Meeting Women Where They Are: Integration of Care As the Foundation of Treatment for At-Risk Pregnant and Postpartum Women.

Purpose In these times of rapidly changing health care policies, those involved in the health care of women, especially during the reproductive years, have a unique and daunting opportunity. There is great potential to positively impact women's health through focus on prevention, attention to addressing disparities, and new focus on the integration of behavioral health care in primary care settings. Description In this report from the field, we suggest that the integration of mental health care into other health services and addressing underlying social needs by partnering with community-based organizations should be a top priority for all settings seeking to provide excellent health care for women. Assessment We describe our experience in a diverse, urban, safety net system to draw attention to four areas of innovation that others might adapt in their own systems: (1) addressing social support and other social determinants of health; (2) tailoring services to the specific needs of a population; (3) developing integrated and intensive cross-disciplinary services for high-risk pregnant women; and (4) bridging the divide between prenatal and postpartum care. Conclusion Women are more likely to be engaged with healthcare during their pregnancy. This engagement, however limited, may be a unique "window of opportunity" to help them address mental health concerns and implement positive behavior change. Future work should include research and program evaluation of innovative programs designed to serve the entire family and meeting at-risk women where they are.

Labor and Delivery Experiences of Mothers with Suspected Large Babies.

OBJECTIVE: To characterize the prevalence of and factors associated with clinicians' prenatal suspicion of a large baby; and to determine whether communicating fetal size concerns to patients was associated with labor and delivery interventions and outcomes. METHODS: We examined data from women without a prior cesarean who responded to Listening to Mothers III, a nationally representative survey of women who had given birth between July 2011 and June 2012 (n = 1960). We estimated the effect of having a suspected large baby (SLB) on the odds of six labor and delivery outcomes. RESULTS: Nearly one-third (31.2%) of women were told by their maternity care providers that their babies might be getting "quite large"; however, only 9.9% delivered a baby weighing ≥4000 g (19.7% among mothers with SLBs, 5.5% without). Women with SLBs had increased adjusted odds of medically-induced labor (AOR 1.9; 95% CI 1.4-2.6), attempted self-induced labor (AOR 1.9; 95% CI 1.4-2.7), and use of epidural analgesics (AOR 2.0; 95% CI 1.4-2.9). No differences were noted for overall cesarean rates, although women with SLBs were more likely to ask for (AOR 4.6; 95% CI 2.8-7.6) and have planned (AOR 1.8; 95% CI 1.0-4.5) cesarean deliveries. These associations were not affected by adjustment for gestational age and birthweight. CONCLUSIONS FOR PRACTICE: Only one in five US women who were told that their babies might be getting quite large actually delivered infants weighing ≥4000 g. However, the suspicion of a large baby was associated with an increase in perinatal interventions, regardless of actual fetal size.

Elevated mercury levels in pregnant woman linked to skin cream from Mexico.

Mercury exposure during pregnancy can have serious health effects for a developing fetus including impacting the child's neurologic and cognitive development. Through biomonitoring in a low-income Latina population in California, we identified a patient with high levels of mercury and traced the source to face creams purchased in a pharmacy in Mexico.

Toxic environmental chemicals: the role of reproductive health professionals in preventing harmful exposures.

Every pregnant woman in the United States is exposed to many and varied environmental chemicals. Rapidly accumulating scientific evidence documents that widespread exposure to environmental chemicals at levels that are encountered in daily life can impact reproductive and developmental health adversely. Preconception and prenatal exposure to environmental chemicals are of particular importance because they may have a profound and lasting impact on health across the life course. Thus, prevention of developmental exposures to environmental chemicals would benefit greatly from the active participation of reproductive health professionals in clinical and policy arenas.

The association between body mass index and gestational diabetes mellitus varies by race/ethnicity.

