Trends in prenatal prescription opioid use among Medicaid beneficiaries in Wisconsin, 2010-2019.

OBJECTIVE: To examine changes in prenatal opioid prescription exposure following new guidelines and policies. STUDY DESIGN: Cohort study of all (262,284) Wisconsin Medicaid-insured live births 2010-2019. Prenatal exposures were classified as analgesic, short term, and chronic (90+ days), and medications used to treat opioid use disorder (MOUD). We describe overall and stratified temporal trends and used linear probability models with interaction terms to test their significance. RESULT: We found 42,437 (16.2%) infants with prenatal exposure; most (90.5%) reflected analgesic opioids. From 2010 to 2019, overall exposure declined 12.8 percentage points (95% CI = 12.1-13.1). Reductions were observed across maternal demographic groups and in both rural and urban settings, though the extent varied. There was a small reduction in chronic analgesic exposure and a concurrent increase in MOUD. CONCLUSION: Broad and sustained declines in prenatal prescription opioid exposure occurred over the decade, with little change in the percentage of infants chronically exposed.

Spillover effects of gestational age on sibling's literacy.

Adverse health events within families can harm children's development, including their early literacy. Using data from a longitudinal Wisconsin birth cohort, we estimated the spillover effect of younger siblings' gestational ages on older siblings' kindergarten-level literacy. We sampled 20,014 sibling pairs born during 2007-2010 who took Phonological Awareness Literacy Screening-Kindergarten tests during 2012-2016. Exposures were gestational age (completed weeks), preterm birth (gestational age <37 weeks), and very preterm birth (gestational age <32 weeks). We used gain-score regression-a fixed effects strategy-to estimate spillover effect. A one-week increase in younger siblings' gestational age improved the older siblings' test score by 0.011 SD (95% confidence interval: 0.001, 0.021 SD). The estimated spillover effect was larger among siblings whose mothers reported having a high school diploma/equivalent only (0.024 SD; 95% CI: 0.004, 0.044 SD). The finding underscores the networked effects of one individual's early-life health shocks on their family members.

Maternal opioid use disorder and infant mortality in Wisconsin, United States, 2010-2018.

OBJECTIVE: The difference in infant health outcomes by maternal opioid use disorder (OUD) status is understudied. We measured the association between maternal OUD during pregnancy and infant mortality and investigated whether this association differs by infant neonatal opioid withdrawal syndrome (NOWS) or maternal receipt of medication for OUD (MOUD) during pregnancy. METHODS: We sampled 204,543 Medicaid-paid births from Wisconsin, United States (2010-2018). The primary exposure was any maternal OUD during pregnancy. We also stratified this exposure on NOWS diagnosis (no OUD; OUD without NOWS; OUD with NOWS) and on maternal MOUD receipt (no OUD; OUD without MOUD; OUD with <90 consecutive days of MOUD; OUD with 90+ consecutive days of MOUD). Our outcome was infant mortality (death at age <365 days). Demographic-adjusted logistic regressions measured associations with odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Maternal OUD was associated with increased odds of infant mortality (OR 1.43; 95% CI 1.02-2.02). After excluding infants who died <5 days post-birth (i.e., before the clinical presentation of NOWS), regression estimates of infant mortality did not significantly differ by NOWS diagnosis. Likewise, regression estimates did not significantly differ by maternal MOUD receipt in the full sample. CONCLUSIONS: Maternal OUD is associated with an elevated risk of infant mortality without evidence of modification by NOWS nor by maternal MOUD treatment. Future research should investigate potential mechanisms linking maternal OUD, NOWS, MOUD treatment, and infant mortality to better inform clinical intervention.

Duration and Timing of In Utero Opioid Exposure and Incidence of Neonatal Withdrawal Syndrome.

