How Much is too Much? High Utilization of Prenatal Care and Its Impact on Primary Cesarean Birth Among Women in the United States.

INTRODUCTION: Nationally, cesarean birth is one of the most performed surgical procedures, yet cesarean births have been linked to an increased risk of delivery complications. Prenatal care (PNC) and education are possible strategies to reduce the number of cesarean births. However, there is scant research assessing the impact of these strategies on safely reducing primary cesarean births. This study evaluates the association between the adequacy of PNC utilization and primary cesarean birth. METHODS: The analysis used 2018 birth certificate data, and the sample included nulliparous women with no reported pregnancy or delivery complications (N = 729,140). Logistic regression was used to model the association between the adequacy of PNC utilization and delivery method, as well as identify other factors associated with the delivery method. RESULTS: Among women with a primary cesarean birth, 36.2% had received adequate plus PNC. After adjustment, there was no significant association between women receiving inadequate, intermediate, or adequate PNC and primary cesarean birth. However, women who received adequate plus PNC had an increased odds of having a primary cesarean birth compared to women with no PNC (OR, 1.23; 95% CI, 1.18-1.28). DISCUSSION: Findings from this study highlight the need to further understand the role of PNC and its potential impact on the delivery method. Within the patient-provider relationship, healthcare providers have the unique opportunity to provide education and inform patients of the risks and benefits of all delivery options. Thus, there is an increased opportunity to safely reduce primary cesarean births.

Pre-pregnancy Diabetes, Pre-pregnancy Hypertension and Prenatal Care Timing among Women in the United States, 2018.

INTRODUCTION: Women with pre-pregnancy diabetes or pre-pregnancy hypertension have increased risks of complications during pregnancy. Women who obtain prenatal care in the first trimester receive necessary routine testing and disease management tools that aid in controlling such conditions. However, research on the association between pre-pregnancy hypertension and pre-pregnancy diabetes and prenatal care timing among US women is limited. METHODS: This study used data from the 2018 National Vital Statistic System (n = 3,618,853). Trained personnel collected information on prenatal care timing, maternal conditions, and demographics. Multivariate logistic regression models evaluated the association between pre-pregnancy hypertension, pre-pregnancy diabetes and prenatal care timing. A stratified analysis was conducted to determine if race/ethnicity modified the associations. RESULTS: After adjustment, women with pre-pregnancy hypertension or pre-pregnancy diabetes had statistically significant increased odds of receiving early prenatal care compared to women without these conditions (OR 1.23; 95% CI: 1.21-1.26 and OR 1.27; 95% CI: 1.24-1.31, respectively). Among non-Hispanic White, non-Hispanic Black, and Hispanic women, those with pre-pregnancy hypertension or pre-pregnancy diabetes had statistically significantly increased odds of receiving early prenatal care compared to women without those pre-existing conditions (P < .001). DISCUSSION: Further research is needed on the transition from preconception care to obstetric care for women with pre-existing diabetes or hypertension. However, these findings suggest that women who have conditions that could cause pregnancy complications are pursuing early prenatal care services to mitigate the development of adverse maternal and infant health conditions.

The Association Between Preconception Care Receipt and the Timeliness and Adequacy of Prenatal Care: An Examination of Multistate Data from Pregnancy Risk Assessment Monitoring System (PRAMS) 2009-2011.