We examined body mass index (BMI) as a screening tool for gestational diabetes (GDM) and its sensitivity among different racial/ethnic groups. In a retrospective cohort study of 24,324 pregnant women at University of California, San Francisco, BMI was explored as a screening tool for GDM and was stratified by race/ethnicity. Sensitivity and specificity were examined using chi-square test and receiver-operator characteristic curves. BMI of ≥25.0 kg/m (2) as a screening threshold identified GDM in >76% of African-Americans, 58% of Latinas, and 46% of Caucasians, but only 25% of Asians ( P < 0.001). Controlling for confounders and comparing to a BMI of ≤25, African-Americans had the greatest increased risk of GDM (adjusted odds ratio [AOR] 5.1, 95% confidence interval [CI]: 3.0 to 8.5), followed by Caucasians (AOR 3.6, 95% CI: 2.7 to 4.8), Latinas (AOR 2.7, 95% CI: 1.9 to 3.8), and Asians (AOR 2.3, 95% CI: 1.8 to 3.0). BMI's screening characteristics to predict GDM varied by race/ethnicity. BMI can be used to counsel regarding the risk of developing GDM, but alone it is not a good screening tool.

Reproductive Rights and Women's Mental Health: Essential Information for the Obstetrician-Gynecologist.

Reproductive health care is crucial to women's well-being and that of their families. State and federal laws restricting access to contraception and abortion in the United States are proliferating. Often the given rationales for these laws state or imply that access to contraception and abortion promote promiscuity, and/or that abortion is medically dangerous and causes a variety of adverse obstetric, medical, and psychological sequelae. These rationales lack scientific foundation. This article provides the evidence for the safety of abortion, for both women and girls, and encourages readers to advocate against restrictions.

Effect of a Low-Glycemic Load Diet Intervention on Maternal and Pregnancy Outcomes in Obese Pregnant Women.

The increased prevalence of obese, pregnant women who have a higher risk of glucose intolerance warrants the need for nutritional interventions to improve maternal glucose homeostasis. In this study, the effect of a low-glycemic load (GL) (n = 28) was compared to a high-GL (n = 34) dietary intervention during the second half of pregnancy in obese women (body mass index (BMI) > 30 or a body fat >35%). Anthropometric and metabolic parameters were assessed at baseline (20 week) and at 28 and 34 weeks gestation. For the primary outcome 3h-glucose-iAUC (3h-incremental area under the curve), mean between-group differences were non-significant at every study timepoint (p = 0.6, 0.3, and 0.8 at 20, 28, and 34 weeks, respectively) and also assessing the mean change over the study period (p = 0.6). Furthermore, there was no statistically significant difference between the two intervention groups for any of the other examined outcomes (p ≥ 0.07). In the pooled cohort, there was no significant effect of dietary GL on any metabolic or anthropometric outcome (p ≥ 0.2). A post hoc analysis comparing the study women to a cohort of overweight or obese pregnant women who received only routine care showed that the non-study women were more likely to gain excess weight (p = 0.046) and to deliver large-for-gestational-age (LGA) (p = 0.01) or macrosomic (p = 0.006) infants. Thus, a low-GL diet consumed during the last half of pregnancy did not improve pregnancy outcomes in obese women, but in comparison to non-study women, dietary counseling reduced the risk of adverse outcomes.

Maternal and paternal race/ethnicity are both associated with gestational diabetes.

OBJECTIVE: The objective of the study was to examine the rates of gestational diabetes mellitus (GDM) associated with both maternal and paternal race/ethnicity. STUDY DESIGN: This was a retrospective cohort study of all women delivered within a managed care network. Rates of GDM were calculated for maternal, paternal, and combined race/ethnicity. RESULTS: Among the 139,848 women with identified race/ethnicity, Asians had the highest rate (P < .001) of GDM (6.8%) as compared with whites (3.4%), African Americans (3.2%), and Hispanics (4.9%). When examining race/ethnicity controlling for potential confounders, we found that the rates of GDM were higher among Asian (adjusted odds ratio [aOR], 1.5; 95% confidence interval [CI], 1.4-1.6) and Hispanic (aOR, 1.2; 95% CI, 1.1-1.4) women as well as Asian (aOR, 1.4; 95% CI, 1.3-1.5) and Hispanic (aOR, 1.3; 95% CI, 1.2-1.4) men as compared with their white counterparts. CONCLUSION: We found that rates of GDM are affected by both maternal and paternal race/ethnicity. In both Asians and Hispanics, maternal and paternal race are equally associated with an increase in GDM. These differences may inform further investigation of the pathophysiology of GDM.

