Examination of the Black-White racial disparity in severe maternal morbidity among Georgia deliveries, 2016 to 2020.

BACKGROUND: Studies find that delivery hospital explains a significant portion of the Black-White gap in severe maternal morbidity. No such studies have focused on the US Southeast, where racial disparities are widest, and few have examined the relative contribution of hospital, residential, and maternal factors. OBJECTIVE: This study aimed to estimate the portion of Georgia's Black-White gap in severe maternal morbidity during delivery through 42 days postpartum explained by hospital, residential, and maternal factors. STUDY DESIGN: Using linked Georgia hospital discharge, birth, and fetal death records for 2016 through 2020, we identified 413,124 deliveries to non-Hispanic White (229,357; 56%) or Black (183,767; 44%) individuals. We linked hospital data from the American Hospital Association and Center for Medicare and Medicaid Services, and area data from the Area Resource File and American Community Survey. We identified severe maternal morbidity indicator conditions during delivery or subsequent hospitalizations through 42 days postpartum. Using race-specific logistic models followed by a decomposition technique, we estimated the portion of the Black-White severe maternal morbidity gap explained by the following: (1) sociodemographic factors (age, education, marital status, and nativity), (2) medical conditions (diabetes mellitus, gestational diabetes, chronic hypertension, gestational hypertension or preeclampsia, and smoking), (3) obstetrical factors (singleton or multiple, and birth order); (4) access to care (no or third trimester care, and payer), (5) hospital factors that are time-varying (delivery volume, deliveries per full-time equivalent nurse, doctor communication, patient safety, and adverse event composite score) or measured time-invariant characteristics (ownership, profit status, religious affiliation, teaching status, and perinatal level), and (6) residential factors (county urban/rural classification, percent uninsured women of reproductive age, obstetrician-gynecologists per women of reproductive age, number of federally-qualified and community health centers, medically-underserved area [yes/no], and census tract neighborhood deprivation index). We estimated models with and without hospital fixed-effects, which account for unobserved time-invariant hospital characteristics such as within-hospital care processes or unmeasured hospital-specific factors. RESULTS: There was 1.8 times the rate of severe maternal morbidity per 100 discharges among non-Hispanic Black (3.15) than among White (1.73) individuals, with an explained proportion of 30.4% in models without and 49.8% in models with hospital fixed-effects. In the latter, hospital fixed-effects explained the largest portion of the Black-White severe maternal morbidity gap (15.1%) followed by access to care (14.9%) and sociodemographic factors (14.4%), with residential factors being protective for Black individuals (-7.5%). Smaller proportions were explained by medical (5.6%), obstetrical (4.0%), and time-varying hospital factors (3.2%). Within each category, the largest explanatory portion was payer type (13.3%) for access to care, marital status (10.3%) for sociodemographic, gestational hypertension (3.3%) for medical, birth order (3.6%) for obstetrical, and patient safety indicator (3.1%) for time-varying hospital factors. CONCLUSION: Models with hospital fixed-effects explain a greater proportion of Georgia's Black-White severe maternal morbidity gap than models without them, thereby supporting the point that differences in care processes or other unmeasured factors within the same hospital translate into racial differences in severe maternal morbidity during delivery through 42 days postpartum. Research is needed to discern and ameliorate sources of within-hospital differences in care. The substantial proportion of the gap attributable to racial differences in access to care and sociodemographic factors points to other needed policy interventions.

Neighborhood Deprivation and Neural Tube Defects.

BACKGROUND: Individual measures of socioeconomic status (SES) have been associated with an increased risk of neural tube defects (NTDs); however, the association between neighborhood SES and NTD risk is unknown. Using data from the National Birth Defects Prevention Study (NBDPS) from 1997 to 2011, we investigated the association between measures of census tract SES and NTD risk. METHODS: The study population included 10,028 controls and 1829 NTD cases. We linked maternal addresses to census tract SES measures and used these measures to calculate the neighborhood deprivation index. We used generalized estimating equations to calculate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) estimating the impact of quartiles of census tract deprivation on NTDs adjusting for maternal race-ethnicity, maternal education, and maternal age at delivery. RESULTS: Quartiles of higher neighborhood deprivation were associated with NTDs when compared with the least deprived quartile (Q2: aOR = 1.2; 95% CI = 1.0, 1.4; Q3: aOR = 1.3, 95% CI = 1.1, 1.5; Q4 (highest): aOR = 1.2; 95% CI = 1.0, 1.4). Results for spina bifida were similar; however, estimates for anencephaly and encephalocele were attenuated. Associations differed by maternal race-ethnicity. CONCLUSIONS: Our findings suggest that residing in a census tract with more socioeconomic deprivation is associated with an increased risk for NTDs, specifically spina bifida.

