Inflammatory markers in serum and placenta in a randomized controlled trial of group prenatal care.

BACKGROUND: Racial and socioeconomic disparities in preterm birth and small for gestational age births are growing in the United States, increasing the burden of morbidity and mortality particularly among Black women and birthing persons and their infants. Group prenatal care is one of the only interventions to show potential to reduce the disparity, but the mechanism is unclear. OBJECTIVE: The goal of this project was to identify if group prenatal care, when compared with individual prenatal care, was associated with a reduction in systemic inflammation during pregnancy and a lower prevalence of inflammatory lesions in the placenta at delivery. STUDY DESIGN: The Psychosocial Intervention and Inflammation in Centering Study was a prospective cohort study that exclusively enrolled participants from a large randomized controlled trial of group prenatal care (the Cradle study, R01HD082311, ClinicalTrials.gov: NCT02640638) that was performed at a single site in Greenville, South Carolina, from 2016 to 2020. In the Cradle study, patients were randomized to either group prenatal care or individual prenatal care, and survey data were collected during the second and third trimesters. The Psychosocial Intervention and Inflammation in Centering Study cohort additionally provided serum samples at these 2 survey time points and permitted collection of placental biopsies for inflammatory and histologic analysis, respectively. We examined associations between group prenatal care treatment and a composite of z scored serum inflammatory biomarkers (C-reactive protein, interleukin-6, interleukin-1 receptor antagonist, interleukin-10, and tumor necrosis factor α) in both the second and third trimesters and the association with the prevalence of acute and chronic maternal placental inflammatory lesions. Analyses were conducted using the intent to treat principle, and the results were also examined by attendance of visits in the assigned treatment group (modified intent to treat and median or more number of visits) and were stratified by race and ethnicity. RESULTS: A total of 1256 of 1375 (92%) Cradle participants who were approached enrolled in the Psychosocial Intervention and Inflammation in Centering Study, which included 54% of all the Cradle participants. The Psychosocial Intervention and Inflammation in Centering Study cohort did not differ from the Cradle cohort by demographic or clinical characteristics. Among the 1256 Psychosocial Intervention and Inflammation in Centering Study participants, 1133 (89.6%) had placental data available for analysis. Among those, 549 were assigned to group prenatal care and 584 of 1133 were assigned to individual prenatal care. In the intent to treat and modified intent to treat cohorts, participation in group prenatal care was associated with a higher serum inflammatory score, but it was not associated with an increased prevalence of placental inflammatory lesions. In the stratified analyses, group prenatal care was associated with a higher second trimester inflammatory biomarker composite (modified intent to treat: B=1.17; P=.02; and median or more visits: B=1.24; P=.05) among Hispanic or Latine participants. CONCLUSION: Unexpectedly, group prenatal care was associated with higher maternal serum inflammation during pregnancy, especially among Hispanic or Latine participants.

U.S. Breastfeeding Outcomes at the Intersection: Differences in Duration Among Racial and Ethnic Groups With Varying Educational Attainment in a Nationally Representative Sample.

BACKGROUND: As breastfeeding rates in the United States increase, barriers persist for Black, Latine, and low-socioeconomic status household dyads when compared to White and high-socioeconomic status household dyads. Previous breastfeeding disparities research has almost exclusively considered the influence of race, ethnicity, and socioeconomic status separately, although these attributes are not randomly distributed across the population. RESEARCH AIM: To identify breastfeeding duration patterns by race/ethnicity and educational attainment in a nationally representative U.S. National Immunization Survey sample. METHOD: We conducted a cross-sectional, secondary analysis of the U.S. Centers for Disease Control and Prevention's 2020 National Immunization Survey-Child public-use data. To examine breastfeeding and exclusive breastfeeding durations at the intersection of race/ethnicity and educational attainment, we created a 12-item, cross-classified variable using three educational attainment groups and four race/ethnicity groups. We used linear regressions to test these associations. RESULTS: In all, 83% of the sample breastfed. Mean durations of breastfeeding were 7.5 (SE = 1.95) months and exclusive breastfeeding duration was 4.9 (SE = 0.87) months. In adjusted models, multi-race/other high-educational attainment participants had the longest breastfeeding duration by almost 3 weeks (ß: 19.53, 95% CI [5.27, 33.79]), and Black low-educational attainment participants exclusively breastfed for 1 month less than White high-educational attainment participants (ß:-30.23, 95% CI [-40.87, -19.58]). CONCLUSIONS: Examining race/ethnicity and educational attainment together provides an intersectional understanding of breastfeeding outcomes and can inform targeted, culturally appropriate interventions.

Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity.

OBJECTIVE: This study aimed to determine whether clinically integrated Breastfeeding Peer Counseling (ci-BPC) added to usual lactation care reduces disparities in breastfeeding intensity and duration for Black and Hispanic/Latine participants. STUDY DESIGN: This study is a pragmatic, randomized control trial (RCT) of ci-BPC care at two ci-BPC-naïve obstetrical hospital facilities in the greater Chicago area. Participants will include 720 patients delivering at Hospital Site 1 and Hospital Site 2 who will be recruited from eight prenatal care sites during midpregnancy. Participants must be English or Spanish speaking, planning to parent their child, and have no exposure to ci-BPC care prior to enrollment. Randomization will be stratified by race and ethnicity to create three analytic groups: Black, Hispanic/Latine, and other races. RESULTS: The primary outcome will be breastfeeding duration. Additional outcomes will include the proportion of breastmilk feeds during the delivery admission, at 6-week postdelivery, and at 6-month postdelivery. A process evaluation will be conducted to understand implementation outcomes, facilitators, and barriers to inform replication and scaling of the innovative ci-BPC model. CONCLUSION: This research will produce findings of relevance to perinatal patients and their families, the vast majority of whom desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest RCT of ci-BPC in the United States to date, this research will improve the quality of evidence available regarding the effectiveness of ci-BPC at reducing disparities. These findings will help patients and stakeholders determine the benefits of accepting and adopting the program and inform policies focused on improving perinatal care and reducing maternal/child health disparities. This study is registered with Clinical Trial (identifier: NCT05441709). KEY POINTS: · Ci-BPC can promote racial breastfeeding equity.. · Ci-BPC has not been tested as a generalized lactation strategy in prior trials and is underused.. · This RCT will identify if ci-BPC can reduce breastfeeding disparities for Black and Hispanic patients..

Group vs traditional prenatal care for improving racial equity in preterm birth and low birthweight: the Centering and Racial Disparities randomized clinical trial study.

BACKGROUND: The United States has persistently high rates of preterm birth and low birthweight and is characterized by significant racial disparities in these rates. Innovative group prenatal care models, such as CenteringPregnancy, have been proposed as a potential approach to improve the rates of preterm birth and low birthweight and to reduce disparities in these pregnancy outcomes. OBJECTIVE: This study aimed to test whether participation in group prenatal care would reduce the rates of preterm birth and low birthweight compared with individual prenatal care and whether group prenatal care would reduce the racial disparity in these rates between Black and White patients. STUDY DESIGN: This was a randomized controlled trial among medically low-risk pregnant patients at a single study site. Eligible patients were stratified by self-identified race and ethnicity and randomly allocated 1:1 between group and individual prenatal care. The primary outcomes were preterm birth at <37 weeks of gestation and low birthweight of <2500 g. The primary analysis was performed according to the intent-to-treat principle. The secondary analyses were performed according to the as-treated principle using modified intent-to-treat and per-compliance approaches. The analysis of effect modification by race and ethnicity was planned. RESULTS: A total of 2350 participants were enrolled, with 1176 assigned to group prenatal care and 1174 assigned to individual prenatal care. The study population included 952 Black (40.5%), 502 Hispanic (21.4%), 863 White (36.8%), and 31 "other races or ethnicity" (1.3%) participants. Group prenatal care did not reduce the rate of preterm birth (10.4% vs 8.7%; odds ratio, 1.22; 95% confidence interval, 0.92-1.63; P=.17) or low birthweight (9.6% vs 8.9%; odds ratio, 1.08; 95% confidence interval, 0.80-1.45; P=.62) compared with individual prenatal care. In subgroup analysis, greater attendance in prenatal care was associated with lower rates of preterm birth and low birthweight. This effect was most noticeable for the rates of low birthweight for Black participants in group care: intent to treat (51/409 [12.5%]), modified intent to treat (36/313 [11.5%]), and per compliance (20/240 [8.3%]). Although the rates of low birthweight were significantly higher for Black participants than White participants seen in individual care (adjusted odds ratio, 2.00; 95% confidence interval, 1.14-3.50), the difference was not significant for Black participants in group care compared with their White counterparts (adjusted odds ratio, 1.58; 95% confidence interval, 0.74-3.34). CONCLUSION: There was no difference in the overall rates of preterm birth or low birthweight between group and individual prenatal care. With increased participation in group prenatal care, lower rates of preterm birth and low birthweight for Black participants were observed. The role of group care models in reducing racial disparities in these birth outcomes requires further study.