When should women with placenta previa be delivered? A decision analysis.

OBJECTIVE: To determine the optimal gestational age of delivery for women with placenta previa by accounting for both neonatal and maternal outcomes. STUDY DESIGN: A decision-analytic model was designed comparing total maternal and neonatal quality-adjusted life years for delivery of women with previa at gestational ages from 34 to 38 weeks. At each week, we allowed for four different delivery strategies: (1) immediate delivery, without amniocentesis or steroids; (2) delivery 48 hours after steroid administration (without amniocentesis); (3) amniocentesis with delivery if fetal lung maturity (FLM) positive or retesting in one week if FLM negative; (4) amniocentesis with delivery if FLM testing is positive or administration of steroids if FLM negative. RESULTS: Delivery at 36 weeks, 48 hours after steroids, for women with previa optimizes maternal and neonatal outcomes. In sensitivity analyses, these results were robust to a wide range of variation in input assumptions. If it is assumed that steroids offer no neonatal benefit at this gestational age, outright delivery at 36 weeks' gestation is the best strategy. CONCLUSION: Steroid administration at 35 weeks and 5 days followed by delivery at 36 weeks for women with placenta previa optimizes maternal and neonatal outcomes.

Cardiovascular Disease-Related Pregnancy Complications Are Associated with Increased Maternal Levels and Trajectories of Cardiovascular Disease Biomarkers During and After Pregnancy.

Background: Having a pregnancy complicated by hypertensive disorders of pregnancy (HDP) and/or having a small or preterm baby put a woman at risk for later cardiovascular disease (CVD). It is uncertain if higher maternal CVD risk factors (reflected by increased peripartum CVD biomarker levels) account for this risk, or if experiencing a complicated pregnancy itself increases a woman's CVD risk (reflected by an increase in biomarker trajectories from early pregnancy to postpartum). Methods: We conducted a secondary analysis of an 8-week mindful eating and stress reduction intervention in 110 pregnant women. We used mixed linear regression analysis to compare CVD biomarker levels and trajectories, between women with and without a CVD-related pregnancy complication (including HDP [gestational hypertension or preeclampsia] or having a small for gestational age [<10th percentile] or preterm [<37 weeks] baby), at three times: (1) 12-20 weeks of gestation, (2) 3 months postpartum, and (3) 9 months postpartum. CVD biomarkers studied included serum glucose, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), body mass index (BMI), blood pressure (BP), interleukin-6 (IL-6), tumor necrosis factor, and lipids. We adjusted for age, maternal smoking, prepregnancy BMI, BP, age × time, and BMI × time. Results: Women had a mean age of 28 years (standard deviation [SD] 6), mean prior pregnancies of 0.8 (SD 1.0), and 22 women had one or more CVD-related pregnancy complications. HOMA-IR, diastolic BP, triglyceride, high-density lipoprotein cholesterol, and IL-6 average levels, but not trajectories, differed among women with complicated versus normal pregnancy (all p values were ≤0.04). Peripartum glucose and systolic BP trajectories were statistically greater in complicated versus normal pregnancies (p values were 0.008 and 0.01, respectively). Conclusion: We conclude that the experience of a complicated pregnancy in addition to elevated CVD risk factor levels may both increase a woman's risk of future CVD. ClinicalTrials.gov Identifier: NCT01307683.

Who is at risk for prolonged and postterm pregnancy?