Joint effects of individual socioeconomic status and residential neighborhood context on vaginal microbiome composition.

Introduction: The vaginal microbiome is a dynamic ecosystem that is important for women's health. Its composition has been associated with risk for menopausal symptoms, sexually transmitted infections, gynecologic cancer, and preterm birth. Conventional risk factors for a vaginal microbiome linked with these adverse health outcomes include sexual behaviors, hygiene practices, individual social factors, and stress levels. However, there has been limited research on socio-contextual determinants, and whether neighborhood context modifies the association with individual socioeconomic factors. Methods: Socioeconomically diverse pregnant African American women in Atlanta, Georgia (n = 439) provided residential addresses and first trimester vaginal swab samples, which underwent sequencing, taxonomic classification, and assignment into mutually exclusive CST (community state types) via hierarchical clustering. Linear probability models were used to estimate prevalence differences (PD) for the associations of neighborhood factors with vaginal microbiome CST and to evaluate for additive interaction with maternal level of education, health insurance type, and recruitment hospital. Results: Factors such as higher (vs. lower) maternal education, private (vs. public) insurance, and private (vs. public) hospital were associated with higher prevalence of Lactobacillus-dominant vaginal microbiome CSTs typically associated with better health outcomes. When considering the joint effects of these individual socioeconomic status and residential neighborhood factors on vaginal microbiome CST, most combinations showed a greater than additive effect among the doubly exposed; however, in the case of local income homogeneity and local racial homogeneity, there was evidence of a crossover effect between those with less-advantaged individual socioeconomic status and those with more-advantaged individual socioeconomic status. Compared to women at the public hospital who lived in economically diverse neighborhoods, women at the private hospital who lived in economically diverse neighborhoods had a 21.9% higher prevalence of Lactobacillus-dominant CSTs, while women at the private hospital who lived in less economically diverse neighborhoods (the doubly exposed) had only an 11.7% higher prevalence of Lactobacillus-dominant CSTs, showing a crossover effect (interaction term p-value = 0.004). Discussion: In this study, aspects of residential neighborhood context were experienced differently by women on the basis of their individual resources, and the joint effects of these exposures on vaginal microbiome CST showed a departure from simple additivity for some factors.

Does a Rising Median Income Lift All Birth Weights? County Median Income Changes and Low Birth Weight Rates Among Births to Black and White Mothers.

Policy Points Policies that increase county income levels, particularly for middle-income households, may reduce low birth weight rates and shrink disparities between Black and White infants. Given the role of aggregate maternal characteristics in predicting low birth weight rates, policies that increase human capital investments (e.g., funding for higher education, job training) could lead to higher income levels while improving population birth outcomes. The association between county income levels and racial disparities in low birth weight is independent of disparities in maternal risks, and thus a broad set of policies aimed at increasing income levels (e.g., income supplements, labor protections) may be warranted. CONTEXT: Low birth weight (LBW; <2,500 grams) and infant mortality rates vary among place and racial group in the United States, with economic resources being a likely fundamental contributor to these disparities. The goals of this study were to examine time-varying county median income as a predictor of LBW rates and Black-White LBW disparities and to test county prevalence and racial disparities in maternal sociodemographic and health risk factors as mediators. METHODS: Using national birth records for 1992-2014 from the National Center for Health Statistics, a total of approximately 27.4 million singleton births to non-Hispanic Black and White mothers were included. Data were aggregated in three-year county-period observations for 868 US counties meeting eligibility requirements (n = 3,723 observations). Sociodemographic factors included rates of low maternal education, nonmarital childbearing, teenage pregnancy, and advanced-age pregnancy; and health factors included rates of smoking during pregnancy and inadequate prenatal care. Among other covariates, linear models included county and period fixed effects and unemployment, poverty, and income inequality. FINDINGS: An increase of $10,000 in county median income was associated with 0.34 fewer LBW cases per 100 live births and smaller Black-White LBW disparities of 0.58 per 100 births. Time-varying county rates of maternal sociodemographic and health risks mediated the association between median income and LBW, accounting for 65% and 25% of this estimate, respectively, but racial disparities in risk factors did not mediate the income association with Black-White LBW disparities. Similarly, county median income was associated with very low birth weight rates and related Black-White disparities. CONCLUSIONS: Efforts to increase income levels-for example, through investing in human capital, enacting labor union protections, or attracting well-paying employment-have broad potential to influence population reproductive health. Higher income levels may reduce LBW rates and lead to more equitable outcomes between Black and White mothers.

