Obstetric Racial Disparities in the Era of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) Trial and the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: To evaluate the influence of the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial and the coronavirus disease 2019 (COVID-19) pandemic on racial and ethnic differences in labor induction, pregnancy-associated hypertension, and cesarean delivery among non-Hispanic Black and non-Hispanic White low-risk, first-time pregnancies. METHODS: We conducted an interrupted time series analysis of U.S. birth certificate data from maternal non-Hispanic Black and non-Hispanic White race and ethnicity, first pregnancy, 39 or more weeks of gestation, with no documented contraindication to vaginal delivery or expectant management beyond 39 weeks. We compared the rate of labor induction (primary outcome), pregnancy-associated hypertension, and cesarean delivery during three time periods: pre-ARRIVE (January 1, 2015-July 31, 2018), post-ARRIVE (November 1, 2018-February 29, 2020), and post-COVID-19 (March 1, 2020-December 31, 2021). RESULTS: In the post-ARRIVE period, the rate of labor induction increased in both non-Hispanic White and non-Hispanic Black patients, with no statistically significant difference in the magnitude of increase between the two groups (rate ratio for race [RR race ] 0.98, 95% CI, 0.95-1.02, P =.289). Post-COVID-19, the rate of labor induction increased in non-Hispanic White but not non-Hispanic Black patients. The magnitude of the rate change between non-Hispanic White and non-Hispanic Black patients was significant (RR race 0.95, 95% CI, 0.92-0.99, P =.009). Non-Hispanic Black pregnant people were more likely to have pregnancy-associated hypertension and more often delivered by cesarean at all time periods. CONCLUSION: Changes in obstetric practice after both the ARRIVE trial and the COVID-19 pandemic were not associated with changes in Black-White racial differences in labor induction, cesarean delivery, and pregnancy-associated hypertension.

Maternal chronic hypertension in women veterans.

OBJECTIVE: To describe the prevalence of maternal chronic hypertension (MCH), assess how frequently blood pressure is controlled before pregnancy among those with MCH, and explore management practices for antihypertensive medications (AHM) during the pre-pregnancy and pregnancy periods. DATA SOURCES, STUDY SETTING, AND STUDY DESIGN: We conducted a descriptive observational study using data abstracted from the Veterans Health Administration (VA) inclusive of approximately 11 million Veterans utilizing the VA in fiscal years 2010-2019. DATA COLLECTION/EXTRACTION METHODS: Veterans aged 18-50 were included if they had a diagnosis of chronic hypertension before a documented pregnancy in the VA EMR. We identified chronic hypertension and pregnancy with diagnosis codes and defined uncontrolled blood pressure as ≥140/90 mm Hg on at least one measurement in the year before pregnancy. Sensitivity models were conducted for individuals with at least two blood pressure measurements in the year prior to pregnancy. Multivariable logistic regression explored the association of covariates with recommended and non-recommended AHMs received 0-6 months before pregnancy and during pregnancy. PRINCIPAL FINDINGS: In total, 8% (3767/46,178) of Veterans with a documented pregnancy in VA data had MCH. Among 2750 with MCH meeting inclusion criteria, 60% (n = 1626) had uncontrolled blood pressure on at least one BP reading and 31% (n = 846) had uncontrolled blood pressure on at least two BP readings in the year before pregnancy. For medications, 16% (n = 437) received a non-recommended AHM during pregnancy. Chronic kidney disease (OR = 3.2; 1.6-6.4) and diabetes (OR = 2.3; 1.7-3.0) were most strongly associated with use of a non-recommended AHM during pregnancy. CONCLUSIONS: Interventions are needed to decrease the prevalence of MCH, improve preconception blood pressure control, and ensure optimal pharmacologic antihypertensive management among Veterans of childbearing potential.

Prenatal Vaccination Patterns among Birthing Individuals with History of Preterm Birth in the Pre- and Post-COVID Era.

