Metformin Plus Insulin for Preexisting Diabetes or Gestational Diabetes in Early Pregnancy: The MOMPOD Randomized Clinical Trial.

Importance: Insulin is recommended for pregnant persons with preexisting type 2 diabetes or diabetes diagnosed early in pregnancy. The addition of metformin to insulin may improve neonatal outcomes. Objective: To estimate the effect of metformin added to insulin for preexisting type 2 or diabetes diagnosed early in pregnancy on a composite adverse neonatal outcome. Design, Setting, and Participants: This randomized clinical trial in 17 US centers enrolled pregnant adults aged 18 to 45 years with preexisting type 2 diabetes or diabetes diagnosed prior to 23 weeks' gestation between April 2019 and November 2021. Each participant was treated with insulin and was assigned to add either metformin or placebo. Follow-up was completed in May 2022. Intervention: Metformin 1000 mg or placebo orally twice per day from enrollment (11 weeks -<23 weeks) through delivery. Main Outcome and Measures: The primary outcome was a composite of neonatal complications including perinatal death, preterm birth, large or small for gestational age, and hyperbilirubinemia requiring phototherapy. Prespecified secondary outcomes included maternal hypoglycemia and neonatal fat mass at birth, and prespecified subgroup analyses by maternal body mass index less than 30 vs 30 or greater and those with preexisting vs diabetes early in pregnancy. Results: Of the 831 participants randomized, 794 took at least 1 dose of the study agent and were included in the primary analysis (397 in the placebo group and 397 in the metformin group). Participants' mean (SD) age was 32.9 (5.6) years; 234 (29%) were Black, and 412 (52%) were Hispanic. The composite adverse neonatal outcome occurred in 280 (71%) of the metformin group and in 292 (74%) of the placebo group (adjusted odds ratio, 0.86 [95% CI 0.63-1.19]). The most commonly occurring events in the primary outcome in both groups were preterm birth, neonatal hypoglycemia, and delivery of a large-for-gestational-age infant. The study was halted at 75% accrual for futility in detecting a significant difference in the primary outcome. Prespecified secondary outcomes and subgroup analyses were similar between groups. Of individual components of the composite adverse neonatal outcome, metformin-exposed neonates had lower odds to be large for gestational age (adjusted odds ratio, 0.63 [95% CI, 0.46-0.86]) when compared with the placebo group. Conclusions and Relevance: Using metformin plus insulin to treat preexisting type 2 or gestational diabetes diagnosed early in pregnancy did not reduce a composite neonatal adverse outcome. The effect of reduction in odds of a large-for-gestational-age infant observed after adding metformin to insulin warrants further investigation. Trial Registration: ClinicalTrials.gov Identifier: NCT02932475.

Society for Maternal-Fetal Medicine Special Statement: Commitment to excellence in obstetrical care, research, and education for people with diverse sexual and gender identities.

The Society for Maternal-Fetal Medicine seeks to ensure excellence in obstetrical outcomes for all people who desire or experience pregnancy, including people with diverse sexual and gender identities. The Society commits to the use of practices in clinical and research settings that affirm the sexual and gender identities of all people, encourages the development of undergraduate and graduate medical education curricula and training programs that address diverse pathways to pregnancy and support clinicians with diverse sexual and gender identities, and promotes the use of inclusive language that is accurate and, when possible, specific.

Is a 'guideline-compliant' primary cesarean delivery associated with a modified risk for maternal and neonatal morbidity?: a clinical evaluation of the 2014 ACOG/SMFM obstetric care consensus statement.