Complaints about excessive use of police force in women's neighborhoods and subsequent perinatal and cardiovascular health.

There are substantial, unexplained racial disparities in women's health. Some of the most pronounced involve elevated rates of preterm delivery (PTD) and cardiovascular disease (CVD) among Black women. We hypothesized that stress associated with excessive use of force by police may contribute to these disparities. In two prospective cohorts derived from electronic health records (pregnancy cohort, N = 67,976; CVD cohort, N = 6773), we linked formal complaints of excessive police force in patients' neighborhoods with health outcomes. Exposed Black women were 1.19 times as likely to experience PTD [95% confidence interval (CI): 1.04 to 1.35] and 1.42 times as likely to develop CVD (95% CI: 1.12 to 1.79), even after adjustment for neighborhood disadvantage and homicide. The excess risks of PTD were also observed in maternal fixed-effects analyses comparing births to the same woman. These findings suggest police violence may be an unrecognized contributor to health inequity for Black women.

The intersection of race and socioeconomic status is associated with inflammation patterns during pregnancy and adverse pregnancy outcomes.

BACKGROUND: Preterm birth rates are higher among individuals of lower socioeconomic status and non-White race, which is possibly related to life-course stressors. It is important to understand the underlying mechanisms of these health disparities, and inflammation is a possible pathway to explain the disparities in birth outcomes. OBJECTIVE: In this study, we aimed to determine whether patterns of inflammation differed by maternal race and socioeconomic status. STUDY DESIGN: Seven hundred and forty-four participants in a multi-site, prospective study of pregnancy and birth outcomes provided biological and psychological data between 12'0-20'6 weeks gestation. Participants with recent infection, fever, antibiotics or steroid treatment were excluded. Cytokines including INFÉ£, IL-10, IL-13, IL-6, IL-8, and TNFα, and the acute phase protein CRP were measured in serum and values and were log-transformed for normality when appropriate, and a non-orthogonal rotation (Oblimid) was performed to allow the extracted factor to inter-correlate. IFNγ, IL-8, IL-10, IL-6, TNF-a, and IL-13 loaded onto Inflammatory Factor 1 (IF-1), while CRP and IL-6 loaded onto Inflammatory Factor 2 (IF-2). Race and education were collected via self-report during an in-person study visit. Multivariable models were used to determine the association of race and SES with IF-1 and IF-2 during the second trimester, and a mediation model was used to examine if inflammation is on the causal pathway. Models were adjusted for study site, prenatal age, pre-pregnancy BMI, smoking during pregnancy, and gestational age at the time of blood collection. RESULTS: Six hundred and five participants were included in our final analysis, with 61.2% of low or moderate SES, and 35.5% identifying as a person of color (POC). Identifying as a POC, being of low and moderate SES, and being both low-SES and POC or moderate-SES and POC were associated with higher odds of preterm birth and lower birth weight percentile infants. Low SES POC participants had significantly higher IF-1 and IF-2 scores when compared to high-SES White participants. Additionally, higher IF-1 and IF-2 were associated with shorter gestation. In the mediation analysis, we observed a significant direct effect of race/SES on preterm birth; however, the results did not support an indirect pathway where IF-1 or IF-2 acted as mediators. CONCLUSION: Maternal race and SES are significantly associated with inflammatory biomarkers during pregnancy, and when race and SES are considered in combination, they are stronger predictors of adverse pregnancy outcomes than when evaluated separately.

Living in a block group with a higher eviction rate is associated with increased odds of preterm delivery.

BACKGROUND: Housing instability is associated with adverse pregnancy outcomes. Recent studies indicate that eviction, which may affect a larger segment of the population than other forms of housing instability, is also associated with adverse pregnancy outcomes. However, these studies evaluate eviction across large areas, such as counties, so it remains unclear whether these patterns extend to individual-level pregnancy outcomes. METHODS: We used data on a cohort of all singleton live births at a single Chicago hospital between March 2008 and March 2018 to investigate the associations between block-group eviction rates and individual adverse pregnancy outcomes. Eviction data were obtained from the Eviction Lab at Princeton University. Generalised estimating equations were used to estimate associations and account for correlations among individuals living in the same block groups. RESULTS: Individuals living in block groups in the highest quartile for eviction filing rate were 1.17 times as likely to deliver preterm (95% CI: 1.08 to 1.27) and 1.13 times as likely to deliver a small for gestational age infant (95% CI: 1.03 to 1.25) as compared with individuals living in block groups in the lowest quartile. Further, tests for linear trend indicated that for each quartile increase in eviction filing rate, there was a corresponding increase in odds of adverse outcomes (p<0.05). Results were strongest in magnitude for those with low neighbourhood and individual socioeconomic status, who are most likely to be renters and affected by local eviction policies. CONCLUSION: Our results suggest that individuals living in block groups with higher eviction rates are more likely to deliver preterm. Future research should explore associations of individual experience with eviction on adverse pregnancy outcomes and examine whether policies to improve tenant protections also impact pregnancy outcomes.

