Lifecourse factors associated with flourishing among US children aged 1-5 years.

AIM: This study aimed to examine the association between lifecourse factors and flourishing among children ages 1-5 years. STUDY DESIGN: Using data from the combined 2016 and 2017 National Survey of Children's Health (N = 18 007 children aged 1-5 years), flourishing was defined as parent-reported child's affection, resilience, curiosity about learning, and affect. Multivariable logistic regression modelled the associations between lifecourse factors and flourishing. These factors were identified according to the lifecourse health development model. RESULTS: Approximately 63% of children aged 1-5 years were flourishing. Children who were female (vs. male, adjusted prevalence ratio [APR]: 1.06, 95% confidence interval [CI]: 1.00-1.11), White, non-Hispanic (vs. Black, non-Hispanic, APR: 1.13, 95% CI: 1.01-1.26), not having a special health care need (vs. special health care need, APR: 1.15, 95% CI: 1.03-1.26), not having an emotional, developmental or behavioural disorder (EBD) (vs. EBD, APR: 1.66, 95% CI:1.23-2.10), spoke English at home (vs. other language, APR: 1.30, 95% CI: 1.06-1.54), parents received emotional social support (vs. no emotional social support, APR: 1.11, 95% CI: 1.01-1.21) and who lived in a supportive neighbourhood (vs. not in supportive neighbourhood, APR: 1.12, 95% CI:1.05-1.18) were more likely to flourish. Children from households within 0%-99% of the federal poverty level (APR: 0.89, 95% CI: 0.79-0.98) were less likely to be flourishing compared with their counterparts from households within 400% of the federal poverty level. CONCLUSIONS: Findings indicate that several lifecourse factors are associated with young children's flourishing, including being female, White, non-Hispanic, not having a special health care need or EBD, English as a primary language, parents receiving emotional social support, having neighbourhood support and a lower household income. Our findings promote the continuation of programmes supporting diverse and low-income children's families and communities such as home visiting and Head Start, which provide avenues for bolstering children's health and development across the lifespan.

A Methodological Approach for Evaluating the Enterprise Community Healthy Start Program in Rural Georgia: An Analysis Using Linked PRAMS, Birth Records and Program Data.

INTRODUCTION: Community Healthy Start program evaluations are often limited by a lack of robust data and rigorous study designs. This study describes an enhanced methodological approach using local program data linked with existing population-level datasets for external comparison to evaluate the Enterprise Community Healthy Start (ECHS) program in two rural Georgia counties and presents results from the evaluation. METHODS: ECHS program data were linked to birth records and the Pregnancy Risk Assessment Monitoring System (PRAMS) for 869 women who delivered a live birth in Burke and McDuffie counties from 2010 to 2011. Multivariate logistic regressions with and without propensity score methods modeled the association between ECHS participation and maternal health indicators and pregnancy outcomes. RESULTS: 107 ECHS participants and 726 non-participants responded to PRAMS and met eligibility criteria. Compared with non-participants, ECHS participants were younger, completed fewer years of education, and were more likely to be non-Hispanic Black, unmarried, insured with Medicaid, participating in WIC, and having an unintended pregnancy. Models with and without propensity score weighting derived similar results: there was a positive association between ECHS participation and receiving adequate or adequate plus prenatal care (p < 0.05); no statistically significant associations were observed between ECHS participation and any other health behaviors, health care access and utilization measures or pregnancy outcomes. DISCUSSION: Rigorous evaluation of a local Healthy Start program using linked PRAMS and birth records with a population-based external comparison group and propensity score methods is an enhanced and feasible approach that can be applied in other local and state jurisdictions.

Initiatives to Reduce Maternal Mortality and Severe Maternal Morbidity in the United States : A Narrative Review.