Objectives Prenatal care (PNC) is a critical preventive health service for pregnant women and infants. While timely PNC has been associated with improved birth outcomes, improvements have slowed since the late 1990s. Therefore, focus has shifted to interventions prior to pregnancy. Preconception care is recommended for all women of reproductive age. This study aimed to examine preconception care and its association with timeliness and adequacy of PNC. Methods This retrospective cohort study used data from a large sample of United States first-time mothers (n = 13,509) who participated in the 2009-2011 Pregnancy Risk Assessment Monitoring System in ten states. Timeliness and adequacy of PNC data came from birth certificates, while preconception care receipt was self-reported. Logistic regression provided odds ratios (ORs) and 95% confidence intervals (CIs) to model the association between preconception care receipt and the two PNC outcomes. Results After adjustment, women who received preconception care had statistically significant increased odds of timely (OR 1.30, 95% CI 1.08, 1.57), but not adequate PNC (OR 1.08, 95% CI 0.94, 1.24) as compared to women who did not receive preconception care. Pregnancy intention modified these associations. Associations were strongest among women with intended pregnancies (timely PNC: OR 1.63 and adequate PNC: OR 1.22). Conclusions for Practice Given that untimely PNC is associated with adverse birth outcomes, the observed association warrants increased focus on implementing preconception care. Future studies should investigate how specific components of preconception care are associated with PNC timeliness/adequacy, health behaviors during pregnancy, and birth outcomes.

Associations of Household Wealth and Individual Literacy with Prenatal Care in Ten West African Countries.

Objective To examine associations of household wealth and individual literacy with prenatal care in West Africa. Methods Data on women with recent births in Benin, Burkina Faso, Ghana, Guinea, Liberia, Mali, Nigeria, Niger, Senegal and Sierra Leone were obtained from 2006 to 2010 Demographic and Health Surveys (n = 58,512). Separate logistic regressions estimated associations of literacy and wealth quintiles with prenatal care, controlling for age, parity, marital status, rural/urban residence, religion, multiple births, pregnancy wantedness, and the woman's involvement in decision-making at home. Any prenatal care was defined by ≥1 prenatal care visit. Adequate prenatal care was defined as at least four prenatal care visits beginning in the first trimester, at least one with a skilled provider. Results Seventy-eight percent of women had any prenatal care; 23 % had adequate care. Women who were not literate had lower odds of having any prenatal care (odds ratio, OR 0.29; 95 % confidence interval, CI 0.26-0.33) and lower odds of adequate care (OR 0.73, CI 0.68-0.78). Women in the poorest wealth quintile were substantially less likely to have any prenatal care than women in the wealthiest quintile (OR 0.24, CI 0.11-0.18), and less likely to have adequate care (OR 0.31, CI 0.27-0.35). Conclusions for Practice A substantial percentage of women in West Africa have no prenatal care. Few have adequate care. Illiteracy and poverty are important risk factors for having little or no prenatal care. Increasing education for girls, promoting culturally appropriate messages about prenatal care, and building trust in providers may increase prenatal care.

The Association Between Maternal Depression During Pregnancy and Adverse Birth Outcomes: A Retrospective Cohort Study of PRAMS Participants.

Women of reproductive age are at higher risk for depression than men; and depressive behaviors and endocrine imbalances could lead to adverse birth outcomes. The purpose of this study was to investigate whether maternal depression during pregnancy affected adverse birth outcomes, specifically preterm birth and small for gestational age (SGA). This study included 4123 women who participated in the 2009-2011 Utah Pregnancy Risk Assessment Monitoring System, an ongoing surveillance project that investigates maternal behaviors in women who have recently had a live birth. Women self-reported information on depression and outcome data were obtained from birth certificates. Logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs). Women who self-reported a diagnosis of depression during pregnancy had statistically significant increased odds of preterm birth as compared to women who had not been diagnosed with depression (OR 1.51; 95% CI 1.07, 2.12); there was no association between depression and SGA (OR 0.92; 95% CI 0.63, 1.34). After adjustment for prenatal care visits, the depression-preterm birth association was attenuated and no longer statistically significant (OR 1.29; 95% CI 0.90, 1.85). After adjustment for smoking, there continued to be no strong association between depression and SGA (OR 0.80; 95% CI 0.54, 1.20). The findings of this study do not support a maternal depression-adverse birth outcomes relationship among a predominantly healthy population of non-Hispanic White, well educated women. Future studies should focus on other diverse populations of women to determine if there is an association for these subgroups.