OBJECTIVE: This study aims to explore vaccination acceptance among individuals with a history of preterm birth between March and June during the pre-COVID (2019), early-COVID (2020), and late-COVID (2021) periods. STUDY DESIGN: This is a cross-sectional, retrospective cohort study of pregnant individuals with a history of preterm birth (<37 weeks' gestation) who initiated care of a subsequent pregnancy during pre-COVID (March-June 2019), early-COVID (March-June 2020), or late-COVID (March-June 2021). The primary outcome of interest was vaccination status for influenza, Tdap, and COVID-19 vaccines. Fisher's exact and chi-square tests were used to investigate association between vaccination status and time periods, race/ethnicity, and insurance. RESULTS: Among 293 pregnancies, influenza vaccination rate was highest in early-COVID (p < 0.05). There was no statistically significant difference in Tdap or COVID-19 vaccination between time periods. COVID-19 vaccination was highest in individuals with private insurance (p < 0.05). There was no statistically significant difference in vaccination status by race/ethnicity. CONCLUSION: In this study on high-risk pregnant individuals, the majority of our cohort remained unvaccinated against COVID-19 into the late-COVID period. Additionally, their influenza vaccination rates were greater than the national average in early-COVID and substantially lower than the national average in late-COVID. This shift in influenza vaccination acceptance may have been sparked by COVID-19 vaccine distribution beginning in January 2021 leading to overall vaccination hesitancy. Standardized guidelines and counseling concerning prenatal safety in recommended immunizations may serve as important tools of reassurance and health promotion. KEY POINTS: · Maternal infections during pregnancy are a risk factor for preterm birth.. · High-risk cohort had low influenza vaccination post-COVID possibly due to COVID-19 vaccine hesitancy.. · Vaccination education may be a uniquely important tool among high-risk pregnant patients..

Predictors of Breastfeeding among Patients Admitted with Preterm Prelabor Rupture of Membranes.

OBJECTIVE: We sought to describe rates of breastmilk feeding (BF) at hospital discharge and 6 weeks postpartum and to identify risk factors for noninitiation or cessation among pregnancies complicated by preterm prelabor rupture of membranes (PPROM). STUDY DESIGN: Retrospective cohort study of pregnant persons with PPROM admitted to a single tertiary center (2013-2019). Patients with deliveries complicated by intrauterine or neonatal demise or with incomplete BF data were excluded. Demographic, antepartum, and delivery characteristics were evaluated. Primary analysis identified rate of BF initiation at maternal discharge and factors associated with noninitiation. Secondary analysis evaluated BF continuation and factors associated with cessation at 6 weeks postpartum. Bivariate statistics were used to compare characteristics and logistic regression was used to estimate adjusted odds ratios (aOR). RESULTS: Of 397 patients with PPROM, 342(86%) initiated BF prior to discharge. Those reporting tobacco use in pregnancy were less likely to initiate BF (aOR: 0.32; 95% confidence interval [CI]: 0.16, 0.64). In contrast, private insurance (aOR: 2.53; 95% CI: 1.19, 5.37) and pregnancy latency ≥ 14 days (aOR: 3.02; 95% CI: 1.09, 8.38) were associated with BF initiation at hospital discharge. Of the 293 patients with postpartum follow-up, only 214 (73%) had BF continuation at 6 weeks postpartum. Maternal age <20 years (aOR: 0.07; 95% CI: 0.01, 0.68) and multiparity (aOR: 0.54; 95% CI: 0.29, 0.99) were associated with BF cessation. Patients with private insurance were observed to have increased odds of BF continuation (aOR: 2.10; 95% CI: 1.07, 4.12). CONCLUSION: Among patients with PPROM, tobacco use may be associated with noninitiation of BF prior to discharge, whereas age < 20 years and multiparity were associated with cessation by 6 weeks postpartum. Longer pregnancy latency ≥ 14 days was associated with BF initiation prior to discharge. Private insurance was associated with increased rates of BF initiation and continuation postpartum. BF education and support should be offered to all patients admitted for PPROM. KEY POINTS: · Tobacco use may be associated with BF noninitiation.. · Young age and multiparity are linked with BF cessation.. · Private insurance resulted in BF initiation and continuation..

Transvaginal Ovarian Cyst Drainage in Third Trimester to Facilitate Vaginal Delivery.

Adnexal masses in the third trimester of pregnancy may obstruct the pelvic outlet precluding labor induction and vaginal delivery. Expectant versus surgical management of adnexal cysts in pregnancy must carefully weigh maternal-fetal benefits and risks. Simple benign appearing cysts with low likelihood of malignancy may be amenable to percutaneous drainage as a bridge to interval postpartum laparoscopic cystectomy. We demonstrated posterior culdocentesis as a safe, minimally invasive technique to decompress a simple benign appearing left adnexal cyst obstructing the pelvic outlet in the third trimester at the time of labor induction to facilitate vaginal delivery and prevent primary cesarean delivery. Detailed sonographic cyst evaluation and counseling on underlying risk of malignancy must be considered to guide shared decision-making.

