = 0.06). In 2019, 99.9% of mother-infant dyads had testing adherent to the mandate in quarters 1 through 4 (p = 0.39). Of individuals who presented without RTTTs, 93.5% (2018) and 98.8% (2019) underwent inpatient testing before delivery. CONCLUSION: Implementation of RTTTs in Illinois was rapid, successful, and sustained in its first 2 years. Public health methodologies from Illinois may benefit other states implementing RTTT programs. KEY POINTS: · In 2018, Illinois enacted statewide RTTT for HIV among all parturients.. · In 2019, over 99% of mother-infant dyads had documentation of both early and repeat HIV testing before hospital discharge.. · Implementation of repeat third-trimester HIV testing in Illinois was rapid, successful, and sustained in its first 2 years.. · Public health methodologies from Illinois may benefit other states implementing similar programs..

Postpartum Management of Hypertensive Disorders of Pregnancy in Six Large U.S. Hospital Systems: Descriptive Review and Identification of Clinical and Research Gaps.

Hypertensive disorders of pregnancy (HDPs) are a key contributor to maternal morbidity and mortality. Several gaps in knowledge remain regarding best practices in the postpartum management of HDPs. In this review, we describe postpartum HDPs management among six large academic U.S. hospital systems: Medical College of Wisconsin, University of Pittsburgh, University of Wisconsin-Madison, Northwestern University, University of Minnesota, and Boston Medical Center. We identified that all six health systems discharge patients with HDPs diagnosed with a blood pressure (BP) cuff and use the same two antihypertensive medications, nifedipine and labetalol, as first- and second-line treatment of HDPs. Northwestern University routinely adds oral furosemide for 5 days for patients with BP that exceeds 150/100 mm Hg. Most hospital systems administer magnesium sulfate routinely when readmission for HDPs occurs. In contrast, there was variation in BP threshold for antihypertensive treatment initiation, use of remote BP monitoring program, use of a transition clinic, delivery or lack of education on long-term cardiovascular disease risk, and BP management through the first 6 weeks postpartum and beyond. Based on the clinical review, we identified clinical gaps and formulated considerations for research priorities in the field of postpartum HDPs management. KEY POINTS: · Several gaps in knowledge remain regarding best practices in postpartum management of HDPs.. · There is a variation in the BP threshold for antihypertensive treatment initiation.. · Data are lacking on the reduction in severe maternal morbidity (SMM) and racial disparities in SMM with remote monitoring..

Unique Profile of Inflammation and Immune Activation in Pregnant People With HIV in the United States.

BACKGROUND: Little is known about inflammation/immune activation during pregnancy in people with HIV (PWH) and growth in their children who are HIV-exposed and uninfected (CHEU). METHODS: Using data from the Pediatric HIV/AIDS Cohort Study and an HIV-seronegative comparison group, we assessed associations of (1) HIV status, mode of HIV acquisition (perinatally vs nonperinatally acquired), and type of antiretroviral therapy (ART) with inflammation/immune activation in pregnancy; and (2) inflammation/immune activation in pregnancy with growth of CHEU at 12 months. Interleukin 6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), soluble(s) TNF-α receptor 1 and 2 (sTNFR1, sTNFR2), sCD14, and sCD163 were measured between 13 and 27 weeks' gestation. Linear regression models were fit to estimate differences between groups for each log-transformed biomarker, adjusted for confounders. RESULTS: Pregnant PWH (188 total, 39 perinatally acquired, 149 nonperinatally acquired) and 76 HIV-seronegative persons were included. PWH had higher IL-6, sTNFR1, sCD14, and sCD163 and lower sTNFR2 compared to HIV-seronegative persons in adjusted models. Among PWH, sCD163 was higher in those with perinatally versus nonperinatally acquired HIV and on PI-based versus INSTI-based ART. Higher maternal concentrations of IL-6, sTNFR2, and hs-CRP were associated with poorer growth at 12 months. CONCLUSIONS: Maternal HIV status is associated with a distinct profile of inflammation/immune activation during pregnancy, which may influence child growth.

Association of Living in a Food Desert and Poor Periconceptional Diet Quality in a Cohort of Nulliparous Pregnant Individuals.

