Sentinel surveillance of SARS-CoV-2 rates and equity impacts using labor and delivery patients in Phoenix, Arizona.

Proactive management of SARS-CoV-2 requires timely and complete population data to track the evolution of the virus and identify at risk populations. However, many cases are asymptomatic and are not easily discovered through traditional testing efforts. Sentinel surveillance can be used to estimate the prevalence of infections for geographical areas but requires identification of sentinels who are representative of the larger population. Our goal is to evaluate applicability of a population of labor and delivery patients for sentinel surveillance system for monitoring the prevalence of SARS-CoV-2 infection. We tested 5307 labor and delivery patients from two hospitals in Phoenix, Arizona, finding 195 SARS-CoV-2 positive. Most positive cases were associated with people who were asymptomatic (79.44%), similar to statewide rates. Our results add to the growing body of evidence that SARS-CoV-2 disproportionately impacts people of color, with Black people having the highest positive rates (5.92%). People with private medical insurance had the lowest positive rates (2.53%), while Medicaid patients had a positive rate of 5.54% and people without insurance had the highest positive rates (6.12%). With diverse people reporting for care and being tested regardless of symptoms, labor and delivery patients may serve as ideal sentinels for asymptomatic detection of SARS-CoV-2 and monitoring impacts across a wide range of social and economic classes. A more robust system for infectious disease management requires the expanded participation of additional hospitals so that the sentinels are more representative of the population at large, reflecting geographic and neighborhood level patterns of infection and risk.

Clinical and economic evaluation of a proteomic biomarker preterm birth risk predictor: cost-effectiveness modeling of prenatal interventions applied to predicted higher-risk pregnancies within a large and diverse cohort.

OBJECTIVES: Preterm birth occurs in more than 10% of U.S. births and is the leading cause of U.S. neonatal deaths, with estimated annual costs exceeding $25 billion USD. Using real-world data, we modeled the potential clinical and economic utility of a prematurity-reduction program comprising screening in a racially and ethnically diverse population with a validated proteomic biomarker risk predictor, followed by case management with or without pharmacological treatment. METHODS: The ACCORDANT microsimulation model used individual patient data from a prespecified, randomly selected sub-cohort (N = 847) of a multicenter, observational study of U.S. subjects receiving standard obstetric care with masked risk predictor assessment (TREETOP; NCT02787213). All subjects were included in three arms across 500 simulated trials: standard of care (SoC, control); risk predictor/case management comprising increased outreach, education and specialist care (RP-CM, active); and multimodal management (risk predictor/case management with pharmacological treatment) (RP-MM, active). In the active arms, only subjects stratified as higher risk by the predictor were modeled as receiving the intervention, whereas lower-risk subjects received standard care. Higher-risk subjects' gestational ages at birth were shifted based on published efficacies, and dependent outcomes, calibrated using national datasets, were changed accordingly. Subjects otherwise retained their original TREETOP outcomes. Arms were compared using survival analysis for neonatal and maternal hospital length of stay, bootstrap intervals for neonatal cost, and Fisher's exact test for neonatal morbidity/mortality (significance, p < .05). RESULTS: The model predicted improvements for all outcomes. RP-CM decreased neonatal and maternal hospital stay by 19% (p = .029) and 8.5% (p = .001), respectively; neonatal costs' point estimate by 16% (p = .098); and moderate-to-severe neonatal morbidity/mortality by 29% (p = .025). RP-MM strengthened observed reductions and significance. Point estimates of benefit did not differ by race/ethnicity. CONCLUSIONS: Modeled evaluation of a biomarker-based test-and-treat strategy in a diverse population predicts clinically and economically meaningful improvements in neonatal and maternal outcomes.