CenteringPregnancy: A Review of Implementation and Outcomes.

Importance: CenteringPregnancy (CP) is a model for group prenatal care associated with improved perinatal outcomes for preterm birth and low birthweight, increased rates of breastfeeding, and higher rates of patient and clinician satisfaction. Objective: The study aims to review the literature related to perinatal outcomes associated with CP, benefits and barriers to implementation, and utility of the model. Evidence: An electronic-based search was performed in PubMed using the search terms "CenteringPregnancy" OR "Centering Pregnancy," revealing 221 articles. Results: The CP model improves patient centeredness, efficiency, and equality in prenatal care. Challenges include administrative buy-in, limited resources, and financial support. Multisite retrospective studies of CP demonstrate improved maternal, neonatal, postpartum, and well-being outcomes, especially for participants from minority backgrounds; however, prospective studies had mixed results. CenteringPregnancy is feasibly implemented with high tenet fidelity in several low- and middle-income settings with improved perinatal outcomes compared with traditional care. Conclusions: CenteringPregnancy is feasible to implement, largely accepted by communities, and shows positive qualitative and quantitative health outcomes. This body of literature supports CP as a potential tool for decreasing racial inequalities in prenatal access, quality of care, and maternal mortality. Further investigation is necessary to inform obstetric clinicians about the potential outcome differences that exist between group and traditional prenatal care.

Factors Associated with Guideline Concordant Clinician Counseling about Low-Dose Aspirin to Prevent Preeclampsia in Nulliparous Patients.

OBJECTIVE: The primary aim of this study was to examine the United States Preventative Services Task Force (USPSTF) guidelines concordant low-dose aspirin (LDA) counseling and factors associated with counseling in nulliparous birthing individuals. STUDY DESIGN: We conducted a retrospective cohort study of nulliparous birthing individuals who delivered between January 1, 2019 and June 30, 2020 and received prenatal care at the Duke High Risk Obstetrical Clinics (HROB). All nulliparous patients over 18 years old who established or transferred care to HROB by 16 weeks, 6 days were included in the analysis. We excluded patients with more than two previous first-trimester pregnancy losses, multiple gestation, a known contraindication to LDA, initiation of LDA prior to their prenatal care, or documented medical history of coagulation disorder. Bivariate associations between demographic/medical characteristics and our primary outcome, receipt of counseling (yes/no), were assessed using two-sample t-tests for continuous variables and chi-square or Fisher's exact test for categorical variables. Factors significantly associated with the primary outcome (p < 0.05) were entered into the multivariable logistic regression model. RESULTS: Among 391 birthing individuals included in the final analysis cohort, 51.7% of eligible patients received guideline consistent LDA counseling. Factors associated with increased odds of LDA counseling were advanced maternal age (adjusted odds ratio [aOR]: 1.05, 95% confidence interval [CI]: 1.01-1.09), Black race compared with White race (aOR:1.75, 95% CI: 1.03-2.98), chronic hypertension (aOR: 4.17, 95% CI: 1.82-9.55), and obesity (aOR: 5.02, 95% CI: 3.12-8.08). CONCLUSION: Approximately half of all nulliparous birthing individuals had appropriately documented LDA counseling. The USPSTF guidelines on LDA for preeclampsia risk reduction are complex, which may lead to ineffective provider adherence. Efforts to simplify guidelines and improve LDA counseling are vital to ensuring this low-cost, evidence-based preeclampsia prevention is used in a consistent and equitable manner. KEY POINTS: · A total of 51.7% of eligible patients received guideline consistent LDA counseling.. · Advanced maternal age , body mass index > 30, Black race, and chronic hypertension associated with increased odds of counseling.. · Among patients most likely to be counseled, high numbers did not receive LDA counseling..

Doula Care: A Review of Outcomes and Impact on Birth Experience.

