Measuring post-traumatic stress after childbirth: a review and critical appraisal of instruments.

BACKGROUND: Addressing psychological trauma after childbirth requires accurate measurement of its prevalence, risk factors, and outcomes using validated instruments that distinguish perceptions of traumatic birth, subclinical post-traumatic stress (PTS) symptoms, and symptoms meeting a diagnostic threshold. OBJECTIVE: The purpose of this study was to review literature on psychological trauma following childbirth and appraise instruments that measure postpartum PTS. METHODS: In January 2020, the authors searched for and evaluated peer-reviewed studies that quantitatively measured PTS following hospital-based live births in the United States, United Kingdom, Canada, Australia, Norway, Sweden, and Switzerland; 37 articles were selected and evaluated. RESULTS: Levels of post-traumatic stress disorder were most commonly measured, followed by PTS symptoms. Diagnostic instruments suggested lower PTS prevalence estimates than those screening for or assessing PTS symptoms. Community samples yielded lower prevalence estimates than samples recruited from the internet or settings specifically addressing mental health. Measurement sooner after birth yielded higher estimates. CONCLUSION: Study design, sample characteristics, instruments, and timing of measurements likely impact postpartum PTS prevalence estimates. Variation in these characteristics make it difficult to draw conclusions on the prevalence of postpartum PTS. Researchers should consider the appraisal of measurement tools presented here and use rigorous study methodology when studying traumatic birth experiences and evaluating interventions.

Women's perceptions of provider communication on birth options after cesarean: A qualitative study.

In the United States, Hispanic and non-Hispanic Black women are more likely to have a repeat cesarean birth (RCB) than non-Hispanic White women. The underrepresentation of Hispanic women and women with previous cesarean births in prior studies has resulted in a limited understanding of the reasons for this disparity. This study used in-depth interviews to investigate the perceptions of 27 Hispanic and non-Hispanic Black and White women about the communication that took place with their providers about their birth options after a previous cesarean. The roles of cultural norms and trust in providers in communication about RCBs were also explored. Results suggest that patient-provider communication and trust of providers for Hispanic and non-Hispanic Black and White women may influence their perception of choice, uptake of information, and ability to make an informed choice regarding birth options. Findings have implications for providers and healthcare management systems who need to account for and attempt to address these differences as they directly affect women's birth outcomes.

Strengthening the Evidence for Maternal and Child Health: Implementing the New Performance Measurement Framework for the Title V Maternal and Child Health Block Grant.

PURPOSE: The Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA MCHB) developed a three-tiered performance measure framework for the Title V Maternal and Child Health Block Grant program (MCH Title V). The third tier, evidence-based/informed strategy measures (ESMs) are developed by states to address National Performance Measures (NPM) goals. To support states' efforts, MCHB funded the "Strengthen the Evidence for Maternal and Child Health" (STE) to: (1) define the concept of evidence for the field with an emphasis on strength; (2) identify available evidence for each NPM, (3) translate ESM research for use at the state level; and (4) provide technical assistance (TA) to states to facilitate implementation. DESCRIPTION: The program conducted evidence reviews defining an "evidence continuum" emphasizing a continuum of strength, provided individual and group TA to MCH Title V grantees, launched a TA referral system, and reviewed state ESMs to assess use of evidence-based/informed strategies. ASSESSMENT: Ten evidence reviews identified multiple strategies as having "emerging" or "moderate" evidence. TA reached all MCH Title V programs, encompassing 59 US states and jurisdictions, and the TA referral system effectively partnered with MCHB resources. All MCH Title V states and territories submitted ESMs for the Block Grant program's first year reporting requirement. CONCLUSION: STE is the first program to review available evidence on effective strategies addressing NPMs for MCH Title V. Identifying actionable next steps responsive to state needs will be a key factor for continued implementation of ESMs and achieving improvements in MCH.

Risks of preterm birth among non-Hispanic black and non-Hispanic white women: Effect modification by maternal age.

