Measuring Childbirth Outcomes Using Administrative and Birth Certificate Data.

BACKGROUND: The number of pregnancy-related deaths and severe maternal complications continues to rise in the United States, and the quality of obstetrical care across U.S. hospitals is uneven. Providing hospitals with performance feedback may help reduce the rates of severe complications in mothers and their newborns. The aim of this study was to develop a risk-adjusted composite measure of severe maternal morbidity and severe newborn morbidity based on administrative and birth certificate data. METHODS: This study was conducted using linked administrative data and birth certificate data from California. Hierarchical logistic regression prediction models for severe maternal morbidity and severe newborn morbidity were developed using 2011 data and validated using 2012 data. The composite metric was calculated using the geometric mean of the risk-standardized rates of severe maternal morbidity and severe newborn morbidity. RESULTS: The study was based on 883,121 obstetric deliveries in 2011 and 2012. The rates of severe maternal morbidity and severe newborn morbidity were 1.53% and 3.67%, respectively. Both the severe maternal morbidity model and the severe newborn models exhibited acceptable levels of discrimination and calibration. Hospital risk-adjusted rates of severe maternal morbidity were poorly correlated with hospital rates of severe newborn morbidity (intraclass correlation coefficient, 0.016). Hospital rankings based on the composite measure exhibited moderate levels of agreement with hospital rankings based either on the maternal measure or the newborn measure (κ statistic 0.49 and 0.60, respectively.) However, 10% of hospitals classified as average using the composite measure had below-average maternal outcomes, and 20% of hospitals classified as average using the composite measure had below-average newborn outcomes. CONCLUSIONS: Maternal and newborn outcomes should be jointly reported because hospital rates of maternal morbidity and newborn morbidity are poorly correlated. This can be done using a childbirth composite measure alongside separate measures of maternal and newborn outcomes.

Ambient wintertime particulate air pollution and hypertensive disorders of pregnancy in Monroe County, New York.

BACKGROUND: Previous studies have reported associations between ambient fine particle (PM2.5) concentrations and hypertensive disorders of pregnancy (HDP). However, none have examined whether ultrafine particles (UFP; < 100 nm), accumulation mode particles (AMP; 100-500 nm), markers of traffic pollution (black carbon; BC), or wood burning (Delta-C; (30% of ambient wintertime PM2.5 in Monroe County, NY is from wood burning)) are associated with an increased odds of HDP. We estimated the odds of HDP associated with increased concentrations of PM2.5, UFP, AMP, BC, and Delta-C in each gestational month during winter months. METHODS: Electronic medical records and birth certificate data were linked with land-use regression models in Monroe County, New York in 2009-2013 to predict monthly pollutant concentrations during winter (November-April) based on maternal residential address for 16,637 births. Using multivariable logistic regression, we estimated the odds of HDP associated with each interquartile range (IQR) increase in PM2.5, UFP, AMP, BC, and Delta-C concentrations during each gestational month, adjusting for maternal characteristics, birth hospital, temperature, and relative humidity. RESULTS: Each 0.52 µg/m3 increase in Delta-C concentration during the 7th gestational month was associated with an increased odds of HDP (odds ratio (OR) = 1.21; 95% confidence interval (CI) = 1.01, 1.45), with a similar sized estimate in month 8 (OR = 1.18; 95%CI = 0.98, 1.43). Non-statistically significant increased odds of HDP associated with IQR increases in BC concentrations during months 3 (OR = 1.12; 95%CI = 0.98, 1.28) and 7 (OR = 1.12; 95%CI = 0.96, 1.29) were observed. Increased odds of HDP were not observed for PM2.5, UFP, or AMP. CONCLUSIONS: Our findings suggest that maternal exposure to wood smoke in Monroe County during winter is associated with an increased odds of HDP during late gestation. Additional studies are needed to evaluate the effect of wood smoke on HDP and to explore effects on other pregnancy outcomes.

Prenatal Prediction of Difficult Intubation in Periviable Neonates Using Standard Fetal Biometric Parameters.