Importance: Doulas are trained professionals that provide comprehensive support during the perinatal period. Doula-supported care is associated with improved maternal and infant outcomes including decreased preterm birth, increased breastfeeding initiation, and higher patient satisfaction. In addition, research suggests that doula support is a promising strategy to mitigate racial disparities in maternal and infant health outcomes. Objective: This article reviews doulas' scope of practice, perinatal outcomes associated with doula-assisted care, and their impact on alleviating racial disparities in maternal-infant outcomes. Evidence Acquisition: A literature search using the search engine PubMed was done. The search terms included ([Doula OR doulas OR labor coach] AND [Preterm OR prenatal care OR race OR racial OR racism OR Black OR African American]). Studies had to be written in English. Results: The search resulted 90 articles of which 18 original articles and 16 review articles were reviewed. The literature demonstrates that doula support increases vaginal delivery while decreasing preterm birth and low birth weight. Studies also show that doula support is uniquely effective for Black patients and is a promising strategy to reduce health care inequities. Conclusions and Relevance: Doulas may provide significant perinatal benefit for birthing patients and their infants, with advantages also noted for Black patients. The current article provides an overview of the literature focused on doula support.

Maternal Cardiovascular Morbidity Events Following Preeclampsia: A Retrospective Cohort Study.

BACKGROUND: Patients with preeclampsia are at high risk for long-term cardiovascular events, yet the short-term, acute cardiovascular complications that follow preeclampsia are understudied. The objective of this study was to compare the short-term, acute maternal cardiovascular morbidity events after delivery among patients with a diagnosis of preeclampsia versus those without this diagnosis. METHODS: In this retrospective cohort study, the Premier inpatient database was used to examine a cohort of obstetric patients older than 18 years, who delivered from January 1, 2016, to September 30, 2020. A diagnosis of preeclampsia and preeclampsia with severe features during delivery hospitalization were the exposures of interest. The primary outcome was a composite of maternal cardiovascular morbidity events during delivery hospital admission. The secondary outcome was the occurrence of maternal cardiovascular morbidity events during a readmission within 90 days of delivery hospitalization. RESULTS: In total, 4,488,759 patients met inclusion criteria, of which 158,114 (3.5%) were diagnosed with preeclampsia without severe features, and 117,940 (2.6%) with preeclampsia with severe features. Adjusted odds of maternal cardiovascular morbidity events were higher in patients with preeclampsia and in those with preeclampsia with severe features compared with those without preeclampsia during delivery hospitalization (adjusted odds ratio [OR] [95% confidence interval {CI}] 1.87 [1.78-1.97] and 4.74 [4.44-5.05], respectively) and within 90 days (adjusted OR [95% CI] 2.01 [1.83-2.21] and 2.32 [2.10-2.57], respectively). CONCLUSIONS: Patients with both preeclampsia and preeclampsia with severe features have higher rates of maternal cardiovascular morbidity events than those without preeclampsia. Future studies are necessary to examine which patients with preeclampsia are at highest risk for cardiovascular complications.

Preterm Birth Rates and Racial Disparities during the COVID-19 Pandemic at a Single Institution in the Southeastern United States.

OBJECTIVE: The COVID pandemic has been associated with varied effects on preterm birth (PTB). We sought to compare rates of PTB during the pre- and post vaccination COVID periods with pre-pandemic PTB rates, stratified by race and ethnicity. STUDY DESIGN: Retrospective cohort comparing all deliveries over 20 weeks at a single tertiary center during "early" (March 2020-June 2020) versus "late" COVID (March 2021-June 2021), and "late" COVID versus pre-COVID (March to June 2014-2019). PTBs <37, <34, and <28 weeks were compared and stratified by race/ethnicity. RESULTS: A total of 16,483 deliveries occurred including 2,068 "early" COVID, 2,115 "late" COVID, and 12,300 pre-COVID. The PTB rate during "late" COVID was lower compared to "early" COVID (12.1 vs. 14.6%, p = 0.02). Rate of PTB <34 was also lower during "late" COVID (4.4 vs. 5.7%, p = 0.05). PTB <28 did not differ. When controlling for prior PTB, "late" COVID remained associated with a decreased risk of PTB compared to "early" COVID, adjusted odds ratio (aOR) of 0.82 (95% confidence interval [CI]: 0.68, 0.98). Although there was no difference in PTB among Hispanic individuals when comparing "late" COVID versus pre-COVID, when further subdivided, a small number of Hispanic Puerto Rican individuals had higher odds of PTB < 37 during "late" COVID versus pre-COVID (aOR = 4.29 [95% CI: 1.12, 16.4]). Additionally, White individuals had reduced odds of PTB <37 (aOR = 0.80 [95% CI: 0.65, 0.98]) during "late" COVID versus pre-COVID while the PTB rate was unchanged when comparing "late" COVID versus pre-COVID in all other racial and ethnic groups. CONCLUSION: During 2021, PTB rates decreased from rates observed in 2020 at the height of COVID restrictions. Among White birthing individuals, PTB decreased in 2021 compared to pre-COVID rates. This decrease was not observed in Black and Hispanic birthing individuals. These data highlight the continued racially disparate impact of the COVID-19 pandemic on PTB rates. KEY POINTS: · The COVID-19 pandemic has been associated with varied effects on the preterm birth (PTB) rate.. · PTB rates decreased in "late" COVID compared to "early" COVID.. · When stratified, PTB decreased among white individuals, but not in Black or Hispanic individuals..