Variation in the Content of Postpartum Visits by Maternal Race/Ethnicity, Preconception, and Pregnancy-Related Cardiovascular Disease Risk, PRAMS, 2016-2017.

OBJECTIVES: Limited evidence suggests racial/ethnic disparities in postpartum visit attendance; however, little is known about patterns in postpartum visit content. We sought to determine whether receipt of screening and counseling varies by race/ethnicity and whether cardiovascular disease (CVD) risk (preconception or pregnancy related) predicts postpartum visit content. METHODS: We used data from the Pregnancy Risk Assessment Monitoring System 2016-2017 (39 sites) to calculate the prevalence of self-reported receipt of screening, services, and counseling at the postpartum visit by race/ethnicity and CVD risk (unweighted analytic sample n = 59 427). We created a score representing receipt of 5 key screenings or messages at the visit (counseling on healthy eating and exercise, cigarettes, pregnancy spacing, and birth control methods; screening for depression), which we used as a binary indicator of visit content in regression models. We fit a logistic regression model to determine the magnitude of association between CVD risk and receipt of the 5 key messages, prevention screening, or CVD-specific counseling (on healthy eating and exercise, smoking), adjusting for maternal age, race/ethnicity, and health insurance status. RESULTS: Overall, 40% of women reported receiving all CVD-specific prevention messages. Both prepregnancy and pregnancy-related CVD risk were associated with increased odds of receipt of CVD prevention messages (adjusted odds ratios [aOR] = 1.2; 95% CI, 1.1-1.3; and 1.1; 95% CI, 1.1-1.2, respectively). Race/ethnicity was a stronger predictor than CVD risk: non-Hispanic Black women were twice as likely as non-Hispanic White women to receive CVD prevention messages, regardless of CVD risk (aOR = 1.9; 95% CI, 1.7-2.0). CONCLUSIONS: Health systems should consider novel strategies to improve and standardize the content of postpartum visits.

Surgical and Radiological Management of Complicated Uterine Leiomyoma Aided by 3D Models in a Patient with Fibrodysplasia Ossificans Progressiva.

BACKGROUND Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder of the connective tissue. Over time, patients with FOP experience decreased range of motion in the joints and the formation of a second skeleton, limiting mobility. Patients with FOP are advised to avoid any unwarranted surgery owing to the risk of a heterotopic ossification flare-up. For patients who do require a surgical procedure, a multidisciplinary team is recommended for comprehensive management of the patient's needs. CASE REPORT A 27-year-old woman with FOP underwent a hysterectomy for removal of a suspected necrotic uterine fibroid. To aid in presurgical planning and management, patient-specific 3-dimensional (3D) models of the patient's tracheobronchial tree, thorax, and lumbosacral spine were printed from the patient's preoperative computed tomography (CT) imaging. The patient required awake nasal fiberoptic intubation for general anesthesia and transversus abdominus plane block for regional anesthesia. Other anesthesia modalities, including spinal epidural, were ruled out after visualizing the patient's anatomy using the 3D model. Postoperatively, the patient was started on a multi-modal analgesic regimen and a course of steroids, and early ambulation was encouraged. CONCLUSIONS Patients with FOP are high-risk surgical patients requiring the care of multiple specialties. Advanced visualization methods, including 3D printing, can be used to better understand their anatomy and locations of heterotopic bone ossification that can affect patient positioning. Our patient successfully underwent supracervical hysterectomy and bilateral salpingectomy with no signs of fever or sepsis at follow-up.