OBJECTIVE: The objective of the study was to examine risk factors for postterm (gestational age >or= 42 weeks) or prolonged (gestational age >or= 41 weeks) pregnancy. STUDY DESIGN: We conducted a retrospective cohort study of all term, singleton pregnancies delivered at a mature, managed care organization. The primary outcome measures were the rates of pregnancies greater than 41 or 42 weeks' gestation. Multivariable logistic regression models were used to control for potential confounding and interaction. RESULTS: Specific risk factors for pregnancy beyond 41 weeks of gestation include obesity (adjusted odds ratio [aOR], 1.26; 95% confidence interval [CI], 1.16-1.37), nulliparity (aOR, 1.46; 95% CI 1.42-1.51), and maternal age 30-39 years (aOR, 1.06; 95% CI, 1.02-1.10) and 40 years or older (aOR, 1.07; 95% CI, 1.02-1.12). Additionally, African American, Latina, and Asian race/ethnicity were all associated with a lower risk of reaching 41 or 42 weeks of gestation. CONCLUSION: Our findings suggest that there may be biological differences that underlie the risk for women to progress to 41 or 42 weeks of gestation. In particular, obesity is a modifiable risk factor and could potentially be prevented with prepregnancy or interpregnancy interventions.

Prepregnancy body mass index and the length of gestation at term.

OBJECTIVE: The purpose of this study was to examine the relationship between prepregnancy body mass index (BMI) and length of gestation at term. STUDY DESIGN: This was a retrospective study of 9336 births at the University of California, San Francisco, at > or = 37 weeks' gestation. We performed univariate and multivariable analyses of the associations between prepregnancy BMI and length of gestation (> or = 40, > or = 41, and > or = 42 weeks' gestation). RESULTS: Overweight women were more likely to deliver at > or = 40, > or = 41, and > or = 42 weeks' gestation than were women who were underweight or normal weight. In multivariable analyses, higher prepregnancy BMI was associated with higher risk of progressing past 40 weeks. Obese women had 69% higher adjusted odds of reaching 42 weeks' gestation, compared with women of normal prepregnancy BMI (adjusted odds ratio, 1.69; 95% confidence interval, 1.23-2.31). CONCLUSION: Higher BMI is associated with prolonged gestation at term. Achieving optimal BMI before conception may reduce the risk of postterm pregnancy and its associated complications.

Maternal and obstetric complications of pregnancy are associated with increasing gestational age at term.

OBJECTIVE: We sought to estimate when rates of maternal pregnancy complications increase beyond 37 weeks of gestation. STUDY DESIGN: We designed a retrospective cohort study of all low-risk women delivered beyond 37 weeks' gestational age from 1995 to 1999 within a mature managed care organization. Rates of mode of delivery and maternal complications of labor and delivery were examined by gestational age with both bivariate and multivariable analyses. RESULTS: We found that, among the 119,254 women who delivered at 37 completed weeks and beyond, the rates of operative vaginal delivery (OR 1.15, 95% CI 1.09, 1.22), 3rd- or 4th-degree perineal laceration (OR 1.15, 95% CI 1.06, 1.24), and chorioamnionitis (OR 1.32, 95% CI 1.21, 1.44) all increased at 40 weeks as compared to 39 weeks of gestation (P < .001), and rates of postpartum hemorrhage (OR 1.21, 95% CI (1.10, 1.32), endomyometritis (OR 1.46, 95% CI 1.14, 1.87), and primary cesarean delivery (1.28, 95% CI 1.20, 1.36) increased at 41 weeks of gestation (P < .001). The cesarean indications of nonreassuring fetal heart rate (OR 1.81, 95% CI 1.49, 2.19) and cephalo-pelvic disproportion (OR 1.64, 95% CI 1.40, 1.94) increased at 40 weeks of gestation (P < .001). CONCLUSION: We found that the risk of maternal peripartum complications increase as pregnancy progresses beyond 40 weeks of gestation. Management of pregnancies that progress past their EDC should include counseling regarding the risks of increasing gestational age.

Gestational weight gain and adverse neonatal outcome among term infants.