For better care we need better data: towards a national obstetrics registry.

Unacceptably high rates of severe maternal morbidity and mortality in the United States and stark racial disparities in outcomes are generating efforts to improve both research capacity and quality improvement in obstetrical care. Comprehensive, high-quality datasets on which to build these efforts are crucial to the success of obstetrical quality improvement efforts. However, existing data sources in obstetrics have notable limitations. Other medical and surgical specialties have addressed similar challenges through the creation of national registries, and we argue that obstetrics must take the same approach to improve outcomes. In this article, we summarized the current availability and limitations of large-scale data in obstetrics research and compared the data with registries developed in other specialties. Moreover, we have outlined the guiding principles for the development of a national obstetrics registry and have proposed future directions.

Group B Streptococcus and Pregnancy: Critical Concepts and Management Nuances.

Importance: Group B Streptococcus (GBS) is a common pathogen with an effective treatment. However, it remains a significant cause of neonatal sepsis, morbidity, and mortality. The screening and management of this infection are some of the first concepts learned during medical training in obstetrics. However, effective screening and evidence-based management of GBS are nuanced with many critical caveats. Objective: The objectives of this review are to discuss the essential aspects of GBS screening and management and to highlight recent changes to recommendations and guidelines. Evidence Acquisition: Original research articles, review articles, and guidelines on GBS were reviewed. Results: The following recommendations are based on review of the evidence and professional society guidelines. Screening for GBS should occur between 36 weeks and the end of the 37th week. The culture swab should go 2 cm into the vagina and 1 cm into the anus. Patients can perform their own swabs as well. Penicillin allergy testing has been shown to be safe in pregnancy. Patients with GBS in the urine should be treated at term with antibiotic prophylaxis, independent of the colony count of the culture. Patients who are GBS-positive with preterm and prelabor rupture of membranes after 34 weeks are not candidates for expectant management, as this population has higher rates of neonatal infectious complications. Patients with a history of GBS colonization in prior pregnancy who are GBS-unknown in this current pregnancy and present with labor should receive intrapartum prophylaxis. Work on the GBS vaccine continues. Conclusions: Although all of the efforts and focus on neonatal early-onset GBS infection have led to lower rates of disease, GBS still remains a major cause of neonatal morbidity and mortality requiring continued vigilance from obstetric providers.

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.

Health inequities start early in life, even before birth: Why race-specific fetal and neonatal growth references disadvantage Black infants.

Clinicians and researchers use published standards to assess and classify the size and growth of the fetus and newborn infant. Fetal growth is slower on average in Black fetuses as compared with White fetuses, and existing standards differ in whether they are race-specific or not. Here, we apply a health equity lens to the topic of fetal and newborn growth assessment by critically appraising two widely available growth standards. We conclude that using race-based standards is not well-justified and could perpetuate or even worsen inequities in perinatal health outcomes. We therefore recommend that neonatal and perinatal providers remove race from the assessment of fetal and newborn size.

Racial and ethnic representation in 17-hydroxyprogesterone caproate preterm birth prevention studies: a systematic review.

OBJECTIVES: The US preterm birth rate varies dramatically by race and ethnicity yet the racial and ethnic representation within studies evaluating 17-hydroxprogesterone caproate (17-P) for preterm birth prevention is unknown. The objectives of our study were to 1) examine the racial and ethnic representation of participants in 17-P preterm birth prevention studies, 2) evaluate adherence to the NIH race and ethnicity reporting guidelines and 3) compare racial and ethnic representation in research studies to national preterm birth incidence. METHODS: We systematically reviewed US studies published between January 2000 and December 2019. Study participant's race and ethnicity were reported using descriptive statistics then compared to US 2017//2018 preterm birth data using Pearson's chi-square. RESULTS: Eighteen studies met the inclusion criteria, 17 studies reported race, 11 studies reported ethnicity, and yet none of the studies followed the NIH criteria. Compared to 2017/2018 US preterm births, the proportion of black/African American study participants was significantly higher whereas the proportions of all other race categories were lower. CONCLUSIONS: More detailed reporting of race and ethnicity is needed in 17-P literature. Black women appear to be well represented while other racial and ethnic groups may be understudied.