Chronic Stress and Preconception Health Among Latina Women in Metro Atlanta.

BACKGROUND: Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta. DESIGN: We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma. RESULTS: Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)). CONCLUSIONS: Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

Association Between Recommended Preconception Health Behaviors and Screenings and Improvements in Cardiometabolic Outcomes of Pregnancy.

INTRODUCTION: Gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are associated with increased risk of maternal and infant illness and long-term elevated cardiometabolic risk. Little information exists on the prevention of either disorder before pregnancy. Our goal was to describe the association between preconception indicators and risk of gestational diabetes and hypertensive disorders of pregnancy. METHODS: We used logistic regression to analyze cross-sectional data from the 2016-2017 Pregnancy Risk Assessment Monitoring System (N = 68,493) to quantify the association between 14 preconception health indicators (across domains of health care, nutrition and physical activity, tobacco and alcohol, chronic conditions, mental health, and emotional and social support) and, separately, GDM and HDP. We accounted for sampling weights and controlled for maternal age, race/ethnicity, prepregnancy insurance, prepregnancy body mass index, and report of a check-up in the year before pregnancy. RESULTS: Prepregnancy obesity was the strongest predictor of both HDP (adjusted odds ratio [aOR], 3.1; 95% CI, 2.8-3.5) and GDM (aOR, 3.1; 95% CI, 2.7-3.5). Individual behaviors (eg, exercise, attending a check-up) were not associated with either HDP or GDM. A diagnosis of diabetes before pregnancy predicted HDP (aOR, 2.3; 95% CI, 1.7-3.0). CONCLUSION: Prepregnancy chronic disease and obesity predicted pregnancy complications (ie, GDM and HDP). Given the challenges in reversing these conditions in the year before pregnancy, efforts to improve preconception health may be best directed broadly to expand access to primary care for all women.

Initial engagement and persistence of health risk behaviors through adolescence: longitudinal findings from urban South Africa.

BACKGROUND: Little is known about longitudinal patterns of adolescent health risk behavior initial engagement and persistence in low- and middle-income countries. METHODS: Birth to Twenty Plus is a longitudinal birth cohort in Soweto-Johannesburg, South Africa. We used reports from Black African participants on cigarette smoking, alcohol, cannabis, illicit drug, and sexual activity initial engagement and adolescent pregnancy collected over 7 study visits between ages 11 and 18 y. We fit Kaplan-Meier curves to estimate behavior engagement or adolescent pregnancy, examined current behavior at age 18 y by age of first engagement, and performed a clustering analysis to identify patterns of initial engagement and their sociodemographic predictors. RESULTS: By age 13 y, cumulative incidence of smoking and alcohol engagement were each > 21%, while the cumulative incidence of other behaviors and adolescent pregnancy were < 5%. By age 18 y (15 y for cannabis), smoking, alcohol, and sexual activity engagement estimates were each > 65%, cannabis and illicit drug engagement were each > 16%; adolescent pregnancy was 31%. Rates of engagement were higher among males. Current risk behavior activity at age 18 y was generally unrelated to age of initial engagement. We identified three clusters reflecting low, moderate, and high-risk patterns of initial risk behavior engagement. One-third of males and 17% of females were assigned to the high-risk cluster. Sociodemographic factors were not associated with cluster membership. CONCLUSIONS: Among urban dwelling Black South Africans, risk behavior engagement across adolescence was common and clustered into distinct patterns of initial engagement which were unrelated to the sociodemographic factors assessed. Patterns of initial risk behavior engagement may inform the timing of primary and secondary public health interventions and support integrated prevention efforts that consider multiple behaviors simultaneously.

Superb Microvascular Imaging Improves Detection of Vascularity in Indeterminate Renal Masses.