OBJECTIVE: To assess whether standard fetal biometric parameters can be used to predict difficult intubations in periviable neonates undergoing resuscitation. STUDY DESIGN: This is a retrospective case-control study of periviable neonates delivered at 23 to 256/7 weeks at an academic hospital during a 5-year period in whom intubation was attempted. Standard fetal biometric measurements were included if they were taken within 7 days of delivery. Primary outcome was intubation in one attempt and was compared with more than one attempt. Data were also collected for fetal gestational age at delivery, neonatal birth weight, estimated fetal weight, head circumference, biparietal diameter, and abdominal circumference. Parametric and nonparametric statistical tests used p < 0.05 as significant. RESULTS: In total, 93 neonates met the inclusion criteria. The mean estimated fetal weight was 675 g (standard deviation [SD] ± 140), and the mean neonatal birth weight was 706 g (SD ± 151). The median interval between fetal ultrasound and delivery was 3 days (range: 0-7 days). A total of 45 neonates (48.3%) required more than one intubation attempt. The median number of intubation attempts was 1 (range: 1-10). There was no association between intubation difficulty and fetal abdominal circumference, biparietal diameter, head circumference, gestational age, estimated fetal weight, and neonatal birth weight (all p > 0.05). CONCLUSION: Standard biometry in periviable neonates does not predict intubation difficulty.

A Statewide Quality Improvement Initiative to Reduce Non-Medically Indicated Scheduled Deliveries.

Objectives To evaluate a large two-phase, statewide quality improvement (QI) collaborative to decrease non-medically indicated (N-MI) deliveries scheduled between 36 and 38 weeks gestation (early). Methods The New York State Department of Health (NYSDOH) convened a Perinatal Quality Collaborative to devise a two-phase QI initiative using a rapid cycle incremental learning model. Phase 1 included Regional Perinatal Centers (RPCs), and Phase 2 added their affiliated perinatal hospitals. Maternal demographics, delivery characteristics, medical indications, and stillbirths were collected on scheduled inductions and cesarean section (CS) deliveries between 36 and 38 weeks. Results There were 35,091 scheduled 36-38 week deliveries reported during the collaborative's 4 years. The percentage of early N-MI scheduled deliveries decreased 41-fold in RPCs (Phase 1 and Phase 2), and 17-fold in affiliates (Phase 2). There was a significant statewide increase in deliveries at ≥39 weeks (P < 0.001), with an estimated 23,732 early deliveries averted. Stillbirths did not increase over time (P = 0.42), although reporting was incomplete. Conclusions A two-phase, statewide QI collaborative in a large state with regionalized perinatal care effectively lowered the number of N-MI deliveries scheduled between 36 and 38 weeks gestation. Associated improvements in neonatal and early childhood developmental outcomes should translate to significant cost savings. This model can effectively be used for similar as well as other obstetrical QI.

Completed Sonographic Anatomic Surveys: The Exception Rather Than the Rule.

OBJECTIVES: To determine how often fetal organ systems are imaged completely and whether this rate varies by hospital. METHODS: All initial sonographic anatomic examinations between 16 and 24 weeks from 3 hospitals (perinatal designation levels I-III) from January 2012 through December 2013 were identified in their obstetric and gynecologic anatomic survey report databases, focusing on 36 anatomic fields. Structures were grouped into regions: brain, face, spine, heart, abdomen, and extremities. Rates of complete visualization of each structure, structure grouping, and the total were calculated and compared by χ2 testing. RESULTS: From 7211 examinations (2578 from level I, 986 from level II, and 3647 from level III), the completion rate was 16.8% (I, 20.6%; II, 20.0%; and III, 13.2%; P < .00001). Brain and extremity imaging was complete 85% of the time or more but spine only 62.4% (sacrum consistently lowest). Completeness rates varied significantly (P< .00001) for the face (28.1%-64.4%, due to low rates of clearing lips at level III, and level I not clearing profiles), heart (37.3%-56.1%, level I < II < III), and abdomen (65.2%-85.7%, due to lower rates of clearing kidneys at level I). Completion of both the heart and spine was 32.0% (I, 23.0%; II, 25.4%; and III, 40.2%; P < .00001). CONCLUSIONS: With a comprehensive reporting system, completion rates for full anatomic sonograms are low. Facial, cardiac, and spinal structures are least complete, and follow-up examinations often remain incomplete. Completion benchmarks would be helpful because "incomplete" studies lead to repeated examinations that increase health care costs.

Third-Trimester Fetal Biometry and Neonatal Outcomes in Term and Preterm Deliveries.