The association between contraceptive use at the time of conception and hypertensive disorders during pregnancy: a retrospective cohort study of prams participants.

Each year approximately 7 % of women experience hypertensive disorders during pregnancy which can result in adverse events for both the mother and child. Previous research suggests that contraception at the time of conception can also predispose one to hypertensive disorders during pregnancy. The objective of this study was to examine the association between contraceptive use at the time of conception and hypertensive complications during pregnancy. A total of 2,395 women aged 18-45 years participated in the 2007-2009 Michigan Pregnancy Risk Assessment Monitoring System. Contraception at the time of conception was self-reported by participants and classified as barrier, nonbarrier, or non-use. Information on hypertensive disorders during pregnancy was primarily from birth certificates. Logistic regression was used to obtain odds ratios (ORs) and 95 % confidence intervals (CIs) to model the contraception-hypertensive disorder association. After adjustment for age and race/ethnicity, there was no strong association between use of barrier contraception at the time of conception and hypertensive disorders during pregnancy as compared to non-users (OR 1.09, 95 % CI 0.62-1.92). After adjustment for the same variables, nonbarrier users had 1.22 times the odds of experiencing hypertensive disorders during pregnancy as compared to non-users (95 % CI 0.75-1.98). Although we did not find an association between contraceptive use at the time of conception and hypertensive disorders during pregnancy, additional studies with larger sample sizes and more explicit categorization of the outcome variable are needed to confirm these findings.

Comparison of prospective and retrospective measurements of frequency of sexual intercourse.

Measurements of sexual intercourse frequency are informative for research on pregnancy, contraception, and the transmission of sexually transmitted infections; however, efficiently collecting data on this sensitive topic is complex. The purpose of this study was to determine whether retrospective recall of sexual intercourse frequency was consistent with information obtained through the use of prospective daily diary methods corresponding to the same time period in a diverse sample of women. A total of 185 women participated in a longitudinal, prospective cohort study of oral contraceptive users and 98 of these women provided complete information on sexual intercourse frequency on diaries (prospective) and postcards (retrospective). Linear mixed models were used to test for variation in response within categories of demographic and other variables. The mean number of days women had sexual intercourse per week was 1.5 days using prospective diary information versus 2.0 days when using 3-month retrospective recall (p < 0.001). Mean differences for the various sociodemographic subgroups were positive for all groups indicating that women consistently reported a higher frequency of sexual intercourse on the retrospective postcards than they recorded on their prospective diaries; however, these mean differences did not vary significantly. If confirmed in other samples, the use of retrospective methods may be adequate to accurately collect data on sexual intercourse frequency-and may be preferable. Using only retrospective measurements could decrease study costs, the burden to participants, and have a higher response rate.

Interbirth Intervals of Immigrant and Refugee Women in the United States: A Cross-Sectional Study.

Background and Objective: Despite guidelines recommending an interval of at least 18-24 months between a live birth and the conception of the next pregnancy, nearly one-third of pregnancies in the United States are conceived within 18 months of a previous live birth. The purpose of this study was to examine the associations between multiple immigration-related variables and interbirth intervals among reproductive-aged immigrant and refugee women living in the United States. Methods: This was a cross-sectional, quantitative study on the sexual and reproductive health (SRH) of reproductive-aged immigrant and refugee women in the United States. The data were collected via an online survey administered by Lucid LLC. We included data on women who had complete information on nativity and birth history in the descriptive analysis (n = 653). The exposure variables were immigration pathway, length of time since immigration, and country/region of birth. The outcome variable was interbirth interval (≤18, 19-35, or ≥36 months). We used multivariable ordinal logistic regression, adjusted for confounders, to determine the factors associated with having a longer interbirth interval among women with second- or higher-order births (n = 245). Results: Approximately 37.4% of study participants had a short interbirth interval. Women who immigrated to the United States for educational (aOR = 4.57; 95% CI, 1.57-9.58) or employment opportunities (aOR = 2.27; 95% CI, 1.07-5.31) had higher odds of reporting a longer interbirth interval (19-35 or ≥36 months) than women born in the United States. Women born in an African country had 0.79 times the odds (aOR = 0.79; 95% CI, 0.02-0.98) of being in a higher category of interbirth interval. Conclusion and Global Health Implications: Although all birthing women should be counseled on optimal birth spacing through the use of postpartum contraception, immigrant and refugee women would benefit from further research and policy and program interventions to help them in achieving optimal birth spacing. SRH research in African immigrant and refugee communities is especially important for identifying ameliorable factors for improving birth spacing.