OBJECTIVES: Vascular assessment of indeterminate renal masses (iRMs) remains a crucial element of diagnostic imaging, as the presence of blood flow within renal lesions suggests malignancy. We compared the utility of Superb Microvascular Imaging (SMI; Canon Medical Systems, Tustin, CA), a novel Doppler technique, to standard color Doppler imaging (CDI) and power Doppler imaging (PDI) for the detection of vascularity within iRMs. METHODS: Patients undergoing contrast-enhanced ultrasound (CEUS) evaluations for iRMs first underwent a renal ultrasound examination with the following modes: CDI, PDI, color Superb Microvascular Imaging (cSMI), and monochrome Superb Microvascular Imaging (mSMI), using an Aplio i800 scanner with an i8CX1 transducer (Canon Medical Systems). After image randomization, each mode was assessed for iRM vascularity by 4 blinded readers on a diagnostic confidence scale of 1 to 5 (5 = most confident). The results were compared to CEUS as the reference standard. RESULTS: Forty-one patients with 50 lesions met inclusion criteria. Relative to the other 3 modalities, mSMI had the highest sensitivity (63.3%), whereas cSMI had the highest specificity (62.1%). Both cSMI and mSMI also had the highest diagnostic accuracy (0.678 and 0.680, respectively; both P < 0.001) compared to CDI (0.568) and PDI (0.555). Although the reader-reported confidence interval of mSMI (mean ± SD, 3.6 ± 1.1) was significantly lower than CDI (4.1 ± 1.0) and PDI (4.0 ± 1.0; P < 0.001), the confidence level of cSMI (4.1 ± 0.9) was not (P > 0.173). CONCLUSIONS: Preliminary data suggest that SMI is a potentially useful modality in detecting microvasculature in iRMs compared to standard Doppler techniques. Future studies should aim to compare the efficacy of both SMI and CEUS and to assess the ability of SMI to characterize malignancy in iRMs.

Interpregnancy interval and risk of stillbirth: a population-based case control study.

PURPOSE: We examined the association between interpregnancy intervals (IPIs) and stillbirth (defined as fetal death ≥20 weeks), as both short and long IPIs have been associated with adverse perinatal outcomes. Prior pregnancy loss is also a known risk factor for stillbirth, and women who suffer a prior loss often have shorter IPIs. For these reasons, we also sought to quantify the proportion of the association between prior pregnancy loss and subsequent stillbirth risk that may be attributed to a short IPI. METHODS: We used data from the Stillbirth Collaborative Research Network, a multisite case-control study conducted in 2006-2008, restricted to singleton pregnancies among multiparous or multigravid women (985 controls and 291 cases). We accounted for complex sample design and nonparticipation with weighted multivariable logistic regression. RESULTS: In the adjusted models, IPIs <6 months, as compared with a reference of 18-23 months, were associated with increased odds of stillbirth (aOR 1.6, 95% CI: 0.8, 3.4). Long IPIs (60-100 months) were also associated with an increased odds of stillbirth (aOR 2.4, 95% CI: 1.2, 4.5). After control for covariates, about one-fifth (21.2%) of the association of prior pregnancy loss (stillbirth, ectopic pregnancy, molar pregnancy, or spontaneous abortion) and stillbirth may be attributable to a short IPI. CONCLUSIONS: Our results suggest that women who experience a prior pregnancy loss may benefit from additional counseling on adequate birth spacing to reduce subsequent stillbirth risk.

Risk Factors for Septicemia Deaths and Disparities in a Longitudinal US Cohort.