Preterm birth, defined as delivery before 37 weeks' gestation, is the leading cause of illness and death in newborns. In the United States, more than 10% of infants are born prematurely, and this rate is substantially higher in lower-income, inner-city and Black populations. Prematurity associates with greatly increased risk of short- and long-term medical complications and can generate significant costs throughout the lives of affected children. Annual U.S. health care costs to manage short- and long-term prematurity complications are estimated to exceed $25 billion.Clinical interventions, including case management (increased patient outreach, education and specialist care), pharmacological treatment and their combination can provide benefit to pregnancies at higher risk for preterm birth. Early and sensitive risk detection, however, remains a challenge.We have developed and validated a proteomic biomarker risk predictor for early identification of pregnancies at increased risk of preterm birth. The ACCORDANT study modeled treatments with real-world patient data from a racially and ethnically diverse U.S. population to compare the benefits of risk predictor testing plus clinical intervention for higher-risk pregnancies versus no testing and standard care. Measured outcomes included neonatal and maternal length of hospital stay, associated costs and neonatal morbidity and mortality. The model projected improved outcomes and reduced costs across all subjects, including ethnic and racial minority populations, when predicted higher-risk pregnancies were treated using case management with or without pharmacological treatment. The biomarker risk predictor shows high potential to be a clinically important component of risk stratification for pregnant women, leading to tangible gains in reducing the impact of preterm birth.

Racism, COVID-19, and Health Inequity in the USA: a Call to Action.

The current national COVID-19 mortality rate for Black Americans is 2.1 times higher than that of Whites. In this commentary, we provide historical context on how structural racism undergirds multi-sector policies which contribute to racial health inequities such as those highlighted by the COVID-19 pandemic. We offer a concrete, actionable path forward to address structural racism and advance health equity for Black Americans through anti-racism, implicit bias, and cultural competency training; capacity building; community-based participatory research (CBPR) initiatives; validated metrics for longitudinal monitoring of efforts to address health disparities and the evaluation of those interventions; and advocacy for and empowerment of vulnerable communities. This necessitates a multi-pronged, coordinated approach led by clinicians; public health professionals; researchers; social scientists; policy-makers at all governmental levels; and local community leaders and stakeholders across the education, legal, social service, and economic sectors to proactively and systematically advance health equity for Black Americans across the USA.

Severe acute respiratory syndrome coronavirus 2: a canary in the coal mine for public safety net hospitals.

BACKGROUND: The coronavirus disease 2019 pandemic has exposed disproportionate health inequities among underserved populations, including refugees. Public safety net healthcare systems play a critical role in facilitating access to care for refugees and informing coordinated public health prevention and mitigation efforts during a pandemic. OBJECTIVE: This study aimed to evaluate the prevalence ratios of severe acute respiratory syndrome coronavirus 2 infection between refugee women and nonrefugee parturient patients admitted to the hospital for delivery. Here, we suspected that the burden of infection was disproportionately distributed across refugee communities that may act as sentinels for community outbreaks. STUDY DESIGN: A cross-sectional study was conducted examining parturient women admitted to the maternity unit between May 6, 2020, and July 22, 2020, when universal testing for severe acute respiratory syndrome coronavirus 2 was first employed. Risk factors for severe acute respiratory syndrome 2 positivity were ascertained, disaggregated by refugee status, and other clinical and sociodemographic variables examined. Prevalence ratios were calculated and comparisons made to county-level community prevalence over the same period. RESULTS: The positive test percentage at the county-level during this study period was 21.6%. Of 350 women admitted to the hospital for delivery, 33 (9.4%) tested positive for severe acute respiratory syndrome 2. When refugee status was determined, 45 women (12.8%) were identified as refugees. Of the 45 refugee women, 8 (17.8%) tested positive for severe acute respiratory syndrome 2 compared with 25 nonrefugee patients (8.19%) who tested positive for severe acute respiratory syndrome 2 (prevalence ratio, 2.16; 95% confidence interval, 1.04-4.51). In addition, 7 of the refugee women who tested positive for severe acute respiratory syndrome coronavirus 2 were from Central Africa. CONCLUSION: The severe acute respiratory syndrome coronavirus 2 outbreak has disproportionately affected refugee populations. This study highlighted the utility of universal screening in mounting a rapid response to an evolving pandemic and how we can better serve refugee communities. Focused response may help achieve more equitable care related to severe acute respiratory syndrome 2 among vulnerable communities. The identification of such populations may help mitigate the spread of the disease and facilitate a timely, culturally, and linguistically enhanced public health response.

Ethical Issues in Maternal-Fetal Care Emergencies.