OBJECTIVES: To determine whether specific biometric thresholds for head circumference, abdominal circumference, femur length, and estimated fetal weight can identify neonates at risk for adverse outcomes. METHODS: We conducted a retrospective analysis of women with sonographic biometry after 26 weeks' gestational age (GA) followed by delivery of term and preterm neonates from 2007 through 2011. The head circumference, abdominal circumference, femur length, and estimated fetal weight were obtained. Sonographic data were merged with birth certificate and neonatal data. Biometry and estimated fetal weight were divided into percentile thresholds: 10th and above (reference), below 10th, below 5th, and below 3rd. Neonatal outcomes included neonatal intensive care unit admission, 5-minute Apgar score less than 7, and a composite of any morbidity/mortality (hypoxic-ischemic encephalopathy, periventricular leukomalacia, necrotizing enterocolitis, sepsis, renal failure, or death). Logistic regression yielded odds ratios and 95% confidence intervals for biometry and outcome, then adjusted for GA at delivery. RESULTS: A total of 2237 patients delivered at term, and 455 delivered before term. Neonatal intensive care unit admission was not associated with any biometric threshold in the term and preterm groups. Five-minute Apgar score less than 7 was associated with head circumference below 10th, abdominal circumference below 3rd, and estimated fetal weight below 5th percentiles in the term group and head circumference below 10th, abdominal circumference below 10th, and femur length below 10th percentiles in the preterm group (P < .05). Composite morbidity/mortality was associated with abdominal circumference below 5th, femur length below 10th, and femur length below 3rd percentiles in the term group and head circumference below 5th, abdominal circumference below 10th, and femur length below 5th percentiles in the preterm group (P< .05). Adjustment for GA did not affect outcomes for term deliveries but did affect nearly all outcomes for preterm deliveries. CONCLUSIONS: Irrespective of GA, no one biometric threshold can accurately predict adverse neonatal outcomes.

Association Between Obesity During Pregnancy and the Adequacy of Prenatal Care.

OBJECTIVE: In the United States, more than a third of women are obese [body mass index (BMI) ≥ 30]. Although obese populations utilize health care at increased rates and have higher health care costs than non-obese patients, the adequacy of prenatal care in this population is not well established and assumed to be suboptimal. We therefore evaluated adequacy of prenatal care among obese women. METHODS: We utilized an electronic database including 7094 deliveries with pre-pregnancy BMI ≥ 18.5 from January 2009 through December 2011. Subjects were categorized as normal weight 18.5-24.9 kg/m2, overweight 25-29.9 kg/m2, and obese ≥30 kg/m2 (class I-II-III). Adequacy of prenatal care (PNC) was evaluated using the Kotelchuck Index (KI), corrected for gestational age at delivery. Adequate care was defined as KI "adequate" or "adequate plus," and non-adequate as "intermediate" or "inadequate." Chi square and logistic regression were used for comparisons. RESULTS: When compared to non-obese women, obese women were more likely to have adequate PNC (74.1 vs. 68.7%; OR 1.30, 95% CI 1.15-1.47). After adjusting for age, race, education, diabetes, hypertension, and practice type, obesity remained a significant predictor of adequate prenatal care (OR 1.29, 95% CI 1.14-1.46). While age and hypertension were not significant independent predictors of adequate PNC, college education, Caucasian, diabetes, and resident or MFM care had positive associations. CONCLUSION: Maternal obesity is associated with increased adequacy of prenatal care. Although some comorbidities associated with obesity increase utilization of prenatal services, this did not explain the improvement in PNC adequacy associated with obesity. SIGNIFICANCE: Overweight and obese women are at a higher risk of pregnancy complications with obesity contributing to increased morbidity and mortality of the mother. Several studies have evaluated barriers to routine health care services, with obese parturients perceiving their weight to be a barrier to obtaining appropriate care. There is limited data available assessing the adequacy of prenatal care in this population. Our study demonstrated that obesity was actually associated with an increased adequacy of prenatal care. The presence of comorbidities did not explain this improvement in prenatal care.

Measuring adequacy of prenatal care: does missing visit information matter?