Depressive symptoms and academic performance of North Carolina college students.

BACKGROUND: Depression negatively affects cognitive functioning and, consequently, academic performance. Studies of this association have yielded conflicting results and have not fully considered other factors that may play a role in academic performance. This study examines the relation between depression and academic performance in students at a large urban university in North Carolina. METHODS: We analyzed data from student responses to the 2008 cross-sectional National College Health Assessment to create categories of depressive symptomatology. E-mail invitations to participate in the assessment were sent to 8,000 students at the university in an effort to obtain at least 900 responses, the minimum number considered valid for a campus of its size. We analyzed the responses of the 1,280 undergraduates who completed the survey. Logistic regression analyses were performed to examine associations between depressive symptoms and academic performance in this group. RESULTS: Students in the second, third, and fourth quartiles of depressive symptomatology had increased, though statistically non-significant, odds of having a lower cumulative grade average, even after adjustment for age, sex, year in school, race/ethnicity, substance use, and level of credit-card debt. This difference was most pronounced among students in the second quartile of depressive symptomatology. LIMITATIONS: This cross-sectional study did not allow for evaluation of causality. In addition, the self-report nature of this questionnaire could have led to some inaccuracy in reporting. CONCLUSIONS: Students reporting even a small number of depressive symptoms may be at increased risk for academic problems.

The effects of hormonal contraceptive use on sleep patterns in women of reproductive age.

PURPOSE: Hormonal contraceptives alter hormone levels in women and have been linked to alterations in sleep patterns; however, previous studies yielded inconsistent results and lacked generalizability. This study examines hormonal contraceptive use and its impact on sleep outcomes, including sleep duration and sleep disturbances. METHODS: Women self-reported their sleep patterns and use of contraceptives in the 2017 population-based Behavioral Risk Factor Surveillance System Survey (n=1,970). Participants were categorized by use of hormonal or non-hormonal contraceptives for the purpose of pregnancy prevention. Sleep duration was defined as having met the recommended sleep levels of 7-9 hours per 24 hours. Sleep disturbances were defined as trouble falling asleep, staying asleep, or sleeping too much ≥ 6 days within a 14-day period. Prevalence ratios (PRs) and 95% confidence intervals (CIs) were calculated to examine the association between contraceptive use and each sleep outcome. SAS-callable SUDAAN was used for analyses to account for the complex sampling design. RESULTS: Women who used hormonal contraceptives had 6% higher prevalence of sleep disturbances (PR: 1.06, 95% CI: 0.99, 1.14) and 17% lower prevalence of not meeting sleep duration recommendations (PR: 0.83, 95% CI: 0.71, 0.98) compared to those who used non-hormonal contraceptives after adjustment for age. CONCLUSION: These findings suggest the use of hormonal contraceptives may have negative impacts on sleep disturbances, and positive effects on sleep duration among women using contraceptives for preventing pregnancy. Future studies should be conducted in diverse populations utilizing objective measurements of sleep patterns.

Associations between Place of Birth, Type of Attendant, and Small for Gestational Age Births among Pregnant non-Hispanic Black Medicaid Recipients.