Maternal mortality and severe maternal morbidity are critical health issues in the United States, with unacceptably high rates and racial, ethnic, and geographic disparities. Various factors contribute to these adverse maternal health outcomes, ranging from patient-level to health system-level factors. Furthermore, a majority of pregnancy-related deaths are preventable. This review briefly describes the epidemiology of maternal mortality and severe maternal morbidity in the United States and discusses selected initiatives to reduce maternal mortality and severe maternal morbidity in the areas of data and surveillance; clinical workforce training and patient education; telehealth; comprehensive models and strategies; and clinical guidelines, protocols, and bundles. Related Health Resources and Services Administration initiatives are also described.

Is Group B Streptococcus Colonization Associated with Maternal Peripartum Infection in an Era of Routine Prophylaxis?

OBJECTIVE: This study aimed to assess whether colonization with group B streptococcus (GBS) is associated with maternal peripartum infection in an era of routine prophylaxis. STUDY DESIGN: This study presented a secondary analysis of women delivering ≥37 weeks who underwent a trial of labor from the U.S. Consortium on Safe Labor (CSL) study. The exposure was maternal GBS colonization and the outcome was a diagnosis of chorioamnionitis, and secondarily, analyses were restricted to deliveries not admitted in labor and measures of postpartum infection (postpartum fever, endometritis, and surgical site infection). Logistic regression with generalized estimating equations was used accounting for within-woman correlations. Models adjusted for maternal age, parity, race, prepregnancy body mass index, pregestational diabetes, insurance status, study site/region, year of delivery, number of vaginal exams from admission to delivery, and time (in hours) from admission to delivery. RESULTS: Among 170,804 assessed women, 33,877 (19.8%) were colonized with GBS and 5,172 (3.0%) were diagnosed with chorioamnionitis. While the frequency of GBS colonization did not vary by chorioamnionitis status (3.0% in both groups), in multivariable analyses, GBS colonization was associated with slightly lower odds of chorioamnionitis (adjusted odds ratio [AOR]: 0.89; 95% confidence interval [CI]: 0.83-0.96). In secondary analyses, this association held regardless of spontaneous labor on admission; and the odds of postpartum infectious outcomes were not higher with GBS colonization. CONCLUSION: In contrast to historical data, GBS colonization was associated with lower odds of chorioamnionitis in an era of routine GBS screening and prophylaxis. KEY POINTS: · Data in an era prior to routine group B streptococcus (GBS) screening and prophylaxis showed that maternal GBS colonization was associated with a higher frequency of maternal peripartum infection.. · In the current study, GBS colonization was associated with lower odds of chorioamnionitis in an era of routine GBS screening and prophylaxis.. · The results highlight potential benefits of GBS screening and intrapartum antibiotic prophylaxis beyond neonatal disease prevention, including mitigating the risk of maternal infectious morbidity..

Prevalence and Treatment of Depression, Anxiety, and Conduct Problems in US Children.

OBJECTIVES: To use the latest data to estimate the prevalence and correlates of currently diagnosed depression, anxiety problems, and behavioral or conduct problems among children, and the receipt of related mental health treatment. STUDY DESIGN: We analyzed data from the 2016 National Survey of Children's Health (NSCH) to report nationally representative prevalence estimates of each condition among children aged 3-17 years and receipt of treatment by a mental health professional. Parents/caregivers reported whether their children had ever been diagnosed with each of the 3 conditions and whether they currently have the condition. Bivariate analyses were used to examine the prevalence of conditions and treatment according to sociodemographic and health-related characteristics. The independent associations of these characteristics with both the current disorder and utilization of treatment were assessed using multivariable logistic regression. RESULTS: Among children aged 3-17 years, 7.1% had current anxiety problems, 7.4% had a current behavioral/conduct problem, and 3.2% had current depression. The prevalence of each disorder was higher with older age and poorer child health or parent/caregiver mental/emotional health; condition-specific variations were observed in the association between other characteristics and the likelihood of disorder. Nearly 80% of those with depression received treatment in the previous year, compared with 59.3% of those with anxiety problems and 53.5% of those with behavioral/conduct problems. Model-adjusted effects indicated that condition severity and presence of a comorbid mental disorder were associated with treatment receipt. CONCLUSIONS: The latest nationally representative data from the NSCH show that depression, anxiety, and behavioral/conduct problems are prevalent among US children and adolescents. Treatment gaps remain, particularly for anxiety and behavioral/conduct problems.