BACKGROUND: Preterm birth (PTB) disproportionately affects African American compared with Caucasian women, although reasons for this disparity remain unclear. Some suggest that a differential effect of maternal age by race/ethnicity, especially at older maternal ages, may explain disparities. OBJECTIVE: To determine whether the relationship between maternal age and preterm birth varies by race/ethnicity among primiparae non-Hispanic blacks (NHB) and non-Hispanic whites (NHW). METHODS: A cross-sectional study of 367 081 singleton liveborn first births to NHB and NHW women in California from 2008 to 2012 was conducted. Rate ratios (RR) were estimated for PTB and its subtypes-spontaneous and clinician-initiated-after adjusting for confounders through Poisson regression. Universal age/race reference groups (NHW, 25-29 years) and race-specific reference groups (NHW or NHB, 25-29 years) were used for comparisons. RESULTS: Among all women, RR of PTB was highest at the extremes of age (<15 and ≥40 years). Among NHBs, the risk of PTB was higher than among NHWs at all maternal ages (adjusted RR of PTB 1.38-2.93 vs 0.98-2.38). However, using race-specific reference groups, the risk of PTB for NHB women (RR 0.91-1.88) vs NHW women (RR 0.98-2.39) was nearly identical at all maternal ages, with overlapping confidence intervals. Analyses did not demonstrate substantial divergence of risk with advancing maternal age. PTB, spontaneous PTB, and clinician-initiated PTB demonstrated similar risk patterns at younger but not older maternal ages, where risk of clinician-initiated PTB increased sharply for all women. CONCLUSIONS: Primiparae NHBs demonstrated increased risk of PTB, spontaneous PTB, and clinician-initiated PTB compared with NHWs at all maternal ages. However, RRs using race-specific reference groups converged across maternal ages, indicating a similar independent effect of maternal age on PTB by race/ethnicity. A differential effect of maternal age does not appear to explain disparities in preterm birth by race/ethnicity.

A Population-Based Study of School Readiness Determinants in a Large Urban Public School District.

Objectives We examined biologic and social determinants of school readiness in an urban population and whether childcare altered these associations. Methods A retrospective cohort study was conducted using school readiness data linked to birth certificates of first-time kindergarten students (n = 39,463) in a large, urban public-school district during 2002-2012. Multivariate linear regression models compared mean readiness scores (MRS) for students born low birthweight (LBW) or preterm (PTB) and by childcare type, adjusting for other student and parent risk factors. Results MRSs for moderately LBW (1000-2499 g), extremely LBW (< 1000 g), moderately PTB (28-36 weeks), early-term (37-38 weeks) and post-term (42 + weeks) students were significantly lower than scores for their normal weight or full-term peers, adjusting for childcare type and other student and parent characteristics. Childcare was an important predictor of MRSs. MRSs were highest for district prekindergarten (PK) students and for students of mothers with greater years of education. Conclusions for Practice Social and biologic differences in MRSs for children entering school in a large urban public-school district suggest the need for greater attention to family and child health backgrounds. Increased enrollment in formal childcare may improve school readiness in these settings.

Unintended pregnancy is a risk factor for depressive symptoms among socio-economically disadvantaged women in rural Bangladesh.