BACKGROUND: There are few longitudinal data on the risk factors and mediators of racial disparities in sepsis among community- dwelling US adults. METHODS: This is a longitudinal study of adult participants in the 1999-2005 National Health Interview Survey with data linked to the 1999-2011 National Death Index. We utilized National Vital Statistics System's ICD-10 schema to define septicemia deaths (A40-A41), utilizing influenza and pneumonia deaths (J09-J11) and other causes of death as descriptive comparators. All statistics utilized survey design variables to approximate the US adult population. RESULTS: Of 206 691 adult survey participants, 1523 experienced a septicemia death. Factors associated with a >2-fold larger hazard of septicemia death included need for help with activities of daily living; self-reported "poor" and "fair" general health; lower education; lower poverty index ratio; self-reported emphysema, liver condition, stroke, and weak or failing kidneys; numerous measures of disability; general health worse than the year prior; >1 pack per day cigarette use; and higher utilization of health care. Blacks had age- and sex-adjusted hazards that were higher for septicemia deaths (hazard ratio [HR], 1.92; 95% confidence interval [CI], 1.65-2.23) than for other causes of death (HR, 1.32; 95% CI, 1.25-1.38). The strongest mediators of the septicemia disparity included self-reported general health condition, family income-poverty ratio, and highest education level achieved. CONCLUSIONS: In this cohort, the major risk factors for septicemia death were similar to those for other causes of death, there was approximately a 2-fold black-white disparity in septicemia deaths, and the strongest mediators of this disparity were across domains of socioeconomic status.

Pregnancy after cancer: Does timing of conception affect infant health?

BACKGROUND: The objective of this retrospective cohort study was to determine whether women who conceive soon after treatment for cancer have higher risks of adverse pregnancy outcomes. METHODS: Vital records data were linked to cancer registry diagnosis and treatment information in 3 US states. Women who conceived their first pregnancy after diagnosis between ages 20 and 45 years with any invasive cancer or ductal carcinoma in situ were eligible. Log-binomial models were used to compare risks in cancer survivors who conceived in each interval to the risks in matched comparison births to women without cancer. RESULTS: Women who conceived ≤1 year after starting chemotherapy for any cancer had higher risks of preterm birth than comparison women (chemotherapy alone: relative risk [RR], 1.9; 95% confidence interval [CI], 1.3-2.7; chemotherapy with radiation: RR, 2.4; 95% CI, 1.6-3.6); women who conceived ≥1 year after starting chemotherapy without radiation or ≥2 years after chemotherapy with radiation did not. In analyses imputing the treatment end date for breast cancer survivors, those who conceived ≥1 year after finishing chemotherapy with or without radiation had no higher risks than women without cancer. The risk of preterm birth in cervical cancer survivors largely persisted but was somewhat lower in pregnancies conceived after the first year (for pregnancies conceived ≤1 year after diagnosis: RR, 3.5; 95% CI, 2.2-5.4; for pregnancies conceived >1 year after diagnosis: RR, 2.4; 95% CI, 1.6-3.5). CONCLUSIONS: In women who received chemotherapy, the higher risk of preterm birth was limited to those survivors who had short intervals between treatment and conception.Cancer 2018;124:000-000.

Geographic Inequalities in Progress against Lung Cancer among Women in the United States, 1990-2015.

Background: Lung cancer-related death rates in the United States have declined steadily since 1990 in men but not until the mid-2000s in women, with the gap in mortality narrowing during the most recent time period. We examined variation in the declining trend among women by county, where many tobacco control policies are implemented.Methods: We obtained county-level lung cancer death rates among women from the National Center for Health Statistics mortality file and calculated relative changes from 1990-1999 to 2006-2015. Optimized hotspot analysis identified contiguous counties with small declines or increases in death rates.Results: We identified two distinct clusters of counties: 669 in Appalachia and the Midwest (Hotspot 1) and 81 in the northern Midwest (Hotspot 2). From 1990-1999 to 2006-2015, death rates among women increased by 13% in Hotspot 1 and by 7% in Hotspot 2 counties, while rates decreased by 6% in the non-hotspot United States. From 1990-2015, death rate ratios (RRs) in hotspot versus non-hotspot counties changed from 4% lower (RR, 0.96; 95% CI, 0.94-0.99) to 28% higher [RR, 1.28; 95% confidence interval (CI), 1.25-1.31] for Hotspot 1 counties and from 18% lower (RR, 0.82; 95% CI, 0.76-0.89) to unity (RR, 0.99; 95% CI, 0.93-1.05) for Hotspot 2 counties.Conclusions: We identified areas in the Midwest and Appalachia where progress against lung cancer mortality among women has lagged compared with a steady national decline.Impact: Targeted tobacco control programs could reduce the excess burden of lung cancer among women living in hotspot counties and prevent widening geographic inequity. Cancer Epidemiol Biomarkers Prev; 27(11); 1261-4. ©2018 AACR.