Good practices for the design, analysis, and interpretation of observational studies on birth spacing and perinatal health outcomes.

BACKGROUND: Meta-analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings. METHODS: In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes. RESULTS: We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio-economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age. CONCLUSION: This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias.

Report of the Office of Population Affairs' expert work group meeting on short birth spacing and adverse pregnancy outcomes: Methodological quality of existing studies and future directions for research.

BACKGROUND: The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low- and middle-resource countries upon which most of the evidence is based. METHODS: To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14-15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician-gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health. RESULTS: Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work. CONCLUSIONS: This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting.

Emergency Care Utilization Among Pregnant Medicaid Recipients in North Carolina: An Analysis Using Linked Claims and Birth Records.

Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as ≥ 4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n = 75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having ≥ 1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.

Assessing Child Health and Health Care in the U.S. Virgin Islands Using the National Survey of Children's Health.

OBJECTIVES: To characterize the health and health care experiences of children in the U.S. Virgin Islands (USVI), assess differences by household poverty status, and provide comparisons to the general U.S. child population. METHODS: Data are from the 2011-2012 National Survey of Children's Health, which included 2342 USVI children, aged 0-17 years. Parent-reported measures of health status and health conditions, behavioral characteristics, and health care access and utilization were assessed. Weighted prevalence estimates were calculated and compared by household poverty status using Chi square tests. RESULTS: Overall, 31.3% of USVI children lived in households below 100% of the federal poverty level (FPL). Children in these low-income households were more likely to have public insurance (33.0% vs. 8.4%) and unmet health needs (11.6% vs. 6.3%) as compared to those in households with incomes ≥ 100% FPL (all p < 0.01). They were also less likely to have a medical home (22.5% vs. 42.2%), including a usual source of sick care (p < 0.01). Compared with U.S. children in general, USVI children had lower rates of preventive medical visits, preventive dental visits, and care received in a medical home. CONCLUSIONS: USVI children experience challenges in accessing and utilizing health care services, particularly those in low-income households, and fare worse than U.S. children on many of these measures. These findings will serve as a baseline comparison for an upcoming survey of maternal and child health to be conducted in eight U.S. territories including the USVI.

Sex-Specific Differences in Late Preterm Neonatal Outcomes.

OBJECTIVE: To estimate sex-specific differences in late preterm outcomes and evaluate whether betamethasone modifies this association. STUDY DESIGN: We conducted a secondary analysis of a multicenter trial of women at risk for late preterm birth randomized to receive betamethasone or placebo. We included women who delivered at 34 to 37 weeks and excluded major fetal anomalies. The primary outcome was severe neonatal morbidity (mechanical ventilation, respiratory distress syndrome, bronchopulmonary dysplasia, sepsis, necrotizing enterocolitis, and intraventricular hemorrhage). Maternal characteristics were compared using chi-square test, t-test, or Mann-Whitney U-test. Multivariable logistic regression estimated the association between sex and morbidity, and likelihood ratio testing assessed for effect modification by betamethasone. RESULTS: Of 2,831 women in the primary trial, 2,331 met the inclusion criteria: 1,236 delivered males and 1,095 delivered females. Betamethasone modified the association between sex and severe morbidity (p = 0.047). Among those who received betamethasone, male sex was associated with higher odds of severe morbidity (adjusted odds ratio: 1.95, 95% confidence interval: 1.25-3.05), compared with female sex. Among those who did not receive betamethasone, there was no significant association between sex and morbidity. CONCLUSION: Male sex is a risk factor for adverse late preterm outcomes, including severe neonatal morbidity after betamethasone receipt.