INTRODUCTION: Although non-Hispanic Black women have increased risks of adverse birth outcomes compared with non-Hispanic white women in the United States, there is a lack of research specifically focusing on non-Hispanic Black women. Thus, this study's purpose was to evaluate whether place of birth and type of attendant used during labor is associated with having a newborn born small for gestational age (SGA) among non-Hispanic Black Medicaid recipients. METHODS: This study used 2017 Natality data from the National Vital Statistics System for non-Hispanic Black women who used Medicaid as a source of payment (N = 322,604). Type of attendant (ie, the medical professional who assisted during childbirth), place of birth (ie, setting where the woman gave birth), maternal factors, and SGA were obtained from birth certificates. We used multivariate logistic regression to investigate the association between place of birth, type of birth attendant, and newborns born SGA. RESULTS: After adjustment, women who used a certified nurse-midwife or other midwife as an attendant during labor had statistically significant decreased odds of having a neonate born SGA compared with those who had a physician as an attendant (odds ratio [OR], 0.69; 95% CI, 0.66-0.71 and OR, 0.68; 95% CI, 0.55-0.85, respectively). Those who gave birth in a birthing center or had planned home births also had statistically significant decreased odds of having a neonate born SGA (OR, 0.52; 95% CI, 0.38-0.69 and OR, 0.37; 95% CI, 0.21-0.66, respectively). However, those who had an unplanned home birth had twice the odds of having a neonate born SGA compared with those who gave birth at a hospital or clinic (OR, 2.00; 95% CI, 1.50-2.64). DISCUSSION: Given the racial disparity in adverse birth outcomes for non-Hispanic Black women, the observed associations provide justification for future research to determine whether birthing location and birth attendant are related to SGA.

Contraceptive use and discontinuation: findings from the contraceptive history, initiation, and choice study.

OBJECTIVE: The purpose of this study is to provide insight on the continuing high rate of unintended pregnancy among adult women. STUDY DESIGN: Contracepting women were recruited while they waited for primary care appointments. A total of 369 completed the baseline questionnaire, and 145 oral contraceptive (OC) users were enrolled in a 5-week, diary-based study of adherence and sexual activity. RESULTS: Most women who reported having discontinued OCs did so because of medical side effects, and most had switched to less effective methods. Among OC users, 26.4% had sexual intercourse on days they missed pills just before or after their placebo week. Nonadherence did not differ by socioeconomic factors or obesity. CONCLUSION: Clinicians may need to encourage their patients to discuss their reasons for wanting to discontinue the use of an effective contraceptive method and assist them with their concerns or to switch to other effective methods to protect themselves from unintended pregnancy.

The association between recreational parks, facilities and childhood obesity: a cross-sectional study of the 2007 National Survey of Children's Health.

BACKGROUND: Despite the rising childhood obesity rates, few studies have examined the association between access to recreational parks and facilities and obesity. METHODS: A cross-sectional study was performed among 42 278 US children who participated in the 2007 National Survey of Children's Health. Access to parks and recreational facilities was self-reported by parents, and body mass index was calculated from parents' self-report of the child's height and weight. Logistic regression was used to obtain ORs and 95% CIs. Since obesity was not a rare occurrence, an OR correction method was used to provide a more reliable estimate of the prevalence ratio (PR). RESULTS: Children with access to parks and facilities had decreased prevalence of obesity as compared to children without access (PR=0.79, 95% CI 0.69 to 0.91). After adjustment for covariates, the magnitude of the association remained unchanged; however, results were no longer statistically significant (PR=0.77, 95% CI 0.55 to 1.07). Race/ethnicity was an effect modifier of the access-obesity relationship (p<0.0001). Among Non-Hispanic White children, there was no strong association (PR=0.89, 95% CI 0.64 to 1.23). However, among Non-Hispanic Black children, those who had access to recreational parks and facilities had 0.40 times the prevalence of obesity as compared to those without access, and this result was statistically significant (95% CI 0.17 to 0.90). CONCLUSIONS: This research highlights potential health disparities in childhood obesity due to limited access to recreational parks and facilities. Additional studies are needed to further investigate this association. If confirmed, providing safe, accessible parks and facilities may be one way to combat childhood obesity, particularly among minority children.