Sickle cell disease and the incidence and etiology of preterm birth.

BACKGROUND: Medically indicated delivery can be defined as delivery owing to intervention for maternal or fetal well-being-most commonly because of preeclampsia or nonreassuring fetal status. Among the general population of the United States, approximately two-thirds of preterm deliveries are because of spontaneous labor and/or premature rupture of membranes, whereas the remaining one-third are medically indicated. Despite the increased risk of preterm birth among women with sickle cell disease, the specific etiologies have not been described in the medical literature. Without an understanding of the etiologies of preterm birth in women with sickle cell disease, it is difficult to develop preventative strategies. OBJECTIVE: This study aimed to estimate the incidence and etiologies of preterm births (spontaneous vs medically indicated) in women with sickle cell disease. STUDY DESIGN: This was a retrospective, institutional review board-exempt cohort study of deliveries at >20 weeks' gestation in women with sickle cell disease at Duke University Hospital (2013-2020). We screened pregnancy-linked hospitalizations with International Classification of Diseases-9/10 codes for sickle cell disease (n=373). We excluded cases of pregnancy with <20 weeks' gestation, multiple gestation, or unproven sickle cell disease. We limited inclusion to deliveries within Duke (n=66). We compared the proportion of preterm birth cases between the sickle cell disease cohort and the overall Duke population (n=18,365), and the proportion of spontaneous vs medically indicated preterm births between the sickle cell disease cohort and a racially matched US population. RESULTS: Of the 66 pregnancies, 65 occurred in patients who self-described as Black (98.5%). There were 60.6% (n=40) term and 39.4% (n=26) preterm births vs 85.9% term (n=15,771) and 14.1% preterm (n=2594) births in the Duke population as a whole. The sickle cell disease cohort was nearly 3 times more likely to deliver preterm than the Duke cohort (risk ratio, 2.79; 95% confidence interval, 2.06-3.77; P<.001). Among the 26 preterm births in the sickle cell disease cohort, 30.8% (n=8) were spontaneous and 69.2% (n=18) were medically indicated. In the US Black population comparison cohort, 65.4% (n=392,984) of preterm births were spontaneous and 34.6% (n=207,614) were medically indicated. The sickle cell disease cohort had 2 times the risk of medically indicated preterm birth compared with the US population cohort (risk ratio, 2.00; 95% confidence interval, 1.55-2.59; P<.001). CONCLUSION: Maternal sickle cell disease confers nearly triple the risk of preterm birth, which is twice as likely to be medically indicated.

A Qualitative Study Documenting Black Birthing Individuals' Perspectives on the Disproportionate Rate of Preterm Birth in the Black Community.

Background: Compared with all other racial and ethnic groups, the rate of preterm birth (PTB) is 50% higher among non-Hispanic Blacks (NHB). There are limited published data focused on the etiology of the racial disparity in PTB from the perspective of Black birthing individuals who have had a lived experience with PTB. Methods: To gain insights into the etiology of the race disparity in PTB from the NHB patient's perspective, we conducted a qualitative descriptive study with NHBs who have a history of PTB. We conducted both focus group discussions (FGDs), in-depth interviews (IDIs), and used applied thematic analysis to analyze the data. Results: Seven individuals participated in 3 FGDs and 15 individuals participated in an IDI. The majority of participants named stress as a contributor to PTB among NHBs. Participants described that stress becomes an ongoing cycle with a cumulative effect on health. Three primary sources of stress were identified: (1) individual including stress from lack of personal wellness, (2) relational stress from intimate partner and familial relationships, and (3) community-level stress from occupations and societal expectations. Conclusion: Uncovering NHB patient's perspectives on the etiology of PTB is a critical step to develop interventions that mitigate the disparity impacting the Black community. Our findings suggest that multilevel interventions targeting individual-, relational-, and community-level stress may be necessary to reduce rates of PTB among NHB individuals.

Symptomatic versus asymptomatic COVID-19: does it impact placental vasculopathy?