Redesigning the Maternal, Infant and Early Childhood Home Visiting Program Performance Measurement System.

Objectives Statute for the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program requires that states and territories receiving Program funding assess improvements for participating families across six areas that address maternal and child well-being. In 2015, the MIECHV Program performance measurement system was redesigned to allow for national-level analyses and cross-grantee comparisons. The new measures were aligned with other federal performance measures to help ensure context for program analyses. The number of measures was also reduced to lessen reporting burden. This paper describes the redesign process and resulting national performance measures. Methods The redesign process included holding listening sessions with stakeholders and experts; reviewing the findings from other home visiting performance initiatives; consulting with experts; soliciting and responding to public comment on draft measures; seeking clearance from the Office of Management and Budget; and specifying each measure with detailed eligibility criteria, the timing and frequency of assessments, and the window for data collection. Results The redesign resulted in a set of 19 measures that all MIECHV-funded home visiting programs began collecting in 2016. This is nearly half the number of measures that MIECHV awardees had been reporting prior to the redesign. The measures are aligned with other federal measures, including those used in Healthy People 2020 and those used for other maternal and child health programs. Conclusions for Practice Data reported by MIECHV Program awardees will be used to assess their performance, identify areas for targeted technical assistance to support continuous improvement, and ensure meaningful impacts for at-risk families.

Implementing Group Prenatal Care in Southwest Georgia Through Public-Private Partnerships.

Introduction CenteringPregnancy® is well-regarded as an innovative group model of prenatal care. In 2009, Georgia's Southwest Public Health District partnered with local obstetricians and medical centers to expand prenatal care access and improve perinatal outcomes for low-income women by implementing Georgia's first public health administered CenteringPregnancy program. This paper describes the successful implementation of CenteringPregnancy in a public health setting with no prior prenatal services; assesses the program's first 5-year perinatal outcomes; and discusses several key lessons learned. Methods Prenatal and hospital medical records of patients were reviewed for the time period from October 2009 through October 2014. Descriptive analyses were conducted to examine demographic and clinical characteristics of women initiating prenatal care and to assess perinatal outcomes among patients with singleton live births who attended at least three CenteringPregnancy sessions or delivered prior to attending the third session. Results Six hundred and six low-income women initiated prenatal care; 55.4 and 36.4% self-identified as non-Hispanic black and Hispanic, respectively. The median age was 23 years (IQR 20, 28). Nearly 69% initiated prenatal care in the first trimester. Perinatal outcomes were examined among 338 singleton live births. The 2010-2014 preterm birth rate (% of births < 37 weeks gestation at delivery) and low birth weight rate (% of births < 2500 g) were 9.1 and 8.9%, respectively. Nearly 77% of women initiated breastfeeding. Discussion CenteringPregnancy administered via public-private partnership may improve access to prenatal care and perinatal outcomes for medically underserved women in low-resource settings.

Maternal obesity and major intraoperative complications during cesarean delivery.