BACKGROUND: It is currently unknown whether primary CDs performed in compliance with the 2014 ACOG/SMFM Obstetric Care Consensus Statement guidelines ("guideline-compliant") are associated with a modified risk of maternal and neonatal morbidity, when compared to primary CDs performed outside the guidelines ("guideline-noncompliant"). Our primary objective was to determine if a guideline-compliant primary CD is associated with a modified risk for maternal or neonatal morbidity, when compared to guideline-noncompliant primary CD. METHODS: A retrospective cohort study of all primary CDs at one tertiary referral center in the calendar year following publication of the Consensus Statement. Logistic regression was performed to calculate the risk of adverse maternal and neonatal outcomes for guideline-compliant primary CDs, when compared to guideline-noncompliant and guideline-not addressed, and when adjusted for maternal age, BMI, hypertension, gestational age at delivery, insurance carrier, and provider practice. RESULTS: Eight hundred twenty-seven primary CDs were included during the study period, of which 34.8, 26.0, and 39.2% were guideline compliant, guideline-noncompliant, and guideline-not addressed. No statistically significant differences in the frequency of adverse maternal outcomes across these three groups were observed with the exception of maternal ICU admission, which was significantly associated with a guideline-not addressed primary CD (p = 0.0002). No statistical difference in rates of NICU admissions, 5 min APGAR < 5, or umbilical artery cord pH < 7 were observed between guideline-compliant and guideline-noncompliant primary CDs. CONCLUSION: Women undergoing guideline-compliant primary CDs were not significantly more likely to experience a maternal or neonatal morbidity when compared to guideline-noncompliant primary CDs.

Intake of Caffeinated Soft Drinks before and during Pregnancy, but Not Total Caffeine Intake, Is Associated with Increased Cerebral Palsy Risk in the Norwegian Mother and Child Cohort Study.

BACKGROUND: Postnatal administration of caffeine may reduce the risk of cerebral palsy (CP) in vulnerable low-birth-weight neonates. The effect of antenatal caffeine exposure remains unknown. OBJECTIVE: We investigated the association of intake of caffeine by pregnant women and risk of CP in their children. METHODS: The study was based on The Norwegian Mother and Child Cohort Study, comprising >100,000 live-born children, of whom 222 were subsequently diagnosed with CP. Mothers reported their caffeine consumption in questionnaires completed around pregnancy week 17 (102,986 mother-child pairs), week 22 (87,987 mother-child pairs), and week 30 (94,372 mother-child pairs). At week 17, participants were asked about present and prepregnancy consumption. We used Cox regression models to estimate associations between exposure [daily servings (1 serving = 125 mL) of caffeinated coffee, tea, and soft drinks and total caffeine consumption] and CP in children, with nonconsumers as the reference group. Models included adjustment for maternal age and education, medically assisted reproduction, and smoking, and for each source of caffeine, adjustments were made for the other sources. RESULTS: Total daily caffeine intake before and during pregnancy was not associated with CP risk. High consumption (≥6 servings/d) of caffeinated soft drinks before pregnancy was associated with an increased CP risk (HR: 1.9; 95% CI: 1.2, 3.1), and children of women consuming 3-5 daily servings of caffeinated soft drinks during pregnancy weeks 13-30 also had an increased CP risk (HR: 1.7; 95% CI: 1.1, 2.8). A mean daily consumption of 51-100 mg caffeine from soft drinks during the first half of pregnancy was associated with a 1.9-fold increased risk of CP in children (HR: 1.9; 95% CI: 1.1, 3.6). CONCLUSIONS: Maternal total daily caffeine consumption before and during pregnancy was not associated with CP risk in children. The observed increased risk with caffeinated soft drinks warrants further investigation.

Co-occurrence of mental illness and substance use among US pregnant individuals, 2012-2021.

AIM: Substance use disorders are increasingly prevalent among pregnant individuals, with evident risks of adverse perinatal outcomes. This study examines substance use (tobacco, alcohol and marijuana) among pregnant individuals with mental illness. METHODS: A national representative sample of pregnant individuals were derived from 2012 to 2021 National Survey of Drug Use and Health data. Associations of past-year mental illness with past-month polysubstance use and each substance use were analyzed by logistic regression models, with complex sampling weights and survey year. RESULTS: Among 6801 pregnant individuals, 16.4% reported having any mental illness (AMI) in 2012 and 2013, increasing to 23.8% in 2020-2021; and SMI increased from 3.3% to 9.4%. Polysubstance use increased disproportionately among those with severe mental illness (SMI), from 14.0% to 18.6%. Pregnant individuals with greater severity of mental illness had higher odds of polysubstance use (Adjusted Odds Ratio, 95% CI: AMI but no SMI vs. without AMI: 1.59 [1.04, 2.44]; SMI vs. without AMI: 5.48 [2.77, 10.82]). CONCLUSIONS: Pregnant individuals with greater severity of mental illness were more likely to engage in substance use. Evidence-based educational, screening and treatment services, and public policy changes are warranted to mitigate the harmful health outcomes of substance use among US pregnant individuals with mental illness.