Comparison of prospective daily diaries and retrospective recall to measure oral contraceptive adherence.

BACKGROUND: The purpose of this study was to determine if retrospective recall of oral contraceptive (OC) adherence provides data that are similar to data collected via daily diaries over the same time period. Factors associated with inconsistent agreement between prospective and retrospective measurements of adherence also were explored. STUDY DESIGN: A total of 185 women participated in a longitudinal, prospective cohort of OC users, and 113 of these women provided complete information on OC adherence during follow-ups. Concordance beyond chance was assessed using weighted kappa statistics, and logistic regression was used to identify factors associated with inconsistent reporting of adherence. RESULTS: There was substantial agreement between prospective and retrospective adherence information (weighted kappa=0.64; 95% CI: 0.52-0.77). Participants with a high school education or less and those who had problems with feeling sad while using OCs had increased odds of inconsistent reporting of adherence (OR=4.38, 95% CI: 1.41-13.61 and OR=3.52, 95% CI: 1.25-9.94, respectively). CONCLUSION: While prospective data collection via diaries may improve accuracy, the added expense and burden on study participants may not be necessary. However, the use of retrospective recall may not be appropriate for all study populations.

Serum micronutrient concentrations and risk of uterine fibroids.

BACKGROUND: Although uterine fibroids are among the most common gynecologic conditions affecting women in the United States, research on uterine fibroids is sparse. This study explored the association between micronutrients and uterine fibroids. METHODS: We conducted a population-based, cross-sectional analysis of 887 women aged 20-49 who participated in the 2003-2004 National Health and Nutrition Examination Survey (NHANES). Serum micronutrient levels were collected during the health examinations, and information on uterine fibroids was assessed on self-reported questionnaires. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) while controlling for confounders. RESULTS: A statistically significant dose-response relationship was observed between vitamin A and uterine fibroids, after adjustment for age, race, education, body mass index (BMI), and oral contraceptive (OC) use (middle vs. low: OR 2.43, 95% CI 1.35-4.37; high vs. low: OR 2.66, 95% CI 1.16-6.10, p for trend=0.02). After adjustment, a dose-response relationship also emerged for vitamin C, although these associations were not statistically significant. CONCLUSIONS: It is possible that certain micronutrients affect uterine fibroid development. If this is confirmed in large prospective studies, clinicians could advise susceptible populations on dietary changes to reduce their risk of uterine fibroids.

Contraceptive use among sexually active university students.

AIMS: The purpose of this exploratory study was to investigate factors related to contraceptive use and nonuse among a group of sexually active women attending a university. METHODS: From October 2006 to August 2007, 326 female students participated in a cross-sectional study at a large, public university. Women self-reported information on contraceptive behaviors via web-based and postal mail questionnaires. Among sexually active women, odds ratios (ORs) and 95% confidence intervals (Cls) were calculated to examine the association between various characteristics and the decision to use contraception. Reasons for contraceptive use and nonuse were also further explored. RESULTS: Of sexually active women, 77.1% reported using contraception. The most popular methods of contraception used were oral contraceptives and male condoms. Twenty-five percent of women not using contraception indicated that cost was an issue. Women who reported that a healthcare worker had ever talked to them about contraception had 6.63 times the odds of currently using contraception (95% CI 2.30, 19.18). CONCLUSIONS: The most common reason for contraceptive nonuse was related to cost. In addition to educating students on the availability of effective, low-cost methods of contraception, healthcare workers can take advantage of well-woman visits to discuss contraceptive use and methods that suit an individual's needs. Such interventions and personalized counseling may lead to higher continuation rates and increased user satisfaction.