BACKGROUND: Multiple studies have demonstrated an association between maternal obesity and postoperative complications, but there is a dearth of information about the impact of obesity on intraoperative complications. OBJECTIVE: To estimate the association between maternal obesity at delivery and major intraoperative complications during cesarean delivery (CD). METHODS: This is a secondary analysis of the deidentified Maternal-Fetal Medicine Unit Cesarean Registry of women with singleton pregnancies. Maternal body mass index (BMI) at delivery was categorized as BMI 18.5 to 29.9 kg/m2, BMI 30 to 39.9 kg/m2, BMI 40 to 49.9 kg/m2, and BMI ≥ 50 kg/m2. The primary outcome, any intraoperative complication, was defined as having at least 1 major intraoperative complication, including perioperative blood transfusion, intraoperative injury (bowel, bladder, ureteral injury; broad ligament hematoma), atony requiring surgical intervention, repeat laparotomy, and hysterectomy. Log-binomial models were used to estimate risk ratios of intraoperative complication in 2 models: model 1 adjusting for maternal race, and preterm delivery <37 weeks; and model 2 adjusting for confounders in Model 1 as well as emergency CD, and type of skin incision. RESULTS: A total of 51,218 women underwent CD; 38% had BMI 18.5 to 29.9 kg/m2, 47% BMI 30 to 39.9 kg/m2, 12% BMI 40 to 49.9 kg/m2 and 3% BMI ≥ 50 kg/m2. Having at least 1 intraoperative complication was uncommon (3.4%): 3.8% for BMI 18.5 to 29.9 kg/m2, 3.2% BMI 30 to 39.9 kg/m2, 2.6% BMI 40 to 49.9 kg/m2 and 4.3% BMI ≥ 50 kg/m2 (P < .001). In the fully adjusted model 2, women with BMI 40 to 49.9 kg/m2 had a lower risk of any intraoperative complication (adjusted risk ratio [ARR], 0.76; 95% confidence interval [CI], 0.64 to 0.89) compared with women with BMI 18.5 to 29.9 kg/m2. Women with BMI 30 to 39.9 kg/m2 (ARR, 0.93; 95% CI, 0.84 to 1.03) had a similar risk of any intraoperative complication compared with nonobese women. Among super obese women, there was evidence of effect modification by emergency CD. Compared with nonobese women, neither super obese women undergoing nonemergency CD (ARR, 1.13; 95% CI, 0.84 to 1.52) nor those undergoing emergency CD (ARR, 0.59; 95% CI, 0.32 to 1.10) had an increased risk of intraoperative complication. CONCLUSION: In contrast to the risk for postcesarean complications, the risk of intraoperative complication does not appear to be increased in obese women, even among those with super obesity.

Gestational age at initiation of 17-alpha hydroxyprogesterone caproate and recurrent preterm birth.