Sex differences in interpersonal violence in Malawi: analysis of a hospital-based trauma registry.

BACKGROUND: Although interpersonal violence ("assault") exists in every society, the World Health Organization (WHO) estimated that 90 % of the exposure burden occurs in low- and middle-income countries. The objectives of this study were to define the incidence of assault-related injuries among subjects presenting for emergency room care secondary to sustained trauma in Lilongwe, Malawi; to measure the impact of sex on incidence, injury type, and care received; and to measure the effect of both sex and geographic location of the injury on time to presentation for medical care. METHODS: This is a retrospective cohort analysis of data prospectively collected in the Kamuzu Central Hospital Trauma Surveillance Registry from July 2008 to December 2010 (n = 23,625). We used univariate, bivariate, and logistic regression analyses to measure association of sex with variables of interest, and geospatial mapping to evaluate the association of location of assault on time to presentation for care. RESULTS: The mean age of our trauma cohort was 27.7 years. Assaults accounted for 26.8 % of all injuries. Of those assaulted, 21.0 % (1299) were female, who were younger (26.2 vs. 28.1 years, p < 0.001), more likely to arrive to the hospital by minibus (p < 0.001), and less likely to arrive by police (p < 0.001). Altogether 62 % of the females were assaulted in their homes-much more often than their male counterparts (p < 0.001). Females were more likely to sustain contusions (p < 0.001) and males more likely to have lacerations and penetrating stab wounds (p < 0.001) or head injury (p < 0.001). Females had delayed hospital presentation following assault (p = 0.001) and were more likely to be treated as outpatients after adjusting for age, injury type, and injury location (adjusted odds ratio 1.74, 95 % CI 1.3-2.3, p < 0.001). Assaults clustered geographically in the Lilongwe district. Delayed presentation of females occurred irrespective of proximity to the hospital. CONCLUSIONS: This study brings attention to sex differences in assault victims. A prevention strategy focusing on sex roles and domestic abuse of women is paramount. Efforts are needed to stop dischargin female assault victims back into a potentially unsafe, abusive environment.

Robotic resection of adnexal masses during pregnancy.

OBJECTIVE: To characterize the safety and feasibility of robotic adnexal surgery during pregnancy, and to compare surgical and obstetric outcomes for robotic versus laparoscopic treatment of adnexal masses during pregnancy. STUDY DESIGN: A retrospective cohort study of all cases of robotic resection of adnexal masses in gravid patients performed at our institution between 2006 and 2009 compared with 50 consecutive historic laparoscopic controls performed between 1999 and 2007. RESULTS: During the study period, 19 parturients underwent planned robotic resection of adnexal masses, all of which were uncomplicated. Compared with 50 consecutive laparoscopic controls, no differences in operative time, conversion to laparotomy, intraoperative or postoperative complications, or observed obstetric outcomes were apparent. The robotic cohort had a significantly shorter length of hospital stay (p < 0.01) and estimated blood loss (p = 0.02). CONCLUSION: Robotic resection of adnexal masses during pregnancy appears both safe and feasible, with similar surgical outcomes when compared with a historic laparoscopic cohort.

"It Just Depends on Their Stability": A Qualitative Examination of Patient Factors Influencing Providers' Contraceptive Counseling Approaches for Persons With Substance Use Disorders.

OBJECTIVES: This qualitative study examined how patient-related factors influence providers' contraceptive counseling for persons with substance use disorders (SUDs). Specifically, we explored individual behavior and social factors that contribute to providers modifying their contraceptive counseling approaches and described how providers alter their counseling recommendations and communication strategies in the presence of such factors. METHODS: In 2019, we purposively recruited a national sample of contraceptive providers (N = 24) and conducted semistructured phone interviews to inquire about their contraceptive counseling practices for women with SUDs. Interviews were audio recorded, transcribed verbatim, and analyzed using thematic analysis with inductive codes. RESULTS: Participants included 10 medical doctors, 8 nurse practitioners, and 6 certified nurse-midwives. We found that providers modify their contraceptive counseling provision when their patients are actively using substances or have unstable living conditions, such as intimate partner violence or homelessness. With patients experiencing these instabilities, providers reported postponing contraceptive discussions until patients are stabilized in treatment, recommending long-active reversible contraceptive methods, and varying communication styles according to their own perceptions of patients' communication needs. Providers perceived that individuals in long-term recovery have increased stability and fewer barriers to contraceptive access and adherence and therefore reported increased willingness to provide greater autonomy during contraceptive decision making and shift the counseling focus to short-acting contraceptive methods. CONCLUSIONS: This study highlights that substance use and social "stability" of patients contributes to how providers approach their contraceptive counseling and make methods recommendations for their patients with SUDs. More research is needed to understand strategies that individuals with SUDs use to overcome barriers to contraceptive access and adherence in the context of active substance use and social instability.