BACKGROUND: Little is known about the relation between unwanted pregnancy and intention discordance and maternal mental health in low-income countries. The study aim was to evaluate maternal and paternal pregnancy intentions (and intention discordance) in relation to perinatal depressive symptoms among rural Bangladeshi women. METHODS: Data come from a population-based, community trial of married rural Bangladeshi women aged 13-44. We examined pregnancy intentions among couples and pregnancy-intention discordance, as reported by women at enrollment soon after pregnancy ascertainment, in relation to depressive symptoms in the third trimester of pregnancy (N = 14,629) and six months postpartum (N = 31,422). We calculated crude and adjusted risk ratios for prenatal and postnatal depressive symptoms by pregnancy intentions. RESULTS: In multivariable analyses, women with unwanted pregnancies were at higher risk of prenatal (Adj. RR = 1.60, 95% CI: 1.37-1.87) and postnatal depressive symptoms (Adj. RR = 1.32, 95% CI: 1.21-1.44) than women with wanted pregnancies. Women who perceived their husbands did not want the pregnancy also were at higher risk for prenatal (Adj. RR = 1.42, 95% CI: 1.22-1.65) and postnatal depressive symptoms (Adj. RR = 1.30, 95% CI: 1.19-1.41). Both parents not wanting the pregnancy was associated with prenatal and postnatal depressive symptoms (Adj. RR = 1.34, 95% CI: 1.19-1.52; Adj. RR = 1.13, 95% CI: 1.06-1.21, respectively), compared to when both parents wanted it. Adjusting for socio-demographic and pregnancy intention variables simultaneously, maternal intentions and pregnancy discordance were significantly related to prenatal depressive symptoms, and perception of paternal pregnancy unwantedness and couple pregnancy discordance, with postnatal depressive symptoms. CONCLUSIONS: Maternal, paternal and discordant couple pregnancy intentions, as perceived by rural Bangladeshi women, are important risk factors for perinatal maternal depressive symptoms.

Risk of Depressive Symptoms Associated with Morbidity in Postpartum Women in Rural Bangladesh.

Objectives Depression following pregnancy is common, but its extent and association with maternal morbidity in the first 6 months postpartum have not been well described in low resource settings such as rural Bangladesh. Methods We used data from a population-based, community trial of approximately 39,000 married rural Bangladeshi women aged 13-44 between 2001 and 2007 to examine the relation between women's reported morbidity symptoms from childbirth to 3 months postpartum, and subsequent depressive symptoms assessed at 6 months postpartum. We calculated crude and adjusted risk ratios for depressive symptoms following women's reports of reproductive, urinary, neurologic, nutrition and other illness measures constructed based on symptomatic reporting. Results In models adjusted for sociodemographic factors and co-morbidities, all postpartum illnesses were associated with an increased relative risk [RR, with 95% confidence intervals (CI) excluding 1] of depressive symptoms by 6 months postpartum. These morbidities included uterine prolapse (RR 1.20, 95% CI 1.04-1.39), urinary tract infection (RR 1.24, 95% CI 1.11-1.38), stress related incontinence (SRI) (RR 1.49, 95% 1.33-1.67), simultaneous SRI and continuously dripping urine (RR 1.60-2.96), headache [RR 1.20 (95% CI 1.12-1.28)], convulsions (RR 1.67, 95%CI 1.36-2.06), night blindness (RR 1.33, 95% CI 1.19-1.49), anemia (RR 1.38, 95% CI 1.31-1.46), pneumonia (RR 1.24, 95% CI 1.12-1.37), gastroenteritis (RR 1.24, 95% CI 1.17-1.31) and hepatobiliary disease (RR 2.10, 96% CI 1.69-2.60). Conclusions for Practice Illnesses during the first three postpartum months were risk factors for depressive symptoms, with the strongest associations noted for convulsions and hepatobiliary disease. Symptoms of depression may be of particular concern among women suffering from physical illnesses. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT0019882.

Investigating racial differences in risk factors for primary cesarean delivery.