OBJECTIVE: To examine the relationship between gestational weight gain and adverse neonatal outcomes among infants born at term (37 weeks or more). METHODS: This was a retrospective cohort study of 20,465 nondiabetic, term, singleton births. We performed univariable and multivariable analyses of the associations between gestational weight gain and neonatal outcomes. We categorized gestational weight gain by the Institute of Medicine guidelines as well as extremes of gestational weight gain (less than 7 kg and more than 18 kg). RESULTS: Gestational weight gain above the Institute of Medicine guidelines was more common than gestational weight gain below (43.3% compared with 20.1%). In multivariable analyses, gestational weight gain above guidelines was associated with a low 5-minute Apgar score (adjusted odds ratio [AOR] 1.33, 95% confidence interval [CI] 1.01-1.76), seizure (AOR 6.50, 95% CI 1.43-29.65), hypoglycemia (AOR 1.52, 95% CI 1.06-2.16), polycythemia (AOR 1.44, 95% CI 1.06-1.94), meconium aspiration syndrome (AOR 1.79, 95% CI 1.12-2.86), and large for gestational age (AOR 1.98, 95% CI 1.74-2.25) compared with women within weight gain guidelines. Gestational weight gain below guidelines was associated with decreased odds of neonatal intensive care unit admission (AOR 0.66, 95% CI 0.46-0.96) and increased odds of small for gestational age (SGA; AOR 1.66, 95% CI 1.44-1.92). Gestational weight gain less than 7 kg was associated with increased risk of seizure, hospital stay more than 5 days, and SGA. Gestational weight gain more than 18 kg was associated with assisted ventilation, seizure, hypoglycemia, polycythemia, meconium aspiration syndrome, and large for gestational age. CONCLUSION: Gestational weight gain above guidelines was common and associated with multiple adverse neonatal outcomes, whereas gestational weight gain below guidelines was only associated with SGA status. Public health efforts among similar populations should emphasize prevention of excessive gestational weight gain.

Weight gain and spontaneous preterm birth: the role of race or ethnicity and previous preterm birth.

OBJECTIVE: To study how the relationship between gestational weight gain and spontaneous preterm birth interacts with maternal race or ethnicity and previous preterm birth status. METHODS: This was a retrospective cohort study of singleton births to women of normal or low prepregnancy body mass index. Gestational weight gain was measured as total weight gain divided by weeks of gestation at delivery, and weight gain was categorized as low (less than 0.27 kg/wk,), normal (0.27-0.52 kg/wk), or high (more than 0.52 kg/wk). Univariable and multivariable analyses were performed on the relationship between weight gain categories and spontaneous preterm birth, stratified by maternal race or ethnicity and history of previous preterm birth. RESULTS: Overall, low weight gain was associated with spontaneous preterm birth (adjusted odds ratio [AOR] 2.5, 95% confidence interval [CI] 2.0-3.1). Although low gain was consistently associated with increased spontaneous preterm birth, some differences were found in subgroup analysis. Among African Americans with a previous preterm birth, both low and high weight gain were associated with increased odds of spontaneous preterm birth (AOR for low weight gain 4.3, 95% CI 1.2-15.5; AOR for high weight gain 6.1, 95% CI 1.8-20.2). For all other groups, high weight gain was not associated with spontaneous preterm birth. Among Asians with a previous preterm birth, low weight gain was not statistically significantly associated with spontaneous preterm birth (AOR 1.9, 95% CI 0.5-7.7). Among Asians there was also a non-statistically significant inverse relationship between high weight gain and spontaneous preterm birth (AOR 0.5, 95% CI 0.3-1.1). CONCLUSION: These results confirm an association between low maternal weight gain and spontaneous preterm birth. The effect modification of maternal race or ethnicity and history of previous preterm birth on this association deserves further study. LEVEL OF EVIDENCE: II-2.

Are there ethnic differences in the length of labor?