Ethical issues that arise in the care of pregnant women are challenging to physicians, especially in critical care situations. By familiarizing themselves with the concepts of medical ethics in obstetrics, physicians will become more capable of approaching complex ethical situations with a clear and structured framework. This review discusses ethical approaches regarding 3 specific scenarios: (1) the life of the fetus versus the life of the mother and situations of questionable maternal decision making; (2) withdrawal of care in a brain-dead pregnant patient; and (3) domestic violence and the pregnant patient.

Interpregnancy intervals and the risk for infant mortality: a case control study of Arizona infants 2003-2007.

There is well-documented evidence on how interpregnancy interval (IPI) is associated with adverse perinatal outcomes and how short and long IPIs are associated with increased risk for preterm birth, low birth weight, and intra-uterine growth restriction. However, the extremes of IPI on infant mortality are less well documented. The current study builds on the existing evidence on IPI to examine if extremes of IPI are associated with infant mortality, and also examines if IPI is associated with both neonatal and post-neonatal mortality after adjusting for several known confounders. Matched birth and death certificate data for Arizona resident infants was drawn for 2003-2007 cohorts. The analysis was restricted to singleton births among resident mothers with a previous live birth (n = 1,466) and a randomly selected cohort of surviving infants during the same time-frame was used as a comparison group (n = 2,000). Logistic regression models were utilized to assess the odds for infant mortality at monthly interpregnancy intervals (<6, 6-11, 12-17, 18-23, 24-59, ≥60), while adjusting for established predictors of infant mortality (i.e., preterm birth, low birth weight, and small for gestational age), and other potential confounders. Unadjusted analysis showed greater clustering at extreme IPIs of <6 months and ≥60 months for infants that died (32%) compared to infants that survived (24.7%). Shorter IPI (i.e., <6 months, 6-11 months, and 12-17 months) compared to 'ideal' IPI (i.e., 18-23 months), were associated with infant mortality even after adjusting for confounders. Short intervals were significantly associated with neonatal, but not post-neonatal deaths. IPI above 23 months were not associated with infant mortality in our analyses. Shorter IPIs (18 months or less) significantly increases the risk for neonatal infant mortality even after controlling for known confounders, and our study adds to the existing evidence on adverse perinatal outcomes. Counseling women of reproductive age on the benefits of spacing pregnancies to at least 18 months addresses one preventable risk for early infant mortality.

Acculturation and health care utilization among Mexican heritage women in the United States.

With the increasing Latino population in the United States, it is critical to examine the influence of the process of acculturation on health care practices and utilization. The purpose of this study was to evaluate the relationship between acculturation level and post-partum visit (PPV) compliance among Latinas participating in a larger psycho-educational intervention aimed at encouraging women to engage in positive healthcare practices. Acculturation was measured with the Bicultural Involvement Questionnaire which assigned participants to five categories: Assimilated, Separated, Moderate, Bicultural and Alienation. Logistic Regression analyses were conducted to predict post-partum visit attendance. Odds ratios and relative risk of not attending the post-partum visit are presented. Results suggest women in the Separation and Assimilation groups were less likely than bicultural group members to attend the PPV. The only other variable that was significant in this analysis is the group condition, indicating that the intervention group was more likely to attend the PPV than the control group. Women identifying as bicultural seem to participate more actively in their own healthcare as they draw on the cultural assets that have a positive influence on informal health practices, such as healthy eating and refraining from drug use. Bicultural group members can also use formal skills related to language and knowledge of the dominant culture to help effectively navigate the healthcare system. Implications for research, intervention and practice are discussed to improve healthcare practices and increase utilization among Latinas.

Knowledge and attitudes regarding preconception care in a predominantly low-income Mexican American population.

OBJECTIVE: The objective of the study was to determine knowledge and attitudes regarding preconception care in a low-income Mexican American population. STUDY DESIGN: This was a cross-sectional survey of 305 reproductive-age women at an urban public hospital. RESULTS: The sample was mostly Hispanic (88%) and pregnant (68%); 35% had not completed high school. Eighty-nine percent agreed that improving preconception health benefits pregnancy. Seventy-seven percent expressed some interest in preconception health care with the obstetrics gynecology office at the preferred location. The average knowledge of preconception care score was 76% (higher score more favorable). Areas of higher knowledge included the effects on pregnancy of folic acid; alcohol use; substance use; and verbal, physical, and sexual abuse; lower knowledge was found for the effects of cat litter and fish products. CONCLUSION: There was interest in preconception education and agreement that preconception health has a positive effect on pregnancy. Fewer respondents agreed that it had a good effect than a suburban sample in the same region (89% vs 98%).