BACKGROUND: Preterm birth is the leading cause of neonatal morbidity and mortality in nonanomalous neonates in the United States. Women with a previous early spontaneous preterm birth are at highest risk for recurrence. Weekly intramuscular 17-alpha hydroxyprogesterone caproate reduces the risk of recurrent prematurity. Although current guidelines recommend 17-alpha hydroxyprogesterone caproate initiation between 16 and 20 weeks, in clinical practice, 17-alpha hydroxyprogesterone caproate is started across a spectrum of gestational ages. OBJECTIVE: The objective of the study was to examine the relationship between the gestational age at 17-alpha hydroxyprogesterone caproate initiation and recurrent preterm birth among women with a prior spontaneous preterm birth 16-28 weeks' gestation. STUDY DESIGN: This was a retrospective cohort study of women from a single tertiary care center, 2005-2016. All women with ≥1 singleton preterm births because of a spontaneous onset of contractions, preterm prelabor rupture of membranes, or painless cervical dilation between 16 and 28 weeks followed by a subsequent singleton pregnancy treated with 17-alpha hydroxyprogesterone caproate were included. Women were grouped based on quartiles of gestational age of 17-alpha hydroxyprogesterone caproate initiation (quartile 1, 140/7 to 161/7; quartile 2, 162/7 to 170/7; quartile 3, 171/7 to 186/7; and quartile 4, 190/7 to 275/7). Women with a gestational age of 17-alpha hydroxyprogesterone caproate initiation in quartiles 1 and 2 were considered to have early-start 17-alpha hydroxyprogesterone caproate; those in quartiles 3 and 4 were considered to have late-start 17-alpha hydroxyprogesterone caproate. The primary outcome was recurrent preterm birth <37 weeks' gestation. Secondary outcomes included recurrent preterm birth <34 and <28 weeks' gestation and composite major neonatal morbidity (diagnosis of grade III or IV intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis stage II or III, or death). Gestational age at delivery was compared by quartile of 17-alpha hydroxyprogesterone caproate initiation using Kaplan-Meier survival curves and the log-rank test. Logistic regression models estimated odds ratios for the association between gestational age at 17-alpha hydroxyprogesterone caproate initiation and preterm birth <37 weeks' gestation, adjusting for demographics, prior pregnancy and antenatal characteristics. RESULTS: A total of 132 women met inclusion criteria; 52 (39.6%) experienced recurrent preterm birth <37 weeks in the studied pregnancy. 17-Alpha hydroxyprogesterone caproate was initiated at a mean 176/7 ± 2.5 weeks. Demographic and baseline characteristics were similar between women with early-start 17-alpha hydroxyprogesterone caproate (quartiles 1 and 2) compared with those with late-start 17-alpha hydroxyprogesterone caproate (quartiles 3 and 4). Women with early-start 17-alpha hydroxyprogesterone caproate trended toward lower rates of recurrent preterm birth <37 weeks compared with those with late-start 17-alpha hydroxyprogesterone caproate (41.3% vs 57.7%, P = .065). Delivery gestational age was inversely proportional to gestational age at 17-alpha hydroxyprogesterone caproate initiation (quartile 1, 374/7 weeks vs quartile 2, 365/7 vs quartile 3, 361/7 weeks vs quartile 4, 340/7, P = .007). In Kaplan-Meier survival analyses, these differences in delivery gestational age by 17-alpha hydroxyprogesterone caproate initiation quartile persisted across pregnancy (log-rank P < .001). In regression models, later initiation of 17-alpha hydroxyprogesterone caproate was significantly associated with increased odds of preterm birth <37 weeks. Women with early 17-alpha hydroxyprogesterone caproate initiation also had lower rates of major neonatal morbidity than those with later 17-alpha hydroxyprogesterone caproate initiation (1.5% vs 14.3%, P = .005). CONCLUSION: Rates of recurrent preterm birth among women with a prior spontaneous preterm birth 16-28 weeks are high. Women beginning 17-alpha hydroxyprogesterone caproate early deliver later and have improved neonatal outcomes. Clinicians should make every effort to facilitate 17-alpha hydroxyprogesterone caproate initiation at 16 weeks.

Maternal super obesity and risk for intensive care unit admission in the MFMU Cesarean Registry.

INTRODUCTION: Obesity is a risk factor for intensive care unit (ICU) admission in nonpregnant populations. Less is known about maternal obesity and ICU admission risk. The objective of this study was to estimate the association between maternal obesity and ICU admission among women who delivered via cesarean section or vaginal birth after cesarean section (VBAC). MATERIAL AND METHODS: This is a retrospective cohort analysis of women who delivered via VBAC or cesarean section in the Maternal-Fetal Medicine Unit (MFMU) Cesarean Registry. We defined exposure as body mass index (BMI) at delivery stratified as non-obese (BMI 18.5-29.9 kg/m2 ), class I or II obese (BMI 30-39.9 kg/m2 ), morbidly obese (BMI 40-49.9 kg/m2 ), and super obese (BMI ≥ 50 kg/m2 ). The primary outcome was ICU admission. Modified Poisson regression models estimated relative risk (RR) of ICU admission by obesity strata, after adjusting for confounders. Mediation analysis was used to estimate the proportion of ICU admission risk attributable specifically to obesity. RESULTS: We included 68 455 women; 40% non-obese, 46% class I or II obese, 12% morbidly obese, and 2% super obese. Super obese women were at higher risk for ICU admission compared with non-obese women (0.7 vs. 1.3%, adjusted RR 1.61; 95% CI 1.01-2.65), after adjusting for confounders. Among super obese women, medical comorbidities mediated 58% of ICU admission risk, suggesting that a significant proportion of ICU admission is driven by maternal obesity. CONCLUSIONS: Super obese women who deliver by cesarean section or VBAC are at increased risk of peripartum ICU admission. Obstetricians and critical care specialists should consider possible ICU admission during delivery planning.