Time-dependent changes in placental mRNA expression after delivery due to delayed specimen collection.

PROBLEM: Current scientific guidelines recommend collecting placental specimens within two hours of delivery for gene expression analysis. However, collecting samples in a narrow time window is a challenge in the dynamic and unpredictable clinical setting, so delays in placental specimen collection are possible. The purpose of our analysis was to investigate temporal changes in placental gene expression by longitudinally sampling placentas over a 24 h period. METHOD OF STUDY: Eight placentas from individuals with uncomplicated, term pregnancies delivered by scheduled cesarean section were collected and sampled following the placental delivery and again at 1, 2, 4, 6, and 24 h post-delivery. At each time point, biopsies of chorionic villous tissue were taken from 3 cotyledons to account for intra-placental heterogeneity. The 3 biopsies from each time point were pooled prior to RNA extraction. Expression of 382 mRNA transcripts was quantified using the NanoString nCounter System. Fold change values were calculated for each time point relative to delivery, and a fold change threshold of 1.25 was used to determine a meaningful change from delivery. RESULTS: Based on a fold change threshold of 1.25, 84.3% of transcripts were stable for at least 1 h, 80.2% were stable for at least two hours, and 20.6% of transcripts were stable through the collection at 24 h. CONCLUSION: Our results suggest that for some mRNA transcripts, expression changes as time to sample collection increases. We have developed a Web application to allow investigators to explore transcripts relevant to their research interests and to set appropriate thresholds to aid in determining whether placentas with delayed sample collection can be included in analyses (https://placentaexpression.foundationsofhealth.org/).

Adverse Pregnancy Outcomes Following the Assassination of John F. Kennedy in 1963.

INTRODUCTION: Women exposed to stressful events during pregnancy are thought to be at increased risk of adverse birth outcomes. However, studies investigating stressful events are often unable to control for important confounders, such as behavioral and genetic characteristics, or to isolate the impact of the stressor from other secondary effects. We used a discordant-sibling design, which provides stronger inferences about causality, to examine whether a widespread stressor with limited impact on day-to-day life (John F. Kennedy assassination) resulted in an increased risk of adverse birth outcomes. METHODS: Data were obtained from the Collaborative Perinatal Project, a prospective, multi-site cohort study conducted in the US from 1959 to 1965. Our analysis was restricted to singleton live births ≥24 weeks born before the assassination (n = 24,406) or in utero at the time (n = 5833). We also evaluated associations within siblings discordant for exposure (n = 1144). We used survival analysis to evaluate associations between exposure and preterm birth and marginal models to evaluate associations with birthweight and placental pathology. RESULTS: First trimester exposure was associated with preterm birth (hazard ratio (HR): 1.17; 95% CI: 1.05, 1.31). In the discordant-sibling model, the point estimate was similar (HR: 1.22; 95% CI: 0.36, 4.06). Third trimester exposure was associated with increased odds of fetal acute inflammation in the placenta (odds ratio (OR): 1.34, 95% CI: 1.05, 1.71). CONCLUSIONS FOR PRACTICE: First trimester exposure to an acute stressor was associated with preterm birth. We did not observe increased odds of placental pathology with first trimester exposure; however, stress may increase preterm birth risk through chronic placental inflammation, which was not evaluated in this sample.

Is there a relationship between personality traits and fruit and vegetable intake among pregnant women?

Previous studies have shown that certain personality traits such as neuroticism and conscientiousness influence dietary choices. Pregnancy is a unique period in a woman's life during which most women are highly intrinsically and extrinsically motivated to start a diet rich in fruit and vegetables. Yet, an adequate consumption of fruits and vegetables remains a challenge for many women. The present study investigates the relationships between personality traits and fish, dairy, fruit, and vegetable intake. Data was collected from 602 pregnant women and analyzed using descriptive statistics and hierarchical regression analyses in order to examine predictive relationships between the variables of interest. The results demonstrated that high scores in openness to experience, older maternal age, higher income, and educational attainment were positively associated with increased fish, vegetable, and fruit intake. These findings have important implications for interventions that seek to improve eating behaviors of pregnant women, thereby increasing the health of their pregnancies.