Impact of restricting early-term deliveries on adverse neonatal outcomes: a statewide analysis.

BACKGROUND: The "39-Week Rule" was adopted by the American College of Obstetricians and Gynecologists in 2009 to eliminate nonmedically indicated (elective) deliveries before 39 weeks in an effort to improve neonatal outcomes. OBJECTIVE: Our primary objective was to quantify the effect of this policy change on adverse neonatal outcomes among a cohort of term births in South Carolina. STUDY DESIGN: Deidentified data from all births in the state of South Carolina from 2000 to 2008 (before the 39-week rule) and from 2013 to 2017 (after statewide implementation and enforcement of the rule) were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic data and International Statistical Classification of Diseases and Related Health Problems Ninth/Tenth Revision codes were obtained for each birth. Our primary outcome was admission to a neonatal intensive care unit. Our secondary outcomes were respiratory morbidities (including respiratory distress syndrome and transient tachypnea of the newborn), hypoxic-ischemic encephalopathy, seizure, sepsis, birth injuries, hyperbilirubinemia, hypoglycemia, and feeding difficulties. Propensity score analysis was used to control for maternal age, body mass index, race, gestational hypertension, infection, placental abruption, and gestational and pregestational diabetes mellitus. After stratification by propensity score, the Cochran-Mantel-Haenszel test was used to compare groups. RESULTS: A total of 620,121 infants were liveborn at term during the 2 study periods. After implementation of the 39-week rule, there was a significant reduction in early-term deliveries. In adjusted analyses, neonatal intensive care unit admission was significantly more common in the postimplementation period. Respiratory morbidities were also significantly more common postimplementation. In contrast, there were significant reductions in birth injuries and hyperbilirubinemia in the postimplementation period. CONCLUSION: Implementation of the 39-week rule was associated temporally with an increase in adverse neonatal outcomes. The outcomes intended to be reduced by the 39-week rule, including neonatal intensive care unit admission and respiratory morbidity, seem to have increased in incidence despite adherence to the proposed guidelines.

Impact of the "39-week rule" on adverse pregnancy outcomes: a statewide analysis.

BACKGROUND: The "39-week rule," adopted by the American College of Obstetricians and Gynecologists circa 2009, discouraged routine elective induction of labor in early-term gestations (37 weeks 0 days-38 weeks 6 days) to decrease the risk of adverse neonatal outcomes. However, little research exists regarding any unintended adverse pregnancy outcomes associated with this policy shift. OBJECTIVE: This study aimed to quantify the difference in incidence of adverse pregnancy outcomes before and after the implementation of the 39-week rule. STUDY DESIGN: Deidentified data from all births in the state of South Carolina from 2000 to 2008 (before the 39-week rule) and from 2013 to 2017 (after statewide implementation and enforcement of the rule) were obtained from the South Carolina Revenue and Fiscal Affairs Office. Demographic data and International Classification of Diseases 9/10 codes were obtained for each birth. Our primary outcome was the incidence of any of the following adverse pregnancy outcomes: cesarean delivery, hypertensive disorders, chorioamnionitis, postpartum hemorrhage, high-degree lacerations, placental abruption, and intensive care unit admission. Propensity score analysis was used to control for age, body mass index, and race. After stratification by propensity score, the Cochran-Mantel-Haenszel test was used to compare the prerule and postrule groups. RESULTS: A total of 633,985 births were eligible for inclusion-412,632 from 2000 to 2008, and 221,353 from 2013 to 2017. There was a significant increase in the primary outcome in the postrule period (39.94% pre vs 42.76% post; P<.01). The incidence of all hypertensive disorders was significantly increased in the postrule period compared with the prerule period (7.75% pre vs 10.1% post; P<.01). The incidence of chorioamnionitis and cesarean delivery also increased in the postrule period (1.45% pre vs 1.92% post; P<.01; 29.6% pre vs 31.82% post; P<.01; respectively). CONCLUSION: There was a significant increase in the primary outcome following the implementation of the 39-week rule. Although the policy shift was driven by a desire to decrease adverse neonatal outcomes, aggregate benefit was not observed for pregnancy outcomes.