Racial Differences in the Association between Parity and Incident Stroke: Results from the REasons for Geographic and Racial Differences in Stroke Study.

BACKGROUND: Circulatory and vascular changes across consecutive pregnancies may increase the risk of later-life cerebrovascular health outcomes. METHODS: The association between parity and incident stroke was assessed among 7674 white and 6280 black women, aged 45 years and older, and enrolled in the REasons for Geographic and Racial Differences in Stroke Study from 2003 to 2007. Parity was assessed at baseline, and incident stroke was ascertained from physician-adjudicated medical records through September 2014. Cox proportional hazards models were used to estimate hazard ratios (HR) for the association between parity and stroke, adjusting for baseline measures. RESULTS: At baseline, 12.7% of white women and 16.2% of black women reported 1 live birth, while 8.2% and 19.0%, respectively, reported 5 or more live births. Mean follow-up time was 7.5 years (standard deviation = 2.8); there were 447 incident strokes. A significant interaction between race and parity was detected (P = .05). Among white women, those with 5 or more live births had a higher stroke risk than those with 1 live birth (HR = 1.57; 95% confidence interval [CI] .93-2.65). However, the association was eliminated after adjustment for baseline characteristics (HR = 1.00, 95% CI .59-1.71). For black women, those with 5 or more live births had the highest stroke risk compared with those with 1 live birth (HR = 1.91, 95% CI 1.25-2.93), but the association was attenuated and no longer statistically significant after adjustment for confounders (HR = 1.40, 95% CI .89-2.18). CONCLUSIONS: In adjusted models, no statistically significantassociations were observed between parity and stroke risk in a diverse cohort of U.S. women. Further studies are needed to elucidate the role of lifestyle and psychosocial factors in the race-specific associations that were observed.

17-Hydroxyprogesterone caproate (17OHP-C) coverage among eligible women delivering at 2 North Carolina hospitals in 2012 and 2013: A retrospective cohort study.

BACKGROUND: Although a weekly injection of 17-hydroxyprogestone caproate is recommended for preventing recurrent preterm birth, clinical experience in North Carolina suggested that many eligible patients were not receiving the intervention. OBJECTIVE: Our study sought to assess how well practices delivering at 2 major hospitals were doing in providing access to 17-hydroxyprogesterone caproate treatment for eligible patients. STUDY DESIGN: This retrospective cohort analysis studied all deliveries occurring between January 1, 2012, and December 31, 2013, at 2 large hospitals in North Carolina. Women were included if they had a singleton pregnancy and history of a prior spontaneous preterm birth. We extracted demographic, payer, and medical information on each pregnancy, including whether women had been offered, accepted, and received 17-hydroxyprogesterone caproate. Our outcome of 17-hydroxyprogesterone caproate coverage was defined as documentation of ≥1 injection of the drug. RESULTS: Over the 2-year study period, 1216 women with history of a prior preterm birth delivered at the 2 study hospitals, of which 627 were eligible for 17-hydroxyprogesterone caproate eligible after medical record review. Only 296 of the 627 eligible women (47%; 95% confidence interval, 43-51%) received ≥1 dose of the drug. In multivariable analysis, hospital of delivery, later presentation for prenatal care, fewer prenatal visits, later gestation of prior preterm birth, and having had a term delivery immediately before the index pregnancy were all associated with failed coverage. Among those women who were "covered," the median number of 17-hydroxyprogesterone caproate injections was 9 (interquartile range, 4-15), with 84 of 296 charts (28%) not having complete information on the number of doses. CONCLUSION: Even under our liberal definition of coverage, less than half of eligible women received 17-hydroxyprogesterone caproate in this sample. Low overall use suggests that there is opportunity for improvement. Quality improvement strategies, including population-based measurement of 17-hydroxyprogesterone caproate coverage, are needed to fully implement this evidence-based intervention to decrease preterm birth.