This study sought to assess the impact of COVID-19 on placental vasculature in the context of maternal symptomatology - comparing asymptomatic to symptomatic pregnant patients - and disease severity - comparing pregnant patients with mild, moderate, severe, and critical COVID-19 infection. PCR-confirmed COVID-19 positive pregnant patients in a single health system who delivered between 3/2020-5/2021 included. All patients had positive COVID test and delivered during the study period. Primary outcome was incidence of any vascular malperfusion on placental pathology. Secondary outcomes were FVM and MVM on placental pathology. Placental pathology compared between symptomatic (sCOVID) and asymptomatic (aCOVID) patients. Secondary analysis of symptomatic patients, comparing placental pathology between mild disease(mCOVID) and worse disease(moderate, severe, or critical-defined by 2020 NIH guidelines) (dCOVID), also performed. Of 112 patients, 53 (47%) had symptoms. Twenty-seven (24.1%) patients had evidence of vascular malperfusion; 26 (23.2%) had MVM. When comparing aCOVID and sCOVID patients, no difference in rate of vascular malperfusion identified, nor any differences in rates of FVM or MVM. Among sCOVID patients (n = 53), 39 (74%) had mCOVID and 14 (26%) had dCOVID (moderate n = 4, severe n = 9, critical n = 1). Patients with dCOVID had earlier median delivery GA (37.4wks vs 39.2wks, p = .03). No difference in latency from diagnosis to delivery seen between mCOVID and dCOVID groups (4.4 vs 3.0wks, p = .96). Twelve (30.8%) patients had vascular malperfusion on pathology, all had mCOVID (p = .02). Eleven (28.2%) mCOVID patients had MVM; no dCOVID patients had evidence of vascular malperfusion (p = .03). No difference in FVM was found between cohorts. Symptomatic COVID-19 infection did not impact placental vasculature differently than asymptomatic infection, even when stratifying by trimester of infection. Among pregnant patients with symptomatic COVID-19, mild disease was associated with placental vascular changes on the maternal side while severe disease was not. Further studies are needed to understand the implications of these findings.

Estimated Prevalence of Risk Factors for Preeclampsia Among Individuals Giving Birth in the US in 2019.

Importance: Low-dose aspirin (LDA) is one of the few evidence-based interventions for preventing preeclampsia, which is a leading cause of maternal or fetal morbidity and mortality. Current guidelines recommend LDA based on the presence of risk factors for preeclampsia, but the population-based prevalence of these factors is unknown. Objective: To estimate population-level prevalence of preeclampsia risk factors used in prophylactic LDA guidelines for pregnant patients and the association of these risk factors with reported rates of pregnancy-related hypertension. Design, Setting, and Participants: A retrospective cohort study was conducted using National Center for Health Statistics birth certificate data to describe the frequency of pregnant individuals with moderate to high-risk factors for preeclampsia and pregnancy-related hypertension rates. The study used all birth records in the United States for the 2019 calendar year. Exposures: Documentation of preeclampsia risk factors: multifetal gestation, pregestational diabetes, chronic hypertension (high-risk factors) and nulliparity, a body mass index greater than 30, African American race, a maternal age 35 years or older, an interval of more than 10-years since last birth, and having low socioeconomic status (moderate risk factors). Main Outcomes and Measures: Prevalence of each risk factor alone and in combinations leading to a recommendation for LDA; incidence of pregnancy-related hypertension by risk factor and combinations of risk factors. Results: There were 3 695 019 pregnancies in 2019, including 528 778 with no risk factors, 169 540 with 1 or more high-risk factors, and 2 996 701 with 1 or more moderate-risk factors. The mean (SD) of the cohort was 29.1 (5.8) years. Multifetal gestation was the most common high-risk factor and found in 123 995 pregnancies (3.4%), and low socioeconomic status was the most common moderate-risk factor and present in 1 732 729 pregnancies (46.9%). Based on 2021 criteria (a single high- or moderate-risk factors for preeclampsia), 3 166 241 pregnant patients (85.7%) were eligible for LDA. The incidence of pregnancy-related hypertension increased with the number of moderate-risk factors. The 2021 guidelines suggest considering or recommend LDA in 92.3% of pregnancies diagnosed with pregnancy-related hypertension. Conclusions and Relevance: These data support the recently published guidelines and suggest further simplified guidelines recommending LDA to patients with any single moderate-risk factors.