Leveraging Digital Technology to Support Pregnant and Early Parenting Women in Recovery from Addictive Substances: A Scoping Review.

Little is known about digital health interventions used to support treatment for pregnant and early parenting women (PEPW) with substance use disorders (SUD). METHODS: Guided by the Arksey and O'Malley's Scoping Review Framework, empirical studies were identified within the CINAHL, PsycInfo, PubMed, and ProQuest databases using subject headings and free-text keywords. Studies were selected based on a priori inclusion/exclusion criteria, and data extraction and descriptive analysis were performed. RESULTS: A total of 27 original studies and 30 articles were included. Varying study designs were used, including several feasibility and acceptability studies. However, efficacious findings on abstinence and other clinically important outcomes were reported in several studies. Most studies focused on digital interventions for pregnant women (89.7%), suggesting a dearth of research on how digital technologies may support early parenting women with SUD. No studies included PEPW family members or involved PEPW women in the intervention design. CONCLUSIONS: The science of digital interventions to support treatment for PEPW is in an early stage, but feasibility and efficacy results are promising. Future research should explore community-based participatory partnerships with PEPW to develop or tailor digital interventions and include family or external support systems to engage in the intervention alongside PEPW.

Efficient use of early obstetric sonography in the emergency department setting.

OBJECTIVES: Transvaginal sonography is frequently used in the emergency department (ED) to triage pregnancies of unknown location. The purpose of this study was to examine the utility of sonography in clinically stable patients with ß-human chorionic gonadotropin (ß-hCG) values below the discriminatory zone. METHODS: We conducted a retrospective cohort study of 408 consecutive ED patients who presented with pregnancies of unknown location and serum ß-hCG levels between 5 and 2500 mIU/mL and underwent transvaginal sonography. Women were classified as receiving immediate treatment or expectant management. Predictors associated with immediate treatment were assessed by bivariate analyses and logistic regression. RESULTS: Of the cohort, 361 women (88.5%) received expectant management, and 6.9%, 3.1%, and 0% of patients with pregnancies of unknown location and ß-hCG levels below 1000, 200, and 75 mIU/mL, respectively, received immediate treatment. Compared to the expectant management group, women receiving immediate treatment (n=47) were further from the last menstrual period (7.86 versus 6.10 weeks; P <.01), were more likely to report pain (59.6% versus 40.2% P = .01), had higher ß-hCG levels(1183 versus 608 mIU/mL; P <.01), and had lower hematocrit levels (35.7% versus 37.0%; P < .01), with pain the most predictive factor for immediate treatment (odds ratio,5.97; 95% confidence interval, 2.45-14.53). A model combining symptoms, ß-hCG, hematocrit, and weeks since the last menstrual period predicted the likelihood of sonography changing management from expectant management to immediate treatment with specificity of 98%. CONCLUSIONS: The diagnostic utility of sonography in clinically stable patients presenting to the ED in very early pregnancy is limited. A model using symptoms, ß-hCG, hematocrit, and the last menstrual period may aid clinicians to triage those who would benefit from immediate sonography.

Provider Perspectives of Barriers to Contraceptive Access and Use among Women with Substance Use Disorders.