OBJECTIVE: The objective of the study was to investigate differences in sociodemographic, medical, and obstetric risk factors for primary cesarean delivery between black and white women. STUDY DESIGN: We conducted a retrospective cohort study among 25,251 black and white women delivering a live, singleton infant with vertex presentation at a large, regional hospital between 2004 and 2010. Demographic and clinical data were derived from electronic hospital records. Differences in risk factors for primary cesarean delivery were analyzed using a modified Poisson regression approach stratified by race and parity. RESULTS: Black and white women had a primary cesarean delivery rate of 24.7% and 22.2%, respectively (P < .001). Black women had an increased risk of cesarean delivery after adjusting for sociodemographic and clinical risk factors (adjusted relative risk [RR], 1.23; 95% confidence interval [CI], 1.17-1.29). Among nulliparas, labor induction had a greater effect on cesarean delivery for black women (adjusted RR, 1.32; 95% CI, 1.20-1.44) than for white women (adjusted RR, 1.13; 95% CI, 1.07-1.20). Among multiparas, labor induction reduced the risk of cesarean delivery for white women (adjusted RR, 0.63; 95% CI, 0.55-0.72), whereas no association was observed for black women (adjusted RR, 1.08; 95% CI, 0.92-1.28). Advanced maternal age was a stronger risk factor for black women (adjusted RR, 1.72; 95% CI, 1.43-2.08) than for white women (adjusted RR, 1.30; 95% CI, 1.11-1.52) among multiparas only. Among nulliparas, delivery at 37-38 weeks' gestation reduced the risk of cesarean delivery for black women (adjusted RR, 0.82; 95% CI, 0.73-0.92), whereas no association was observed for white women (adjusted RR, 0.96; 95% CI, 0.90-1.04). CONCLUSION: Labor induction, among nulliparous women, and advanced maternal age, among multiparous women, are stronger risk factors for primary cesarean delivery for black women than for white women.

Early maternal depressive symptoms and child growth trajectories: a longitudinal analysis of a nationally representative US birth cohort.

BACKGROUND: Maternal depressive symptoms are negatively associated with early child growth in developing countries; however, few studies have examined this relation in developed countries or used a longitudinal design with data past the second year of the child's life. We investigated if and when early maternal depressive symptoms affect average growth in young children up to age 6 in a nationally representative sample of US children. METHODS: Using data from 6,550 singleton births from the Early Childhood Longitudinal Study -- Birth Cohort (ECLS-B), we fit growth trajectory models with random effects to examine the relation between maternal depressive symptoms at 9 months based on the twelve-item version of the Center for Epidemiologic Studies Depression Scale (CES-D) and child height and body mass index (BMI) to age 6 years. RESULTS: Mothers with moderate/severe depressive symptoms at 9 months postpartum had children with shorter stature at this same point in time [average 0.26 cm shorter; 95% CI: 5 cm, 48 cm] than mothers without depressive symptoms; children whose mothers reported postpartum depressive symptoms remained significantly shorter throughout the child's first 6 years. CONCLUSIONS: Results suggest that the first year postpartum is a critical window for addressing maternal depressive symptoms in order to optimize child growth. Future studies should investigate the role of caregiving and feeding practices as potential mechanisms linking maternal depressive symptoms and child growth trajectories.

Does Delayed Fertility Explain the Rise in Comorbidities Among the Birthing Population?

Background: The increasing prevalence of preexisting health conditions among pregnant people is often attributed to the concurrent rise in maternal age. However, the link between advanced maternal age (AMA) and increases in chronic conditions among the birthing population has not been systematically documented at the population level. Materials and Methods: This retrospective population-based cohort study was based on linked hospitalization discharge and birth certificate data for live birth deliveries in California from 1991 to 2012. Decomposition techniques evaluated whether changes in the prevalence of selected preexisting health conditions during delivery (autoimmune conditions, chronic hypertension, cardiac disease, diabetes, and renal disease) were explained by population-level increases in maternal age. Analyses further adjusted for maternal education, plurality, insurance status, and availability of paternal information on the birth certificate. Results: Between 1991 and 2012, there were more than 11.5 million live birth deliveries in California. AMA (≥35 years) increased nearly 70% over this period. The prevalence of autoimmune conditions, chronic hypertension, diabetes, and renal disease rose among the birthing population, while cardiac disease declined. The prevalence of all conditions was higher for AMA, but changes in maternal age accounted for only 5.3%, 8.4%, 13.9%, and 0.4%, of the increase in autoimmune conditions, chronic hypertension, diabetes, and renal disease, respectively. Conclusion: While AMA was associated with higher rates of preexisting health conditions, it contributed little to the increase in autoimmune conditions, chronic hypertension, and diabetes and nothing to the rise in renal disease during childbirth.