BACKGROUND: A poor diet can result from adverse social determinants of health and increases the risk of adverse pregnancy outcomes. OBJECTIVE: We aimed to assess, using data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be prospective cohort, whether nulliparous pregnant individuals who lived in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert. METHODS: The exposure was living in a food desert based on a spatial overview of food access indicators by income and supermarket access per the Food Access Research Atlas. The outcome was periconceptional diet quality per the Healthy Eating Index (HEI)-2010, analyzed by quartile (Q) from the highest or best (Q4, reference) to the lowest or worst dietary quality (Q1); and secondarily, nonadherence (yes or no) to 12 key aspects of dietary quality. RESULTS: Among 7,956 assessed individuals, 24.9% lived in a food desert. The mean HEI-2010 score was 61.1 of 100 (SD: 12.5). Poorer periconceptional dietary quality was more common among those who lived in a food desert compared with those who did not live in a food desert (Q4: 19.8%, Q3: 23.6%, Q2: 26.5%, and Q1: 30.0% vs. Q4: 26.8%, Q3: 25.8%, Q2: 24.5%, and Q1: 22.9%; overall P < 0.001). Individuals living in a food desert were more likely to report a diet in lower quartiles of the HEI-2010 (i.e., poorer dietary quality) (aOR: 1.34 per quartile; 95% CI: 1.21, 1.49). They were more likely to be nonadherent to recommended standards for 5 adequacy components of the HEI-2010, including fruit, total vegetables, greens and beans, seafood and plant proteins, and fatty acids, and less likely to report excess intake of empty calories. CONCLUSIONS: Nulliparous pregnant individuals living in a food desert were more likely to experience poorer periconceptional diet quality compared with those who did not live in a food desert.

Can allostatic load in pregnancy explain the association between race and subsequent cardiovascular disease risk: A cohort study.

OBJECTIVE: To assess the relationship between allostatic load, a measure of cumulative chronic stress in early pregnancy and cardiovascular disease risk, 2-7 years postpartum, and pathways contributing to racial disparities in cardiovascular disease risk. DESIGN: Secondary analysis of a prospective cohort study. SETTING MULTICENTER POPULATION: Pregnant women. METHODS: Our primary exposure was high allostatic load in the first trimester, defined as at least 4 of 12 biomarkers (systolic blood pressure, diastolic blood pressure, body mass index, cholesterol, low-density lipoprotein, high-density lipoprotein, high-sensitivity C-reactive protein, triglycerides, insulin, glucose, creatinine and albumin) in the unfavourable quartile. Logistic regression was used to test the association between high allostatic load and main outcome adjusted for confounders: time from index pregnancy and follow up, age, education, smoking, gravidity, bleeding in the first trimester, index adverse pregnancy outcomes, and health insurance. Each main outcome component and allostatic load were analysed secondarily. Mediation and moderation analyses assessed the role of high allostatic load in racial disparities of cardiovascular disease risk. MAIN OUTCOME MEASURE: Incident cardiovascular disease risk: hypertension, or metabolic disorders. RESULTS: Cardiovascular disease risk was identified in 1462/4022 individuals (hypertension: 36.6%, metabolic disorder: 15.4%). After adjustment, allostatic load was associated with cardiovascular disease risk (adjusted odds ratio [aOR] 2.0, 95% CI 1.8-2.3), hypertension (aOR 2.1, 95% CI 1.8-2.4) and metabolic disorder (aOR 1.7, 95% CI 1.5-2.1). Allostatic load was a partial mediator between race and cardiovascular disease risk. Race did not significantly moderate this relationship. CONCLUSIONS: High allostatic load during pregnancy is associated with cardiovascular disease risk. The relationships between stress, subsequent cardiovascular risk and race warrant further study.

Improving Postpartum and Long-Term Health After an Adverse Pregnancy Outcome: Examining Interventions From a Health Equity Perspective.

Gestational diabetes mellitus and hypertensive disorders in pregnancy are adverse pregnancy outcomes (APOs) that affect 15% of pregnancies in the United States. These APOs have long-term health implications, with greater risks of future cardiovascular and chronic disease later in life. In this manuscript, we review the importance of timely postpartum follow-up and transition to primary care after APOs for future disease prevention. We also discuss interventions to improve postpartum follow-up and long-term health after an APO. In recognizing racial and ethnic disparities in APOs and chronic disease, we review important considerations of these interventions through a health equity lens.

SweetMama: Usability Assessment of a Novel Mobile Application Among Low-Income Pregnant People to Assist With Diabetes Management and Support.