Characteristics of workplace violence prevention training and violent events among home health and hospice care providers.

BACKGROUND: In the rapidly growing home health and hospice industry, little is known about workplace violence prevention (WVP) training and violent events. METHODS: We examined the characteristics of WVP training and estimated violent event rates among 191 home health and hospice care providers from six agencies in California. Training characteristics were identified from the Occupational Safety and Health Administration guidelines. Rates were estimated as the number of violent events divided by the total number of home visit hours. RESULTS: Between 2008 and 2009, 66.5% (n = 127) of providers reported receiving WVP training when newly hired or as recurrent training. On average, providers rated the quality of their training as 5.7 (1 = poor to 10 = excellent). Among all providers, there was an overall rate of 17.1 violent events per 1,000 visit-hours. CONCLUSION: Efforts to increase the number of home health care workers who receive WVP training and to improve training quality are needed.

Recognizing Excellence in Maternal and Child Health (MCH) Epidemiology: The 2014 National MCH Epidemiology Awards.

PURPOSE: The impact of programs, policies, and practices developed by professionals in the field of maternal and child health (MCH) epidemiology is highlighted biennially by 16 national MCH agencies and organizations, or the Coalition for Excellence in MCH Epidemiology. DESCRIPTION: In September 2014, multiple leading agencies in the field of MCH partnered to host the national CityMatCH Leadership and MCH Epidemiology Conference in Phoenix, Arizona. The conference offered opportunities for peer exchange; presentation of new scientific methodologies, programs, and policies; dialogue on changes in the MCH field; and discussion of emerging MCH issues relevant to the work of local, state, and national MCH professionals. During the conference, the National MCH Epidemiology Awards were presented to individuals, teams, institutions, and leaders for significantly contributing to the improved health of women, children, and families. ASSESSMENT: During the conference, the Coalition presented seven deserving health researchers and research groups with national awards in the areas of advancing knowledge, effective practice, outstanding leadership, young professional achievement, and lifetime achievement. The article highlights the accomplishments of these national-level awardees. CONCLUSION: Recognition of deserving professionals strengthens the field of MCH epidemiology, and sets the standard for exceptional research, mentoring, and practice.

Importance of Performance Measurement and MCH Epidemiology Leadership to Quality Improvement Initiatives at the National, State and Local Levels.

Purpose In recognition of the importance of performance measurement and MCH epidemiology leadership to quality improvement (QI) efforts, a plenary session dedicated to this topic was presented at the 2014 CityMatCH Leadership and MCH Epidemiology Conference. This paper summarizes the session and provides two applications of performance measurement to QI in MCH. Description Performance measures addressing processes of care are ubiquitous in the current health system landscape and the MCH community is increasingly applying QI processes, such as Plan-Do-Study-Act (PDSA) cycles, to improve the effectiveness and efficiency of systems impacting MCH populations. QI is maximally effective when well-defined performance measures are used to monitor change. Assessment MCH epidemiologists provide leadership to QI initiatives by identifying population-based outcomes that would benefit from QI, defining and implementing performance measures, assessing and improving data quality and timeliness, reporting variability in measures throughout PDSA cycles, evaluating QI initiative impact, and translating findings to stakeholders. MCH epidemiologists can also ensure that QI initiatives are aligned with MCH priorities at the local, state and federal levels. Two examples of this work, one highlighting use of a contraceptive service performance measure and another describing QI for peripartum hemorrhage prevention, demonstrate MCH epidemiologists' contributions throughout. Challenges remain in applying QI to complex community and systems-level interventions, including those aimed at improving access to quality care. Conclusion MCH epidemiologists provide leadership to QI initiatives by ensuring they are data-informed and supportive of a common MCH agenda, thereby optimizing the potential to improve MCH outcomes.