Postpartum Care Visit Attendance Within 60 Days of Delivery Among Women With and Without Opioid Use During Pregnancy: An Analysis of Commercial Insurance Data.

BACKGROUND: Postpartum care (PPC) is a key component of maternal health, particularly for people who use opioids during pregnancy. Little is known about the prevalence and correlates of PPC visit attendance among those using opioids compared with nonusers in a privately insured population. METHODS: A retrospective cohort study was conducted using nationwide private insurance claims between 2011 and 2017 (N = 1,291,352 women) comparing the following opioid use groups: nonusers, nonchronic prescription users, chronic prescription users, and women with opioid use disorder (OUD). Multivariable logistic and linear regressions evaluated the odds of PPC attendance and the mean time to an initial PPC visit for each user group. Stratified models identified factors associated with PPC attendance by opioid use type. RESULTS: Overall, 45% of the cohort attended a PPC visit and nearly 10% had any opioid use during pregnancy. More women in the three opioid use categories attended PPC than nonusers (50-56% vs. 45%). Opioid use regardless of type was associated with higher odds and earlier PPC visitation than women with no opioid use; nonchronic and chronic users had 17% and 40% greater odds of PPC than nonusers (adjusted odds ratio [aOR]: 1.17; 95% confidence interval [CI]: 1.16-1.19; aOR: 1.40, 95% CI: 1.34-1.46), whereas women with OUD had 7% higher odds (aOR: 1.07; 95% CI: 1.00-1.13). Antenatal care and psychiatric, hypertensive, and pain conditions were most strongly associated with higher odds of attending PPC; older maternal age was negatively associated with PPC. Stratified analysis showed opioid correlates varied similarly across user groups. CONCLUSIONS: PPC use was generally low in this study cohort of privately insured women. Women who used opioids and those with chronic conditions had greater odds of attending PPC. Improved efforts are needed to engage people in PPC, as well as service integration and coordination for people who use opioids during pregnancy.

The impact of wealth on the cognitive development of children who were preterm infants.

PURPOSE: : The purpose of this study was to explore the influence wealth has on cognitive development in 2-year-old children who were born preterm, and to determine whether racial/ethnic differences in wealth explained disparities in cognitive development. SUBJECTS: : A nationally representative sample of 1400 children who were born between 22 and 36 weeks' gestation. DESIGN: : Cohort study. METHODS: : Secondary data analysis of the Early Childhood Longitudinal Survey-Birth Cohort (ECLS-B). The ECLS-B was a prospective national longitudinal study of infants born in the United States during the calendar year 2001 drawn from birth certificates in the United States. MAIN OUTCOMES: : The impact wealth (parental homeownership and investments) had on cognitive development at 2 years and whether wealth eliminated the cognitive disparity seen between white, African American, and Hispanic children. PRINCIPAL RESULTS: : Wealth (homeownership and investments) did not have an independent effect on cognitive development, but it did eliminate the disparity between white children and African American children (P ≥ .05). However, wealth did not eliminate the disparity in cognitive development between white children and Hispanic children. Hispanic children scored 3.91 points lower than white children (P ≤ .001). CONCLUSION: : In contrast to other follow-up studies showing persistent differences in cognitive development between white children and African American children, this study found that wealth indicators attenuated the difference. Wealth may be a more accurate proxy for socioeconomic status in studying factors influencing cognitive outcomes in children born preterm than just using measures such as maternal education and income. In future follow-up studies of multiracial preterm children, indicators that represent wealth should be included for an accurate representation of social economic status.

Advanced Maternal Age and Its Association With Cardiovascular Disease in Later Life.