OBJECTIVE: To evaluate the association between prenatal prescription opioid analgesic exposure (duration, timing) and neonatal opioid withdrawal syndrome (NOWS). METHODS: We conducted a retrospective cohort study of Wisconsin Medicaid-covered singleton live births from 2011 to 2019. The primary outcome was a NOWS diagnosis in the first 30 days of life. Opioid exposure was identified with any claim for prescription opioid analgesic fills during pregnancy. We measured exposure duration cumulatively in days (1-6, 7-29, 30-89, and 90 or more) and identified timing as early (first two trimesters only) or late (third trimester, regardless of earlier pregnancy use). We used logistic regression modeling to assess NOWS incidence by exposure duration and timing, with and without propensity score matching. RESULTS: Overall, 31,456 (14.3%) of 220,570 neonates were exposed to prescription opioid analgesics prenatally. Among exposed neonates, 19,880 (63.2%) had 1-6 days of exposure, 7,694 (24.5%) had 7-29 days, 2,188 (7.0%) had 30-89 days, and 1,694 (5.4%) had 90 or more days of exposure; 15,032 (47.8%) had late exposure. Absolute NOWS incidence among neonates with 1-6 days of exposure was 7.29 per 1,000 neonates (95% CI 6.11-8.48), and incidence increased with longer exposure: 7-29 days (19.63, 95% CI 16.53-22.73); 30-89 days (58.96, 95% CI 49.08-68.84); and 90 or more days (177.10, 95% CI 158.90-195.29). Absolute NOWS incidence for early and late exposures were 11.26 per 1,000 neonates (95% CI 9.65-12.88) and 35.92 per 1,000 neonates (95% CI 32.95-38.90), respectively. When adjusting for confounders including timing of exposure, neonates exposed for 1-6 days had no increased odds of NOWS compared with unexposed neonates, whereas those exposed for 30 or more days had increased odds of NOWS (30-89 days: adjusted odds ratio [aOR] 2.15, 95% CI 1.22-3.79; 90 or more days: 2.80, 95% CI 1.36-5.76). Late exposure was associated with elevated odds of NOWS (aOR 1.57, 95% CI 1.25-1.96) when compared with unexposed after adjustment for exposure duration. CONCLUSION: More than 30 days of prenatal prescription opioid exposure was associated with NOWS regardless of exposure timing. Third-trimester opioid exposure, irrespective of exposure duration, was associated with NOWS.

Adverse Pregnancy Outcomes and Future Metabolic Syndrome.

Background: Metabolic syndrome (MetS) is associated with a history of gestational diabetes (GDM), hypertensive disorders of pregnancy (HDP), and preterm birth (PTB), but it is unclear whether this association is due to the pregnancy complication(s) or prepregnancy/early pregnancy confounders. The study examines the association of GDM, HDP, and PTB with MetS 2-7 years later, independent of early pregnancy factors. Materials and Methods: Large, diverse cohort of nulliparous pregnant people with singleton gestations enrolled during their first trimester and who attended a follow-up study visit 2-7 years after delivery. The longitudinal cohort was recruited from eight medical centers across the United States. Using standardized protocols, anthropometry, biospecimens, and surveys were collected at study visits and pregnancy outcomes were abstracted from medical records. We estimated the relative risk of prevalent MetS at the follow-up study visit for participants with GDM, HDP, or PTB (vs. no complications), adjusting for early pregnancy age, body mass index, self-reported race/ethnicity, insurance type, and smoking status. Results: Of 4,402 participants, 738 (16.8%) had MetS at follow-up: 13.1% (441/3,365) among those with no complications, and 27.9% (290/1,002) among those with complications. MetS occurred in 39.0% of GDM (73/187, adjusted relative risk [aRR] = 1.75; 95% confidence interval [CI] 1.42-2.16); 29.2% of HDP (176/603, aRR = 1.49; 95% CI 1.27-1.75); and 29.7% of PTB (113/380, aRR = 1.78; 95% CI 1.49-2.12). Those who had both HDP and PTB (n = 113) had an aRR = 1.95 (95% CI 1.50-2.54). Conclusions: People whose pregnancies were complicated by GDM, HDP, or PTB are at a higher risk of MetS within 2-7 years after delivery, independent of early pregnancy risk factors. The highest MetS risk follows pregnancies complicated by both HDP and PTB.

Caring for community members during the COVID-19 pandemic: results of a statewide survey.

Aim: Community health workers (CHWs) and home visitors (HVs) are members of the public health workforce who are uniquely poised to support vulnerable populations during the COVID-19 pandemic. In this study, we assess the experiences of CHWs and HVs in Wisconsin during the early stages of the COVID-19 pandemic to learn about their experiences related to mitigation strategies and vaccination efforts. Subject and methods: Working closely with community partners, we recruited CHWs and HVs via email to complete an online survey between June 24 and August 10, 2021. Participants were eligible if they worked at any time since March 25, 2020, when the Safer at Home Order was put into place. The survey asked CHWs and HVs about their experiences during the COVID-19 pandemic and vaccination efforts. Results: Eligible respondents included 48 HVs and 26 CHWs. Most CHWs (96%) and HVs (85%) reported discussing the COVID-19 vaccine with clients, and 46% of HVs and 85% of CHWs said they planned to encourage their clients to vaccinate themselves against COVID-19. We found that many CHWs and HVs identified the COVID-19 pandemic as a threat to the health of the US population, and many reported that they thought mitigation strategies were effective at keeping people safe from COVID-19. There was inconsistency in regard to respondents plans to encourage their clients to receive vaccination for COVID-19. Conclusion: Future study, training, and support for CHWs and HVs should focus on facilitating vaccination efforts and other emerging public health interventions.