Background: Mobile health tools may be effective strategies to improve engagement, education, and diabetes-related health during pregnancy. We developed SweetMama, a patient-centered, interactive mobile application (app) designed to support and educate low-income pregnant people with diabetes. Our objective was to evaluate the SweetMama user experience and acceptability. Methods: SweetMama is a mobile app with static and dynamic features. Static features include a customized homepage and resource library. Dynamic features include delivery of a theory-driven diabetes-specific curriculum via 1) motivational, tip, and goal-setting messages aligning with treatment and gestational age; 2) appointment reminders; and 3) ability to mark content as "favorite." In this usability assessment, low-income pregnant people with gestational or type 2 diabetes used SweetMama for 2 weeks. Participants provided qualitative feedback (via interviews) and quantitative feedback (via validated usability/satisfaction measures) on their experience. User analytic data detailed the duration and type of interactions users had with SweetMama. Results: Of 24 individuals enrolled, 23 used SweetMama and 22 completed exit interviews. Participants were mostly non-Hispanic Black (46%) or Hispanic (38%) individuals. Over the 14-day period, users accessed SweetMama frequently (median number of log-ins 8 [interquartile range 6-10]), for a median of 20.5 total minutes, and engaged all features. A majority (66.7%) rated SweetMama as having moderate or high usability. Participants emphasized design and technical strengths and beneficial effects on diabetes self-management and also identified limitations of the user experience. Conclusion: Pregnant people with diabetes found SweetMama to be user-friendly, informative, and engaging. Future work must study its feasibility for use throughout pregnancy and its efficacy to improve perinatal outcomes.

Understanding Food Security as a Social Determinant of Diabetes-Related Health during Pregnancy.

Gestational and pregestational diabetes during pregnancy are substantial and growing public health issues. Low-income individuals and individuals who identify as racial and ethnic minorities are disproportionately affected. Food security, which is defined as the degree to which individuals have capacity to access and obtain food, is at the center of nutritional resources and decisions for individuals with diabetes. While increasingly recognized as an important mediator of health disparities in the United States, food insecurity is understudied during pregnancy and specifically among pregnant individuals with diabetes, for whom the impact of food-related resources may be even greater. Previous research has suggested that food insecurity is associated with type 2 diabetes mellitus diagnoses and disease exacerbation in the general adult population. An emerging body of research has suggested that food insecurity during pregnancy is associated with gestational diabetes mellitus diagnoses and adverse diabetes-related outcomes. Additionally, food insecurity during pregnancy may be associated with adverse maternal and neonatal outcomes. Future research and clinical work should aim to further examine these relationships and subsequently develop evidence-based interventions to improve diabetes-related outcomes among pregnant individuals with food insecurity. The purpose of this article is to offer a working definition of food security, briefly review issues of food insecurity and diabetes, summarize research on food insecurity and diabetes-related pregnancy health, and discuss clinical recommendations and areas for future investigation. KEY POINTS: · Research on food insecurity and diabetes-related health is limited.. · The impact of food security on diabetes management and obstetric outcomes is likely significant.. · Future work to evaluate perinatal food security screening is warranted..

Disparities in Trial of Labor among Women with Twin Gestations in the United States.

OBJECTIVE: The aim of the study is to examine clinical and demographic factors associated with trial of labor (TOL) among women with twin gestations eligible for a vaginal delivery. STUDY DESIGN: This was a population-based cohort study of women giving birth to twin gestations in the United States (2012-2014). Inclusion criteria for the analysis included live births greater than 23 weeks' gestation and a cephalic presenting twin. Women with prior cesarean delivery were excluded. Women were categorized by whether they underwent a TOL. Clinical and demographic characteristics associated with TOL status were evaluated using multivariable logistic regression analyses. Secondary analyses with stratification by parity and by second twin presentation were performed. RESULTS: Of 90,000 women eligible for inclusion, a minority (39.3%) underwent TOL. Women who had a greater gestational age at delivery were more likely to have a TOL. In contrast, several demographic factors were associated with decreased likelihood of TOL, including maternal age >35 years and identifying as Hispanic or Asian compared with non-Hispanic White. No differences in odds of TOL were observed for women who were identified as non-Hispanic Black versus non-Hispanic White, nor were other demographic factors such as marital status, insurance status, or educational attainment associated with undergoing TOL. Clinical factors associated with decreased odds of TOL included nulliparity, obesity, and hypertensive disorders of pregnancy. Results did not substantively change when stratified by parity or second twin presentation, nor did findings differ in the subgroup who delivered at 32 weeks of gestation or greater. CONCLUSION: In this large population of women with twins who were eligible for a TOL, a minority of individuals attempted a vaginal delivery. Demographic and clinical factors such as older maternal age, Asian or Hispanic racial or ethnic identification, nulliparity, and obesity are associated with decreased odds of undergoing TOL. KEY POINTS: · Understanding disparities in trial of labor among patients with twins is key to promoting equity.. · Older maternal age and identifying as Hispanic or Asian were associated with lower odds of TOL.. · Nulliparity, obesity, and hypertension were associated with decreased odds of TOL..