INTRODUCTION: Fertility among women at advanced maternal age (AMA) is increasing at a rapid rate in the United States. Although much is known about the impact of older maternal age on the risk for proximate adverse pregnancy outcomes, it is unclear whether older maternal age affects subsequent health. The objective of this study was to evaluate whether AMA is associated with cardiovascular disease (CVD) later in life, adjusting for important social and health factors related to maternal age. METHODS: Data were obtained from the Nurses' Health Study II, a longitudinal prospective cohort study. We investigated whether women with an AMA first or subsequent birth were at higher risk for developing CVD (myocardial infarction or stroke) after age 42 than women without births at AMA. Cox proportional hazard models were estimated to evaluate this association, adjusting for demographic, fertility, and health characteristics. RESULTS: A total of 5,471 women (7.7%) in the sample had a first birth at an AMA and 1,282 (1.8%) developed CVD at age 42 or older. Women with first births at AMA had a 26% lower unadjusted hazard of CVD than women not at an AMA during their first birth (hazard ratio, 0.74; 95% confidence interval, 0.57-0.95). This association was attenuated (hazard ratio, 0.80; 95% confidence interval, 0.62-1.05) and no longer significant after adjustment for covariates; the modest association remained significant for women with any AMA birth. CONCLUSIONS: We found no evidence that AMA births were associated with increased risk for developing CVD later in life in this sample.

Adverse Birth Outcomes Among Women of Advanced Maternal Age With and Without Health Conditions in Maryland.

BACKGROUND: Advanced maternal age (AMA) has been linked to both higher risk of adverse birth outcomes and higher levels of comorbidities. It is unclear if adverse outcomes are higher for older healthy women. This study examined the association between AMA and adverse birth outcomes among women with and without preexisting and pregnancy-related health conditions. METHODS: Analysis of data for 14,933 singleton births between 2004 and 2015 from the population-based Maryland Pregnancy Risk Assessment Monitoring System was conducted, comparing women aged 20-34 years and 35 years and older. Multivariable logistic regression estimated the difference in odds of preterm birth (PTB) and low birthweight (LBW) by age group among women with and without health conditions. The analysis of women without health conditions was stratified by parity. RESULTS: Among women without health conditions, AMA was associated with higher odds of PTB regardless of birthweight, LBW regardless of term, LBW term births, and LBW PTBs; stratified analysis showed higher risk of these outcomes among both older primiparas and multiparas. Compared with younger women with hypertensive disorders, older women with similar health conditions had higher odds of PTB regardless of birthweight. Older women with asthma had higher odds of LBW term births. CONCLUSIONS: AMA is associated with adverse birth outcomes among women with and without health conditions compared with younger women with similar health status. Improved screening and management of health conditions during pregnancy is needed for older women, regardless of parity.

Development of measures for assessing mistreatment of women during facility-based childbirth based on labour observations.

INTRODUCTION: Mistreatment of women during childbirth is increasingly recognised as a significant issue globally. Research and programmatic efforts targeting this phenomenon have been limited by a lack of validated measurement tools. This study aimed to develop a set of concise, valid and reliable multidimensional measures for mistreatment using labour observations applicable across multiple settings. METHODS: Data from continuous labour observations of 1974 women in Nigeria (n=407), Ghana (n=912) and Guinea (n=655) were used from the cross-sectional WHO's multicountry study 'How women are treated during facility-based childbirth' (2016-2018). Exploratory factor analysis was conducted to develop a scale measuring interpersonal abuse. Two indexes were developed through a modified Organisation for Economic Co-operation and Development approach for generating composite indexes. Measures were evaluated for performance, validity and internal reliability. RESULTS: Three mistreatment measures were developed: a 7-item Interpersonal Abuse Scale, a 3-item Exams & Procedures Index and a 12-item Unsupportive Birth Environment Index. Factor analysis results showed a consistent unidimensional factor structure for the Interpersonal Abuse Scale in all three countries based on factor loadings and interitem correlations, indicating good structural construct validity. The scale had a reliability coefficient of 0.71 in Nigeria and approached 0.60 in Ghana and Guinea. Low correlations (Spearman correlation range: -0.06-0.19; p≥0.05) between mistreatment measures supported our decision to develop three separate measures. Predictive criterion validation yielded mixed results across countries. Both items within measures and measure scores were internally consistent across countries; each item co-occurred with other items in a measure, and scores consistently distinguished between 'high' and 'low' mistreatment levels. CONCLUSION: The set of concise, comprehensive multidimensional measures of mistreatment can be used in future research and quality improvement initiatives targeting mistreatment to quantify burden, identify risk factors and determine its impact on health and well-being outcomes. Further validation and reliability testing of the measures in other contexts is needed.