The risk of preterm birth and growth restriction in pregnancy after cancer.

It is unclear whether cancer and its treatments increase the risk of adverse pregnancy outcomes. Our aim was to examine whether cancer survivors have higher risks of poor outcomes in pregnancies conceived after diagnosis than women without cancer, and whether these risks differ by cancer type and race. Diagnoses from cancer registries were linked to pregnancy outcomes from birth certificates in three U.S. states. Analyses were limited to the first, live singleton birth conceived after diagnosis. Births to women without a previous cancer diagnosis in the registry were matched to cancer survivors on age at delivery, parity, race/ethnicity and education. Log-binomial regression was used to estimate risk ratios. Cervical cancer survivors had higher risks of preterm birth (Risk ratio = 2.8, 95% Confidence interval: 2.1, 3.7), as did survivors of invasive breast cancer (RR = 1.3, 95% CI: 1.1, 1.7) and leukemia (RR = 2.1, 95% CI: 1.3, 3.5). We observed a higher risk of small for gestational age (SGA) infants (<10% of weight for age based on a national distribution) in survivors of brain cancer (RR = 1.7, 95% CI: 1.1, 2.8) and extranodal non-Hodgkin lymphoma (RR = 2.3, 95% CI: 1.5, 3.6). We did not see an increased risk of infants born preterm, low birth weight, or SGA in pregnancies conceived after ductal carcinoma in situ, thyroid cancer, melanoma, or Hodgkin lymphoma. While our results are reassuring for survivors of many cancers, some will need closer monitoring during pregnancy.

Differences in Women's Use of Medical Help for Becoming Pregnant by the Level of Urbanization of County of Residence in Georgia.

PURPOSE: Our goal was to determine if there are differences by place of residence in visiting a doctor for help getting pregnant in a population-based study. METHODS: Using data from the Furthering Understanding of Cancer, Health, and Survivorship in Adult (FUCHSIA) Women's Study, a cohort study of fertility outcomes in reproductive-aged women in Georgia, we fit models to estimate the association between geographic type of residence and seeking help for becoming pregnant. FINDINGS: The prevalence of visiting a doctor for help getting pregnant ranged from 13% to 17% across geographic groups. Women living in suburban counties were most likely to seek medical care for help getting pregnant compared with women living in urbanized counties (adjusted prevalence ratio (aPR) = 1.14, 95% CI: 0.74-1.75); among women who reported infertility this difference was more pronounced (aPR = 1.59, 95% CI: 1.00-2.53). Women living in rural counties were equally likely to seek fertility care compared with women in urbanized counties in the full sample and among women who experienced infertility. CONCLUSIONS: Women living in urban and rural counties were least likely to seek infertility care, suggesting that factors including but not limited to physical proximity to providers are influencing utilization of this type of care. Increased communication about reproductive goals and infertility care available to meet these goals by providers who women see for regular care may help address these barriers.

Race and ethnicity and preconception folic acid supplement use among pregnant women in Georgia, PRAMS 2009 to 2011.

BACKGROUND: The United States Public Health Service recommends that all women of reproductive age consume 400 µg of folic acid daily to prevent major neural tube defects. Hispanics have the highest prevalence of neural tube defects compared with other race/ethnic groups. We studied prevalence of preconception folic acid supplement use, and its association with race/ethnicity among pregnant women in Georgia. METHODS: Using state-wide population-based data from 2009 to 2011 Georgia Pregnancy Risk Assessment Monitoring System, we examined the prevalence of preconception folic acid supplement use among pregnant women aged 18 to 45 years. We conducted multivariable logistic regression and estimated adjusted odds ratios and 95% confidence intervals to examine the association between race/ethnicity and supplemental folic acid use among study participants. RESULTS: Overall, 25% of all participants reported taking folic acid supplements daily before conception. Only 21% of Hispanic women reported preconception folic acid supplement use. Hispanic women were twice as likely to not take folic acid supplements (adjusted odds ratio = 2.15; 95% confidence interval, 1.35-3.40) compared with non-Hispanic whites, after controlling for maternal age, parity, pregnancy intention, knowledge that folic acid prevents birth defects, and preconception smoking and exercise. CONCLUSION: Hispanics are a growing population in the United States with an expected 14 million women of child-bearing age by 2020, and the prevalence of preconception folic acid supplement use is low in this group with a high risk of neural tube defects. Promotion of voluntarily fortified corn masa flour can lower neural tube defects in Hispanics. Mandatory corn masa fortification will be a more effective public health policy.Birth Defects Research 109:38-48, 2017. © 2016 Wiley Periodicals, Inc.