OBJECTIVE: The purpose of this study was to examine the lengths of the first and second stages of labor among different racial/ethnic groups to determine whether different norms should be established. STUDY DESIGN: This was a retrospective cohort study of all laboring, term, singleton, vertex deliveries in a single academic institution. Median lengths of first and second stages of labor were compared among 4 racial/ethnic groups: black, Asian, white, and Latina. Kruskal-Wallis, Wilcoxon rank sum tests, and multivariate linear and logistic regression models were performed. RESULTS: In 27,521 births, the lengths of first stage of labor did not differ significantly among groups in the multivariate analysis. In the second stage of labor, black women had shorter labors, both overall and stratified by epidural use. In the multivariate analysis, when controlled for demographics, parity, epidural, chorioamnionitis, birthweight, delivery year, and labor management, black women had a shorter second stage than did white women (nulliparous women, 22 minutes; multiparous women, 7.5 minutes; P < .001) and lower rates of prolonged second stage (odds ratio, 0.6; P < .001). Nulliparous Asian women had a significantly longer second stage and higher rates of prolonged second stage, and nulliparous Latina women had a shorter second stage, compared with nulliparous white women. CONCLUSION: When data are controlled for confounding factors, black women had a shorter length of second stage of labor than did women in other ethnic groups. These differences appear to be clinically significant. This contributes to the support of a multifactorial redefinition of labor curves, which are used widely in the management of labor.

Prepregnancy Body Mass Index and Infant Mortality in 38 U.S. States, 2012-2013.

OBJECTIVE: To estimate whether prepregnancy body mass index (BMI) is related to infant mortality and whether adherence to weight gain recommendations mitigates the relationship between BMI and infant mortality. METHODS: This was a cohort study using 2012-2013 U.S. national linked birth certificate and infant death files for 38 states and the District of Columbia with the BMI measure, including 6,419,836 singleton births and 36,691 infant deaths (infant mortality rate 5.72/1,000). Prenatal weight gain in three categories was based on adherence to Institute of Medicine recommendations. The outcome measure was infant deaths in the first year of life subdivided into two time periods: neonatal (less than 28 days) and postneonatal (28 days to 1 year). RESULTS: With normal prepregnancy weight as a reference, after adjustment, the odds ratio (OR) for an infant death rose from 1.32 (95% confidence interval [CI] 1.27-1.37) for mothers in the obese I category to 1.73 (95% CI 1.64-1.83) for obese III. Higher BMI was related to higher rates of both neonatal and postneonatal mortality. The adjusted OR for the risk of an infant death among singleton, term, vertex births for those gaining less than the recommended weight was 1.07 (95% CI 1.01-1.12) and 1.04 (95% CI 0.99-1.09) for those gaining more than recommended. CONCLUSION: Even after controlling for multiple risks, prepregnancy BMI was strongly related to infant mortality. Efforts to lower the infant mortality rate may benefit from a focus on reducing obesity among women of reproductive age.

Applying the COM-B model to creation of an IT-enabled health coaching and resource linkage program for low-income Latina moms with recent gestational diabetes: the STAR MAMA program.

BACKGROUND: One of the fastest growing risk groups for early onset of diabetes is women with a recent pregnancy complicated by gestational diabetes, and for this group, Latinas are the largest at-risk group in the USA. Although evidence-based interventions, such as the Diabetes Prevention Program (DPP), which focuses on low-cost changes in eating, physical activity and weight management can lower diabetes risk and delay onset, these programs have yet to be tailored to postpartum Latina women. This study aims to tailor a IT-enabled health communication program to promote DPP-concordant behavior change among postpartum Latina women with recent gestational diabetes. The COM-B model (incorporating Capability, Opportunity, and Motivational behavioral barriers and enablers) and the Behavior Change Wheel (BCW) framework, convey a theoretically based approach for intervention development. We combined a health literacy-tailored health IT tool for reaching ethnic minority patients with diabetes with a BCW-based approach to develop a health coaching intervention targeted to postpartum Latina women with recent gestational diabetes. Current evidence, four focus groups (n = 22 participants), and input from a Regional Consortium of health care providers, diabetes experts, and health literacy practitioners informed the intervention development. Thematic analysis of focus group data used the COM-B model to determine content. Relevant cultural, theoretical, and technological components that underpin the design and development of the intervention were selected using the BCW framework. RESULTS: STAR MAMA delivers DPP content in Spanish and English using health communication strategies to: (1) validate the emotions and experiences postpartum women struggle with; (2) encourage integration of prevention strategies into family life through mothers becoming intergenerational custodians of health; and (3) increase social and material supports through referral to social networks, health coaches, and community resources. Feasibility, acceptability, and health-related outcomes (weight loss, physical activity, consumption of healthy foods, breastfeeding, and glucose screening) will be evaluated at 9 months postpartum using a randomized controlled trial design. CONCLUSIONS: STAR MAMA provides a DPP-based intervention that integrates theory-based design steps. Through systematic use of behavioral theory to inform intervention development, STAR MAMA may represent a strategy to develop health IT intervention tools to meet the needs of diverse populations. TRIAL REGISTRATION: ClinicalTrials.gov NCT02240420.