Birth Mode after Primary Cesarean among Hispanic and non-Hispanic Women at One U.S. Institution.

BACKGROUND: Despite a lower percentage of primary cesareans than non-Hispanic White and Black women, Hispanic women in the United States had the highest rate of repeat cesarean deliveries (RCD) in 2016; it is unclear if reasons for differences are due to known risk factors. Our study examined the association between ethnicity/race and RCD among women with one previous cesarean and whether demographic (age, marital status, education, language, and delivery year), anthropomorphic (height, prepregnancy body mass index), obstetrical/medical (parity, gestational age, infant birth weight, gestational diabetes, labor induction or augmentation, vaginal birth after cesarean delivery history), or health system (delivery day/time, payer source, provider gender) factors accounted for any observed differences by ethnicity/race. METHODS: Our retrospective cohort study used logistic regression to evaluate the relationship between ethnicity/race and RCD based on data from electronic delivery and prenatal records from 2010 to 2016, including 1800 births to Hispanic and non-Hispanic women with one previous cesarean at a District of Columbia hospital. RESULTS: Statistically significant differences by ethnicity/race were noted after adjustment for obstetric/medical factors, particularly parity and use of induction or augmentation methods. Hispanic (adjusted odds ratio, 2.48; 95% confidence interval, 1.03-6.01) and Black women (adjusted odds ratio, 2.83; 95% confidence interval, 1.67-4.81) had higher odds of RCD than White women. CONCLUSIONS: Adjustment for parity and use of induction or augmentation methods revealed higher odds of RCD for Hispanic and Black women than White women. Demographic and anthropometric factors did not alter these results. Our work is a first step in creating effective public health policy and programs that target potentially preventable RCD by highlighting the need to evaluate risk factors beyond those included in the literature to date.

Drug use and limited prenatal care: an examination of responsible barriers.

OBJECTIVE: The purpose of this study was to determine sociodemographic, psychosocial, and health belief factors that explain the association between maternal drug use and little or no prenatal care. STUDY DESIGN: A cohort of 812 low-income women who delivered at Johns Hopkins Hospital were administered a postpartum survey. Drug use was determined by self-report, medical record, and toxicologic screens. Medical records were abstracted to determine little or no prenatal care, as defined by

A critical appraisal of vasomotor symptom assessment tools used in clinical trials evaluating hormone therapy compared to placebo.

OBJECTIVE: Vasomotor symptoms (VMS) have been consistently reported as the leading predictor of health-related quality of life (HRQOL) among menopausal women, and the strongest indication for treatment. The North American Menopause Society endorses the use of oral estrogen for the treatment of VMS based on a Cochrane meta-analysis. The Cochrane review concludes that oral hormone therapy reduces the frequency and severity of VMS. The objective of this review is to critically appraise the outcome measures used in these clinical trials to evaluate whether there is adequate evidence that oral hormone therapy improves HRQOL. METHODS: Each trial in the 2004 Cochrane review of oral hormone therapy for the management of VMS was evaluated with respect to study design, outcome measures, and method of analysis. RESULTS: Twenty-four randomized, double-blind, placebo-controlled clinical trials were appraised. Six trials were excluded from the Cochrane meta-analysis due to inadequate reporting of outcome measures. Of the remaining trials, 15 trials assessed only symptom frequency and/or severity. One trial used a subscale of the General Health Questionnaire. Two trials used the Greene Climacteric Scale, a validated outcome measure in menopausal women, to directly assess the impact of hormone therapy on HRQOL. Both studies showed an improvement in HRQOL in the hormone-treated group, although the sample size was small (n = 118) and the effect was modest. CONCLUSION: Although oral hormone therapy improves VMS scores, there is a paucity of evidence on whether it improves HRQOL in menopausal women. Future studies using validated, patient-reported outcome measures that directly assess HRQOL are needed.