BACKGROUND: Kotelchuck's Adequacy of Prenatal Care Utilization (APNCU) Index is frequently used to classify levels of prenatal care. In the Finger Lakes Region (FLR) of upstate New York, prenatal care visit information late in pregnancy is often not documented on the birth certificate. We studied the extent of this missing information and its impact on the validity of regional APNCU scores. METHODS: We calculated the "weeks between" a mother's last prenatal care visit and her infant's date of birth. We adjusted the APNCU algorithm creating the Last Visit Adequacy of Prenatal Care (LV-APNC) Index using the last recorded prenatal care visit date as the end point of care and the expected number of visits at that time. We compared maternal characteristics by care level with each index, examining rates of reclassification and number of "weeks between" by birth hospital. Stuart-Maxwell, McNemar, chi-square, and t-tests were used to determine statistical significance. RESULTS: Based on 58,462 births, the mean "weeks between" was 2.8 weeks. Compared with their APNCU Index score, 42.4 percent of mothers were reclassified using the LV-APNC Index. Major movement occurred from Intermediate (APNCU) to Adequate or Adequate Plus (LV-APNC) leaving the Intermediate Care group a more at-risk group of mothers. Those with Adequate or Adequate Plus Care (LV-APNC) increased by 31.6 percent, surpassing the Healthy People 2020 objective. CONCLUSIONS: In the FLR, missing visit information at the end of pregnancy results in an underestimation of mothers' prenatal care. Future research is needed to determine the extent of this missing visit information on the national level.

Labor epidural anesthesia, obstetric factors and breastfeeding cessation.

Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia's association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95% confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH: 1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.

Current Role of Robotic Hysterectomy.

Background: While robotic surgery for gynecologic indications received U.S. government approval in 2005, and has been rapidly and widely adopted, it is currently unclear how often this approach to hysterectomy is utilized. Objective: The aim of this research was to assess length of stay (LOS), mortality, indications, and current use of robotic hysterectomy, compared to other types of hysterectomy. Methods: A retrospective study of hysterectomies performed in New York State (NYS) in 2011 was performed. Data, including indication for surgery, age, procedure, LOS, and discharge status were obtained from the NYS Department of Health Statewide Planning and Research Cooperative System (SPARCS). Outcome Measures: LOS and mortality rate, were calculated according to institution, procedure, and indication for surgery. Results: For 22073 hysterectomies performed in NYS, the mean LOS was 2.9 days, and there were 29 (0.13%) deaths. The mean LOS for abdominal (12774 cases, 3.9 days) hysterectomies was longer than for laparoscopic (3927 cases, 1.6 days), robotic (2814 cases, 1.6 days), or vaginal (2558 cases, 1.7 days) hysterectomies (p<0.05). The adjusted mortality rates for abdominal (0.20%), laparoscopic (0.03%), robotic (0.07%), and vaginal (0.04%) hysterectomies were not significantly different. Overall, robotic surgery was performed in 29% of hospitals, by 11% of physicians and in 13% of cases. A robotic approach was utilized in 35% of patients with uterine cancer, 13% with endometriosis, 11% with excessive bleeding, 8% with leiomyomata, and 8% with pelvic relaxation. Conclusions: Despite the advantages in reduced LOS for robotic and other minimally invasive types of hysterectomies, the abdominal route is still predominant in most institutions. (J GYNECOL SURG XX:1).

The Geographical Correlation Between Historical Preterm Birth Disparities and COVID-19 Burden.

Similar to obstetric outcomes, rates of SARS-CoV-2 (COVID-19) infection are not homogeneously distributed among populations; risk factors accumulate in discrete locations. This study aimed to investigate the geographical correlation between pre-COVID-19 regional preterm birth (PTB) disparities and subsequent COVID-19 disease burden. We performed a retrospective, ecological cohort study of an upstate New York birth certificate database from 2004 to 2018, merged with publicly available community resource data. COVID-19 rates from 2020 were used to allocate ZIP codes to "low-," "moderate-," and "high-prevalence" groups, defined by median COVID-19 diagnosis rates. COVID-19 cohorts were associated with poverty and educational attainment data from the US Census Bureau. The dataset was analyzed for the primary outcome of PTB using ANOVA. GIS mapping visualized PTB rates and COVID-19 disease rates by ZIP code. Within 38 ZIP codes, 123,909 births were included. The median COVID-19 infection rate was 616.5 (per 100 K). PTB (all) and COVID-19 were positively correlated, with high- prevalence COVID-19 ZIP codes also being the areas with the highest prevalence of PTB (F = 11.06, P = .0002); significance was also reached for PTB < 28 weeks (F = 15.87, P < .0001) and periviable birth (F = 16.28, P < .0001). Odds of PTB < 28 weeks were significantly higher in the "high-prevalence" COVID-19 cohort compared to the "low-prevalence" COVID 19 cohort (OR 3.27 (95% CI 2.42-4.42)). COVID-19 prevalence was directly associated with number of individuals below poverty level and indirectly associated with median household income and educational attainment. GIS mapping demonstrated ZIP code clustering in the urban center with the highest rates of PTB < 28 weeks overlapping with high COVID-19 disease burden. Historical disparities in social determinants of health, exemplified by PTB outcomes, map community distribution of COVID-19 disease burden. These data should inspire socioeconomic policies supporting economic vibrancy to promote optimal health outcomes across all communities.