Maternal ethnicity, paternal ethnicity, and parental ethnic discordance: predictors of preeclampsia.

OBJECTIVE: To examine the association of maternal and paternal ethnicity as well as parental ethnic discordance with preeclampsia. METHODS: Retrospective cohort study of all low-risk women delivered from 1995 to 1999 within a mature managed care organization. Rates of preeclampsia were calculated for maternal, paternal, and combined ethnicity using both univariate and multivariate analyses. RESULTS: Among the 127,544 low-risk women, when examining maternal ethnicity in a multivariate model controlling for maternal age, parity, education, and gestational age, we found that the rates of preeclampsia were higher among African American (5.2%; odds ratio [OR] 1.41, 95% confidence interval [CI] 1.25-1.62) women and lower among Latina (4.0%; OR 0.90, 95% CI 0.84-0.97) and Asian women (3.5%; OR 0.79, 95% CI 0.72-0.88), with all results being statistically significant as compared with white women. When paternal ethnicity was controlled for separately, however, the difference in the rate of preeclampsia among Asian women disappeared, the effect of African-American maternal ethnicity increased slightly (OR 1.49, 95% CI 1.33-1.72), and Asian paternity was found to be associated with the lowest rate of preeclampsia (3.2%; OR 0.76, 95% CI 0.68-0.85). Further, parental ethnic discordance was associated with an increase in the rate of preeclampsia (OR 1.13, 95% CI 1.02 - 1.26). CONCLUSION: We found that rates of preeclampsia were lower with Asian paternal ethnicity. We also found that having a differing paternal and maternal ethnicity was associated with increased rates of preeclampsia. For every 1,000 pregnancies, there would be approximately 10 fewer cases of preeclampsia in the setting of Asian paternity and 5 more cases of preeclampsia in the setting of parental ethnic discordance. These differences may be useful in further investigation of the cause of preeclampsia. LEVEL OF EVIDENCE: II-2.

Body mass index, provider advice, and target gestational weight gain.

OBJECTIVE: To study the relationships among prepregnancy body mass index (BMI), women's target gestational weight gain, and provider weight gain advice. METHODS: Project WISH, the acronym for Women and Infants Starting Healthy, is a longitudinal cohort study of pregnant women in the San Francisco Bay area. We excluded subjects with preterm birth, multiple gestation, or maternal diabetes. RESULTS: Among overweight women (prepregnancy BMI 26.1-29.0), 24.1% reported a target weight gain above the Institute of Medicine (IOM) guidelines, compared with 4.3% of normal weight women (P < .001). Among women with a low prepregnancy BMI (< 19.8), 51.2% reported a target weight gain below the guidelines, compared with 10.4% of normal weight women (P < .001). These patterns persisted in a multivariate analysis. Latina ethnicity, lower maternal education, low prepregnancy BMI (< 19.8), lack of provider advice about weight gain, and provider advice to gain below guidelines were all independently associated with a target weight gain below IOM guidelines. Prepregnancy BMI more than 26, multiparity, lower age, and provider advice to gain above guidelines were all associated with a target gain above IOM guidelines. CONCLUSION: Women's beliefs about the proper amount of weight gain and provider recommendations for weight gain vary significantly by maternal prepregnancy BMI. Many women report incorrect advice about gestational weight gain, and women with high or low prepregnancy BMI are more likely to have an incorrect target weight gain. New approaches to provider education are needed to implement the IOM guidelines for gestational weight gain.