OBJECTIVES: Previous studies conducted from the patient perspective indicate that women with substance use disorders (SUDs) experience extensive barriers to contraceptive access and use (CAU), but there is limited research investigating this topic from the provider perspective. We explored provider perspectives on the barriers to CAU for women with SUDs. As a secondary objective, we highlighted provider contraceptive counseling strategies to address patient CAU barriers. METHODS: We conducted 24 qualitative interviews with a purposeful sample of women's health providers, including medical doctors, nurse practitioners, and certified nurse-midwives. We used thematic analysis to code the interviews with inductive codes and organized findings according to levels of influence within the Dahlgren and Whitehead rainbow model, a socioecological model of health. RESULTS: Provider-reported barriers to CAU were identified at four levels of socioecological influence and included reproductive misconceptions; active substance use; trauma, interpersonal violence, and reproductive coercion; limited social support; lack of housing, employment, health insurance, and transportation; stigma; discrimination; and punitive prenatal substance use policies and child welfare reporting requirements. Strategies for addressing CAU barriers mainly focused on patient-centered communication, including open information exchange, shared decision-making, and relationship building. However, providers described disproportionately highlighting the benefits of long-acting reversible contraception (LARC) and directing conversations toward LARC when they perceived that such methods would help patients to overcome adherence and other challenges related to active substance use or logistical barriers. Notably, there was no mention of CAU facilitators during the interviews. CONCLUSIONS: Providers perceived that women with SUDs experience a range of CAU barriers, which they addressed within the clinical setting through use of both patient-centered communication and highlighting the benefits of LARC when they perceived that such methods would help clients to overcome barriers. Improving CAU for women with SUDs will require multidisciplinary, multipronged strategies that prioritize reproductive autonomy and are implemented across clinical, community, and policy settings.

Understanding Alcohol Use Discourse and Stigma Patterns in Perinatal Care on Twitter.

(1) Background: perinatal alcohol use generates a variety of health risks. Social media platforms discuss fetal alcohol spectrum disorder (FASD) and other widespread outcomes, providing personalized user-generated content about the perceptions and behaviors related to alcohol use during pregnancy. Data collected from Twitter underscores various narrative structures and sentiments in tweets that reflect large-scale discourses and foster societal stigmas; (2) Methods: We extracted alcohol-related tweets from May 2019 to October 2021 using an official Twitter search API based on a set of keywords provided by our clinical team. Our exploratory study utilized thematic content analysis and inductive qualitative coding methods to analyze user content. Iterative line-by-line coding categorized dynamic descriptive themes from a random sample of 500 tweets; (3) Results: qualitative methods from content analysis revealed underlying patterns among inter-user engagements, outlining individual, interpersonal and population-level stigmas about perinatal alcohol use and negative sentiment towards drinking mothers. As a result, the overall silence surrounding personal experiences with alcohol use during pregnancy suggests an unwillingness and sense of reluctancy from pregnant adults to leverage the platform for support and assistance due to societal stigmas; (4) Conclusions: identifying these discursive factors will facilitate more effective public health programs that take into account specific challenges related to social media networks and develop prevention strategies to help Twitter users struggling with perinatal alcohol use.

Placenta previa in the second trimester: sonographic and clinical factors associated with its resolution.

We identify characteristics that predict resolution of placenta previa and develop a clinical model for likelihood of resolution. We conducted a retrospective study of 366 singleton pregnancies complicated by placenta previa diagnosed with resolution of the previa as the primary outcome. Regression analyses were performed to determine variables associated with resolution and optimal timing for repeat sonographic evaluation. A likelihood of resolution model was created using a parametric survival model with Weibull hazard function. Of the 366 cases, 84% of complete placentae previae and 98% of marginal placentae previae resolved at a mean gestational age of 28.6 ± 5.3 weeks. Only gestational age and distance from the internal cervical os at the time of diagnosis were significantly associated with resolution ( P < 0.01). Likelihood of resolution was not significantly associated with any other variables. Marginal previae diagnosed in the second trimester do not appear to warrant repeat ultrasound evaluation for resolution.

Contraceptive initiation after delivery among women with and without opioid use disorders: A retrospective cohort study in a statewide Medicaid population, 2005-2016.