Coronavirus Disease 2019 (COVID-19)-Related Stress and Menstrual Changes.

OBJECTIVE: To evaluate how stress related to the coronavirus disease 2019 (COVID-19) pandemic has affected women's menstrual cycles. We hypothesized that women with high levels of COVID-19-related stress would have more menstrual changes compared with those with lower levels of stress. METHODS: Using a cross-sectional study design, we recruited a representative sample of U.S. adult women of reproductive age (18-45 years) using nonhormonal birth control to participate in an online REDCap (Research Electronic Data Capture, Vanderbilt University) survey. COVID-19-related stress was assessed with the PSS-10-C (COVID-19 Pandemic-related Perceived Stress Scale) and dichotomized as low stress (scores lower than 25) and high stress (scores 25 or higher). Self-reported menstrual outcomes were identified as changes in cycle length, duration, or flow and increased frequency of spotting between cycles. We used χ 2 and Fisher exact tests to compare differences in outcome between the two stress groups and logistic regression models for effect estimates. RESULTS: A total of 354 women of reproductive age across the United States completed both the menstrual and COVID-19-related stress components of our survey. More than half of these women reported at least one change in their menstrual cycles since the start of the pandemic (n=191), and 10.5% reported high COVID-19-related stress (n=37). Compared with those with low COVID-19-related stress, a greater proportion of women with high COVID-19-related stress reported changes in cycle length (shorter or longer; P =.008), changes in period duration (shorter or longer; P <.001), heavier menstrual flow ( P =.035), and increased frequency of spotting between cycles ( P =.006) compared with prepandemic times. After adjusting for age, smoking history, obesity, education, and mental health history, high COVID-19-related stress was associated with increased odds of changes in menstrual cycle length (adjusted odds ratio [aOR] 2.32; 95% CI 1.12-4.85), duration (aOR 2.38; 95% CI 1.14-4.98), and spotting (aOR 2.32; 95% CI 1.03-5.22). Our data also demonstrated a nonsignificant trend of heavier menstrual flow among women with high COVID-19-related stress (aOR 1.61; 95% CI 0.77-3.34). CONCLUSION: High COVID-19-related stress is associated with significant changes in menstrual cycle length, alterations in period duration, and increased intermenstrual spotting as compared with before the pandemic. Given that menstrual health is frequently an indicator of women's overall well-being, clinicians, researchers, and public health officials must consider the association between COVID-19-related stress and menstrual disturbances.

Obstetric variation, intervention, and outcomes: doing more but accomplishing less.

Obstetric interventions, particularly induction of labor and cesarean section, are done more and more commonly, although there is a wide variation between hospitals and practitioners in specific rates. This degree of variation implies imprecision and uncertainty about diagnoses and indicated management. Although the net result of this variation has been a "more is better" approach leading to increasing use of obstetric interventions, little evidence of commensurate improvements in outcome is available. A combined package of using currently available evidence, formulating best practices, instituting regular review and feedback to hospitals and practitioners about intervention rates, and a public health approach to educate women has the potential to achieve an acceptable balance between when intervention in the labor and delivery process is warranted and when it is unnecessary.

Elective delivery before 39 weeks: the risk of infant admission to the neonatal intensive care unit.

Despite American College of Obstetricians and Gynecologists guidelines suggesting that non-urgent planned deliveries be scheduled at/after 39 weeks; elective delivery before 39 weeks occurs often in the United States. The objective of this study is to estimate the elective delivery rate between 36(0/7) and 38(6/7) weeks gestation and compare NICU admission rates between elective and non-elective deliveries. We conducted a retrospective cohort (n = 1,577) study. Charts were reviewed for all singleton deliveries (2006-2007) between 36(0/7) and 38(6/7) weeks gestation taking place at one hospital in NYS to determine delivery status. We computed adjusted relative risks (RR) with 95% confidence intervals (CI) for elective delivery in relation to NICU admission using robust Poisson regression. 32.8% of all births were elective: 20.7% of vaginal and 55.7% of cesarean births. Elective delivery increased with increasing gestational age. After controlling for potential confounders, infants born via a vaginal elective delivery (RR = 1.40, CI: 1.00, 1.94), an elective cesarean (RR = 2.05, CI: 1.53, 2.76), or a non-elective cesarean (RR = 2.00, CI: 1.50, 2.66) are at significantly increased risk of NICU admission compared to infants born via a non-elective vaginal delivery. Elective delivery before 39 weeks is common and increases the risk of infant NICU admission.