Spillover Effects of Prenatal Care Coordination on Older Siblings Beyond the Mother-Infant Dyad.

BACKGROUND: Pregnancy care coordination increases preventive care receipt for mothers and infants. Whether such services affect other family members' health care is unknown. OBJECTIVE: To estimate the spillover effect of maternal exposure to Wisconsin Medicaid's Prenatal Care Coordination (PNCC) program during pregnancy with a younger sibling on the preventive care receipt for an older child. RESEARCH DESIGN: Gain-score regressions-a sibling fixed effects strategy-estimated spillover effects while controlling for unobserved family-level confounders. SUBJECTS: Data came from a longitudinal cohort of linked Wisconsin birth records and Medicaid claims. We sampled 21,332 sibling pairs (one older; one younger) who were born during 2008-2015, who were <4 years apart in age, and whose births were Medicaid-covered. In all, 4773 (22.4%) mothers received PNCC during pregnancy with the younger sibling. MEASURES: The exposure was maternal PNCC receipt during pregnancy with the younger sibling (none; any). The outcome was the older sibling's number of preventive care visits or preventive care services in the younger sibling's first year of life. RESULTS: Overall, maternal exposure to PNCC during pregnancy with the younger sibling did not affect older siblings' preventive care. However, among siblings who were 3 to <4 years apart in age, there was a positive spillover on the older sibling's receipt of care by 0.26 visits (95% CI: 0.11, 0.40 visits) and by 0.34 services (95% CI: 0.12, 0.55 services). CONCLUSION: PNCC may only have spillover effects on siblings' preventive care in selected subpopulations but not in the broader population of Wisconsin families.

Serum Cotinine and Adverse Cardiovascular Outcomes: A Cross-sectional Secondary Analysis of the nuMoM2b Heart Health Study.

OBJECTIVE: We aimed to (1) compare serum cotinine with self-report for ascertaining smoking status among reproductive-aged women; (2) estimate the relative odds of adverse cardiovascular (CV) outcomes among women by smoking status; (3) assess whether the association between adverse pregnancy outcomes (APOs) and CV outcomes varies by smoking status. STUDY DESIGN: We conducted a cross-sectional study of the nuMoM2b Heart Health Study. Women attended a study visit 2 to 7 years after their first pregnancy. The exposure was smoking status, determined by self-report and by serum cotinine. Outcomes included incident chronic hypertension (HTN), metabolic syndrome (MetS), and dyslipidemia. Multivariable logistic regression estimated odds ratios (ORs) for each outcome by smoking status. RESULTS: Of 4,392 women with serum cotinine measured, 3,610 were categorized as nonsmokers, 62 as secondhand smoke exposure, and 720 as smokers. Of 3,144 women who denied tobacco smoke exposure, serum cotinine was consistent with secondhand smoke exposure in 48 (1.5%) and current smoking in 131 (4.2%) After adjustment for APOs, smoking defined by serum cotinine was associated with MetS (adjusted OR [aOR] = 1.52, 95% confidence interval [CI]: 1.21, 1.91) and dyslipidemia (aOR = 1.28, 95% CI: 1.01, 1.62). When stratified by nicotine exposure, nonsmokers with an APO in their index pregnancy had higher odds of stage 1 (aOR = 1.64, 95% CI: 1.32, 2.03) and stage 2 HTN (aOR = 2.92, 95% CI: 2.17, 3.93), MetS (aOR = 1.76, 95% CI: 1.42, 2.18), and dyslipidemia (aOR = 1.55, 95% CI: 1.25, 1.91) relative to women with no APO. Results were similar when smoking exposure was defined by self-report. CONCLUSION: Whether determined by serum cotinine or self-report, smoking is associated with subsequent CV outcomes in reproductive-aged women. APOs are also independently associated with CV outcomes in women. KEY POINTS: · Cotinine was detected in 5.7% of reported nonsmokers.. · Smoking and APOs were independently associated with CV health.. · Smoking was associated with MetS and dyslipidemia..

Factors Influencing Provider Behavior Around Delivery of Preconception Care.