BACKGROUND: This study examined contraceptive initiation patterns in the 12 months following childbirth among women with opioid use disorder (OUD), women with non-opioid substance use disorders (SUDs), and women without SUDs. METHODS: We conducted a retrospective cohort study using claims data from South Carolina Medicaid-enrolled women aged 15-44 who had singleton live birth between January 2005 and December 2016. Study outcomes were initiation of most or moderately effective (MME) contraceptive methods. Using multivariable and propensity score-weighted logistic regression, we analyzed the relationship between OUD and contraceptive initiation within 12 months after delivery. RESULTS: We identified 71,283 live birth deliveries during the study period. In multivariable analysis, women with non-opioid SUDs and women without SUDs compared to women with OUD were more likely to initiate a MME method vs a least effective method or no method by 3 months (non-opioid SUDs: odds ratio [OR] = 1.32, 95 % confidence interval [CI] = 1.14-1.52; no SUDs: OR = 1.55, 95 % CI = 1.36-1.77) and 12 months (non-opioid SUD: OR = 1.23, 95 % CI = 1.06-1.42; no SUD: OR = 1.46, 95 % CI = 1.27-1.66) after delivery. With regards to the timing of initiation, women with non-opioid SUDs and women without SUDs were more likely than women with OUD to initiate a MME method vs a least effective method or no method after the immediate postpartum period through 3 months following delivery (non-opioid SUDs: OR = 1.41, 95 % CI = 1.18-1.68; no SUDs: OR = 1.87, 95 % CI = 1.59-2.21). We detected the similar patterns in analyses that used propensity score weighting. CONCLUSION: OUD was associated with decreased likelihood of initiating a MME contraceptive method within 12 months after delivery.

Exercise Counseling in Pregnancy: Do Women Perceive Receiving the Information They Need?

The American College of Obstetricians and Gynecologists recommends that women exercise throughout pregnancy unless they have a condition-related contraindication. This study's purpose was to determine if pregnant women perceive receiving exercise counseling by their providers with details of frequency, intensity, type, and time (FITT principle). Women in 2 postpartum care units of a large health care system were invited to complete a voluntary, anonymous survey regarding whether they received exercise counseling during their prenatal care. Survey results were descriptively reported, stratified by demographic variables, and analyzed using Fisher's exact tests. Of 224 postpartum women surveyed, 130 (58.0%) perceived receiving exercise counseling during pregnancy; 119 (91.5%) did not recall receiving counseling on exercise frequency. Though 165 (73.6%) exercised before becoming pregnant, 64 (38.8%) ceased exercise during pregnancy. Eighty-eight (39.3%) received advice from other sources/non-health care professionals. Privately insured women reported receiving exercise counseling at a higher rate (70.1%) than those on Medicaid (44.8%) or uninsured (40.0%; P = .004). A disproportionate number of pregnant women perceived not receiving adequate prenatal exercise counseling or received incomplete counseling. Women at a socioeconomic disadvantage may be vulnerable. As social determinants of health, structural barriers, and socioeconomic status likely contribute, women may benefit from more targeted inclusive and equitable messaging.

"It's a very nuanced discussion with every woman": Health care providers' communication practices during contraceptive counseling for patients with substance use disorders.

OBJECTIVE: To explore health care providers' communication practices during contraceptive counseling for women with substance use disorders (SUDs). STUDY DESIGN: In 2019, we conducted semi-structured phone interviews with a purposive sample of medical doctors and advanced practice nurses (n = 24). A two-member team analyzed these interviews for themes using deductive and inductive techniques and ATLAS.ti to manage the data. RESULTS: Providers discussed that developing strong interpersonal relationships and trust is critically important to provide effective contraceptive counseling to women with SUDs. Providers reported exchanging information with patients by asking open-ended questions, tailoring discussions to patients' responses, and being direct but not judgmental. To facilitate contraceptive decision-making, providers described eliciting patients' preferences for contraceptive methods while simultaneously using their own clinical judgment and professional experience to identify which methods would be most effective and appropriate for their patients. Most often these were long-acting reversible contraceptive methods, and providers emphasized the benefits of these methods for women with SUDs. CONCLUSION: Providers used a variety of communication strategies, some of which were grounded in the principles of patient-centered care and others that were directive, to discuss contraception with women with SUDs. IMPLICATIONS: Because of past and ongoing stigma and discrimination by health care professionals and the general public, women with SUDs may be distrustful of contraceptive providers. Patient-centered contraceptive counseling may be an effective approach to increase trust and improve relationships and communication between women with SUDs and their providers. Additional research with women with SUDs is needed to understand women's experiences with and preferences for patient-provider communication during contraceptive counseling.