The clinical content of preconception care: care of psychosocial stressors.

In the period before conceiving, many women are under considerable psychosocial stress, which may affect their ability to conceive and to carry a pregnancy successfully to term. Thus, health care providers who interact with women in the preconception and interconception period should ask their patients about possible psychosocial risks. It is no longer sufficient to wait until the woman mentions a problem or seeks advice; the provider must be proactive, because many women do not realize the potential impact of stressors on their pregnancy outcomes nor are they always aware that their provider is interested in their psychosocial as well as their physical health. An income that puts women below or near the federal poverty level is one such stress. If a woman's economic situation can be improved before the pregnancy, she is more likely to be healthy after conception, because increased income can reduce financial stress, improve food security, and improve well-being in other ways. Therefore, all women should be asked about their economic status and those who appear to be struggling financially should be referred to an agency that can check their eligibility for various types of financial assistance. Many women of childbearing age have difficulty accessing the primary care services needed for preconception care. Usually this is due to lack of insurance, but it may also be caused by living in an area with an insufficient number of providers. Certainly all women who are uninsured, and possible many who are on Medicaid and have difficulty finding providers who will accept Medicaid, have access problems. All women should be asked about their health insurance coverage and their usual source of care. If they do not have health insurance, they should be referred to an agency that can determine their eligibility. If they do not have a usual source of care, one should be established that will accept their insurance coverage or provide care free of charge or on a sliding fee basis. Intimate partner violence, sexual violence outside of an intimate relationship (usually rape), and maltreatment (abuse or neglect) as a child or adolescent place a woman at elevated risk during a pregnancy, as well as having possible adverse impacts on the fetus, the infant, and the child. Studies show that women believe it is appropriate for health care providers to ask about interpersonal violence, but that they will not report it spontaneously. Therefore, screening for ongoing and historical interpersonal violence, sexual violence, and child maltreatment should be incorporated into routine care by all health care providers.

Use of home visit and developmental clinic services by high risk Mexican-American and white non-Hispanic infants.

OBJECTIVE: To investigate whether US-born infants of mothers of Mexican descent who were enrolled in Arizona's Newborn Intensive Care Program (NICP) received follow-up services (developmental clinic and community health nurse [(CHN)] home visits) at the rates similar to White non-Hispanic (WNH) infants. Socio-economic and health status characteristics were controlled using stepped regressions in order to assess the impact of each on service use. METHODS: This population-based study used retrospective data from the NICP administrative database that were linked to birth certificates for years 1994-1998. The study population was limited to Arizona-born infants; it included 7442 infants of WNH mothers, 2612 infants of US-born Mexican American (MA) mothers and 2872 infants of Mexico-born mothers. Four service use indicators were used in the analysis. RESULTS: Both Hispanic infant subgroups were less likely to have a CHN visit by 6 months and by 1 year, and to average fewer CHN visits. A smaller percent attended the developmental clinic by age one. After controlling for language, demographics, health status, socio-economic characteristics, and mothers' prenatal care use, infants of US-born MA mothers had rates of use similar to WNH. However, even after controlling for the study variables, infants of Mexico-born mothers were less likely (OR = .83) to use the developmental clinic. Hispanics continued to lag behind in the use of services compared with WNHs. The disparity is not a function of ethnicity, but appears attributable to demographic and socio-economic characteristics. Infants who had a CHN visit were significantly more likely (OR = 2.51) to use the developmental clinic than those without a nurse visit. Infants whose mothers had inadequate prenatal care were less likely to use these follow-up services even after controlling for study variables. CONCLUSIONS: Infants whose mothers had inadequate prenatal care should be targeted for more intense CHN visits. Infants of mothers born in Mexico may need additional support/assistance in using the developmental clinic.