Severe Maternal Morbidity at Delivery and Risk of Hospital Encounters Within 6 Weeks and 1 Year Postpartum.

BACKGROUND: Little is known about the impact of severe maternal morbidity (SMM) after delivery. We examined the risk of rehospitalization in the first year postpartum among deliveries to women with and without SMM. MATERIALS AND METHODS: We used the Pregnancy to Early Life Longitudinal data system, in which vital birth/fetal death records were linked with hospital delivery discharge data and subsequent nondelivery hospitalization data, including observational stays (OSs) and in-patient stays (hospital discharge [HD]) for Massachusetts residents during 2002-2011. We excluded deliveries to women with preexisting chronic conditions: hypertension, diabetes, asthma, and autoimmune conditions for a final sample of 685,228 deliveries. Multivariable log binomial regression with generalized estimating equations modeled the relative risk (RR) of hospital encounters 6 weeks and 1 year postpartum. RESULTS: The rate of SMM was 99 per 10,000 deliveries. In the first year postpartum, 2.8% of deliveries to women without chronic medical conditions experienced at least one HD encounter and 1.0% at least one OS encounter. The adjusted relative risk (aRR) of any HD encounter for deliveries with SMM was 2.48 (95% confidence interval [CI]: 2.20-2.80) within 6 weeks postpartum and 2.04 (95% CI: 1.87-2.23) within 1 year. For OS encounters, aRRs among deliveries with SMM at delivery were 2.47 (95% CI: 1.94-3.14) in the first 6 weeks and 1.69 (95% CI: 1.43-2.01) in 1 year. CONCLUSIONS: In Massachusetts, SMM increased the risk of rehospitalization in the first year postpartum among deliveries to women without chronic medical conditions.

Parental satisfaction with early pediatric care and immunization of young children: the mediating role of age-appropriate well-child care utilization.

OBJECTIVE: To prospectively evaluate the impact of parental satisfaction on childhood immunization and the mediating role of age-appropriate well-child care. DESIGN: Secondary analyses of cohort data from the National Evaluation of Healthy Steps for Young Children. Data sources included an enrollment questionnaire, parent interview at 2 to 4 months, and medical records. SETTING: Twenty-four pediatric practices across the United States. PARTICIPANTS: A total of 4896 (85%) of the initial 5565 enrolled families who were interviewed at 2 to 4 months and had abstracted medical records. MAIN EXPOSURE: Parental satisfaction with overall pediatric care assessed at 2 to 4 months as excellent, good, or fair/poor. MAIN OUTCOME MEASURES: Age-appropriate first dose of diphtheria-tetanus-pertussis; third dose of diphtheria-tetanus-pertussis; and measles, mumps, and rubella vaccinations; and up-to-date vaccinations at 24 months (4 diphtheria-tetanus-pertussis, 3 polio, and 1 measles, mumps, and rubella). RESULTS: The majority of parents were satisfied with their child's health care; only 4% rated overall care as fair or poor. Children whose parents reported fair/poor satisfaction with care had a reduced odds of receiving age-appropriate first dose of diphtheria-tetanus-pertussis vaccination (odds ratio, 0.43; 95% confidence interval, 0.28-0.67); third dose of diphtheria-tetanus-pertussis vaccination (odds ratio, 0.52; 95% confidence interval, 0.36-0.74); and measles, mumps, and rubella vaccination (odds ratio, 0.58; 95% confidence interval, 0.37-0.92); and of being up to date by 24 months (odds ratio, 0.65; 95% confidence interval, 0.43-0.99) compared with children whose parents reported excellent care, independent of sociodemographic and maternal health care utilization variables. The negative effect of fair/poor satisfaction on immunization was largely explained by reduced utilization of age-appropriate well-child care. CONCLUSION: Quality assurance activities that assess parental satisfaction with care may have added value in identifying children who are less likely to receive timely preventive services.