OBJECTIVE: Despite growing consensus about the clinical value of preconception care (PCC), gaps and disparities remain in its delivery. This study aimed to examine the factors influencing behavior of health care providers around PCC in outpatient clinical settings in the United States. METHODS: Twenty health care providers who serve people of reproductive age were interviewed using semi-structured interviews. Data was coded based on a modified Theoretical Domains Framework and analyzed using deductive content analysis. RESULTS: We interviewed eight family medicine physicians, four obstetricians/gynecologists, seven nurse practitioners, and one nurse midwife. Overall, we found a wide variety in practices and attitudes towards PCC. Barriers and challenges to delivering PCC were shared across sites. We identified six themes that influenced provider behavior around PCC: (1) lack of knowledge of PCC guidelines, (2) perception of lack of preconception patient contact, (3) pessimism around patient "compliance," (4) opinion about scope of practice, (5) clinical site structure, and (6) reliance on the patient/provider relationship. CONCLUSIONS FOR PRACTICE: Overall, our findings call for improved provider understanding of PCC and creative incorporation into current health care culture and practice. Given that PCC-specific visits are perceived by some as outside the norm of clinical offerings, providers may need to incorporate PCC into other encounters, as many in this study reported doing. We amplify the call for providers to understand how structural inequities may influence patient behavior and the value of standardized screening, within and beyond PCC, as well as examination of implicit and explicit provider bias.

Fertility rates in women with intellectual and developmental disabilities in Wisconsin Medicaid.

BACKGROUND: Women with intellectual and developmental disabilities (IDD) face stigma and inequity surrounding opportunity and care during pregnancy. Little work has quantified fertility rates among women with IDD which prevents proper allocation of care. OBJECTIVE: Our objective was to cross-sectionally describe fertility patterns among women with and without intellectual and developmental disabilities (IDD) in 10-years of Medicaid-linked birth records. STUDY DESIGN: Our sample was Medicaid-enrolled women with live births in Wisconsin from 2007 to 2016. We identified IDD through prepregnancy Medicaid claims. We calculated general fertility-, age-specific-, and the total fertility-rates and 95% confidence intervals (95% CI) for women with and without IDD and generated estimates by year and IDD-type. RESULTS: General fertility rate in women with IDD was 62.1 births per 1000 women with IDD (95% CI 59.2, 64.9 per 1000 women) and 77.1 per 1000 for women without IDD (95% CI: 76.8, 77.4 per 1000 women). General fertility rate ratio was 0.81 (95% CI: 0.7, 0.9). Total fertility was 1.80 births per woman with IDD and 2.05 births per woman without IDD (rate ratio: 0.89 95% CI: 0.5, 1.5). Peak fertility occurred later for autistic women (30-34 years), compared with women with other IDD (20-24 years). CONCLUSION: In Wisconsin Medicaid, general fertility rate of women with IDD was lower than women without IDD: the difference was attenuated when accounting for differing age distributions. Results highlight the disparities women with IDD face and the importance of allocating pregnancy care within Medicaid.

Birth outcomes affecting infants of mothers with intellectual and developmental disabilities.

BACKGROUND: Women with intellectual and developmental disabilities (IDD) face increased risk of adverse maternal pregnancy outcomes, yet less is known about infant outcomes. OBJECTIVES: To examine birth outcomes of infants born to mothers with IDD and assess associations with demographics and IDD-type. METHODS: We used data from the Big Data for Little Kids project, which links Wisconsin birth records to Medicaid claims for live births covered by Medicaid from 2007 to 2016. We identified IDD using maternal prepregnancy Medicaid claims and ran Poisson regression (with a log link function) with robust variance clustered by mother to compare prevalence of outcomes between singleton births with and without mothers with IDD. We adjusted the associations for demographic factors and estimated prevalence ratios (PR) as the effect measure. We assessed outcomes by IDD-type (intellectual disability, genetic conditions, cerebral palsy, and autism spectrum disorder) to explore differences by categories of IDD. RESULTS: Of 267,395 infants, 1696 (0.6%) had mothers with IDD. A greater percentage of infants with mothers with IDD were born preterm (12.8% vs 7.8%; PR 1.64, 95% confidence interval [CI] 1.42, 1.89), small for gestational age (8.5% vs 5.4%; PR 1.42, 95% CI 1.25, 1.61), and died within 12 months of birth (3.2% vs 0.7%; PR 4.93, 95% CI 3.73, 6.43) compared to infants of mothers without IDD. Prevalence ratios were robust to adjustment for demographics factors. Estimates did not meaningfully differ when comparing different IDD-types. CONCLUSIONS: A greater porportion of infants born to mothers with IDD who were covered by Medicaid had poor outcomes compared to other infants. Prevalence of poor infant outcomes was greater for mothers with IDD even after accounting for demographic differences. It is imperative to understand why infants of mothers with IDD are at greater risk so interventions and management can be developed.