Is the accuracy of prior preterm birth history biased by delivery characteristics?

To assess the sensitivity of birth certificates to preterm birth history and determine whether omissions are randomly or systemically biased. Subjects who experienced a preterm birth followed by a subsequent pregnancy were identified in a regional database. The variable "previous preterm birth" was abstracted from birth certificates of the subsequent pregnancy. Clinical characteristics were compared between subjects who were correctly versus incorrectly coded. 713 subjects were identified, of whom 65.5% were correctly coded in their subsequent pregnancy. Compared to correctly coded patients, patients who were not correctly identified tended to have late and non-recurrent preterm births or deliveries that were secondary to maternal or fetal indications. A recurrence of preterm birth in the subsequent pregnancy was also associated with correct coding. The overall sensitivity of birth certificates to preterm birth history is suboptimal. Omissions are not random, and are associated with obstetrical characteristics from both the current and prior deliveries. As a consequence, resulting associations may be flawed.

Inflammatory cytokines and antioxidants in midtrimester amniotic fluid: correlation with pregnancy outcome.

OBJECTIVE: Elevated interleukin-6 (IL-6) level in midtrimester amniotic fluid is associated with preterm delivery. We hypothesized that, in patients with elevated IL-6, vitamin C and alpha-fetoprotein may provide protection from spontaneous preterm delivery through antioxidant functions. STUDY DESIGN: Antioxidant potential of alpha-fetoprotein was assessed in vitro. Amniotic fluid was collected from a prospective cohort of patients who underwent midtrimester amniocentesis. In patients with IL-6 >600 pg/mL, alpha-fetoprotein, vitamin C, tumor necrosis factor-alpha, tumor necrosis factor receptors, and antioxidant capacity were compared between subjects with spontaneous preterm and term deliveries. RESULTS: Alpha-fetoprotein demonstrated 75% the antioxidant capacity of albumin in vitro. Of 388 subjects, 73 women had elevated IL-6 levels. Among these subjects, alpha-fetoprotein, but not vitamin C, was significantly lower in 9 women with preterm birth. Antioxidant capacity correlated with vitamin C and tumor necrosis factor receptors, but not with alpha-fetoprotein or pregnancy outcome. CONCLUSION: Amniotic fluid alpha-fetoprotein, but not vitamin C, may protect against preterm birth in patients with elevated midtrimester IL-6 levels.

Maternal and neonatal morbidity among nulliparous women undergoing elective induction of labor.

OBJECTIVE: To determine rates of adverse maternal and neonatal outcomes among nulliparous women undergoing elective labor induction compared with spontaneous labor. STUDY DESIGN: Retrospective chart review of term, nulliparous women with singleton gestations in 2007. Elective induction was defined as induction occurring from 37(0/7) to 41(0/7) weeks without ruptured membranes, fetal/maternal complications, or abnormal fetal testing. The primary outcome was cesarean delivery; secondary outcomes were maternal and fetal complications. Continuous variables were compared with t test and Mann-Whitney U, categorical with chi2 and Fisher's exact test. Logististic and linear regression were used to control for confounders and to assess independent effects of induction. RESULTS: Of850 nulliparous, singleton, term deliveries, 485 met criteria for inclusion. Cesarean delivery rate was 19.8% in the labor group and 33.6% in the induction group (p = 0.002). Odds ratio for cesarean was 2.1 (p = 0.001), 1.8 after adjustment for gestational age and birth weight, (p = 0.01). Length of stay (LOS) was significantly associated with induction even after adjustment for cesarean (beta = 0.7, p < 0.001). Rates ofepidural, postpartum hemorrhage, pediatric delivery attendance and neonatal oxygen requirement were higher with induction, before and after adjustment (p < 0.05). CONCLUSION: Elective induction of labor in nulliparas is associated with increased rates of cesarean, postpartum hemorrhage, neonatal resuscitation and longer LOS without improvement in neonatal outcomes.