Which female cancer patients fail to receive fertility counseling before treatment in the state of Georgia?

OBJECTIVE: To assess which characteristics are associated with failure to receive fertility counseling among a cohort of young women diagnosed with cancer. DESIGN: Population-based cohort study. SETTING: Not applicable. PATIENT(S): A total of 1,282 cancer survivors, of whom 1,116 met the inclusion criteria for the analysis. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): The main outcome in this study was whether or not women reported receiving any information at the time of their cancer diagnosis on how cancer treatment might affect their ability to become pregnant. RESULT(S): Forty percent of cancer survivors reported that they did not receive fertility counseling at the time of cancer diagnosis. Women were more likely to fail to receive counseling if they had only a high school education or less or if they had given birth. Cancer-related variables that were associated with a lack of counseling included not receiving chemotherapy as part of treatment and diagnosis with certain cancer types. CONCLUSION(S): Counseling about the risk of infertility and available fertility preservation options is important to cancer patients. Additionally, counseling can make women aware of other adverse reproductive outcomes, such as early menopause and its associated symptoms. Less-educated women and parous women are at particular risk of not getting fertility-related information. Programs that focus on training not just the oncologist, but also other health care providers involved with cancer care, to provide fertility counseling may help to expand access.

The Affordable Care Act and Cancer Stage at Diagnosis Among Young Adults.

The Affordable Care Act-dependent coverage expansion provision implemented in 2010 allows young adults to be covered under their parents' health insurance until age 26 years, and millions of young adults have gained insurance as a result. The impact of this policy on cancer patients has yet to be determined. Using 2007 to 2012 data from 18 registries of the Surveillance, Epidemiology, and End Results Program, comparing cancer patients age 19 to 25 years to a control group of patients age 26 to 34 years who were not affected by the provision, we observed a 2.0 (95% confidence interval [CI] = 0.7 to 3.4) percentage point decrease in uninsured rate and a 2.7 (95% CI = 0.6 to 4.8) percentage point increase in diagnosis at stage I disease for patients age 19-25 years. Further analyses by specific cancer site revealed that the statistically significant shifts were confined to carcinoma of cervix (21.2, 95% CI = 9.6 to 32.7 percentage points) and osseous and chondromatous neoplasms (14.4, 95% CI = 0.3 to 28.5 percentage points), which are detectable by either screening or clinical manifestation. These early observations suggest the policy has had positive benefits in cancer outcomes.

Racial Disparities in Seeking Care for Help Getting Pregnant.

BACKGROUND: Fertility counselling and treatment can help women achieve their desired family size; however, disparities exist in the utilisation of this care. METHODS: This study examines the persistence of a racial disparity in visiting a doctor for help getting pregnant by estimating the direct effect of this association using data from the Furthering Understanding of Cancer Health and Survivorship in Adult Women's Study, a population-based cohort study. This cohort included 1073 reproductive age women (22-45 years) with 28% reporting infertility. We fit log binomial models to quantify the magnitude of the racial difference in reported care seeking after adjustment for hypothesised mediators using inverse probability weighting. RESULTS: Compared with white women, black women were less likely to visit a doctor in the total population [adjusted risk ratio (RR) 0.57, 95% confidence interval (CI) 0.41, 0.80] and in the subgroup of women with infertility [RR 0.75, 95% CI 0.56, 0.99]. In addition, black women waited twice as long, on average, before seeking help compared with white women. CONCLUSIONS: There were notable racial differences in visiting a doctor for help getting pregnant in this study although reports of infertility were similar by race. These differences may be mitigated through improved communication about the range of counselling and treatment options available.