County Poverty, Urban-Rural Classification, and the Causes of Term Infant Death : United States, 2012-2015.

OBJECTIVE: Higher mortality among full-term infants (term infant deaths) contributes to disparities in infant mortality between the United States and other developed countries. We examined differences in the causes of term infant deaths across county poverty levels and urban-rural classification to understand underlying mechanisms through which these factors may act. METHODS: We linked period birth/infant death files for 2012-2015 with US Census poverty estimates and county urban-rural classifications. We grouped the causes of term infant deaths as sudden unexpected death in infancy (SUDI), congenital malformations, perinatal conditions, and all other causes. We computed the distribution and relative risk of overall and cause-specific term infant mortality rates (term IMRs) per 1000 live births and 95% CIs for county-level factors. RESULTS: The increase in term IMR across county poverty and urban-rural classification was mostly driven by an increase in the rate of SUDI. The relative risk of term infant deaths as a result of SUDI was 1.6 (95% CI, 1.5-1.8) times higher in medium-poverty counties and 2.3 (95% CI, 1.2-2.5) times higher in high-poverty counties than in low-poverty counties. Cause-specific IMRs of congenital malformations, perinatal conditions, and death from other causes did not differ by county poverty level. We found similar trends across county urban-rural classification. Sudden infant death syndrome was the main cause of SUDI across both county poverty levels and urban-rural classifications, followed by unknown causes and accidental suffocation and strangulation in bed. CONCLUSIONS: Interventions aimed at reducing SUDI, particularly in high-poverty and rural areas, could have a major effect on reducing term IMR disparities between the United States and other developed countries.

Early Pregnancy Atherogenic Profile in a First Pregnancy and Hypertension Risk 2 to 7 Years After Delivery.

Background Cardiovascular risk in young adulthood is an important determinant of lifetime cardiovascular disease risk. Women with adverse pregnancy outcomes (APOs) have increased cardiovascular risk, but the relationship of other factors is unknown. Methods and Results Among 4471 primiparous women, we related first-trimester atherogenic markers to risk of APO (hypertensive disorders of pregnancy, preterm birth, small for gestational age), gestational diabetes mellitus (GDM) and hypertension (130/80 mm Hg or antihypertensive use) 2 to 7 years after delivery. Women with an APO/GDM (n=1102) had more atherogenic characteristics (obesity [34.2 versus 19.5%], higher blood pressure [systolic blood pressure 112.2 versus 108.4, diastolic blood pressure 69.2 versus 66.6 mm Hg], glucose [5.0 versus 4.8 mmol/L], insulin [77.6 versus 60.1 pmol/L], triglycerides [1.4 versus 1.3 mmol/L], and high-sensitivity C-reactive protein [5.6 versus 4.0 nmol/L], and lower high-density lipoprotein cholesterol [1.8 versus 1.9 mmol/L]; P<0.05) than women without an APO/GDM. They were also more likely to develop hypertension after delivery (32.8% versus 18.1%, P<0.05). Accounting for confounders and factors routinely assessed antepartum, higher glucose (relative risk [RR] 1.03 [95% CI, 1.00-1.06] per 0.6 mmol/L), high-sensitivity C-reactive protein (RR, 1.06 [95% CI, 1.02-1.11] per 2-fold higher), and triglycerides (RR, 1.27 [95% CI, 1.14-1.41] per 2-fold higher) were associated with later hypertension. Higher physical activity was protective (RR, 0.93 [95% CI, 0.87-0.99] per 3 h/week). When evaluated as latent profiles, the nonobese group with higher lipids, high-sensitivity C-reactive protein, and insulin values (6.9% of the cohort) had increased risk of an APO/GDM and later hypertension. Among these factors, 7% to 15% of excess RR was related to APO/GDM. Conclusions Individual and combined first-trimester atherogenic characteristics are associated with APO/GDM occurrence and hypertension 2 to 7 years later. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02231398.

The Association Between Exposure to Maternal Depression During Year 2 of a Child's Life and Future Child Problem Behavior.

INTRODUCTION: We examined the association of exposure to maternal depression during year 2 of a child's life with future child problem behavior. We conducted a secondary analysis to investigate whether race/ethnicity is a moderator of this relationship. METHODS: We used Fragile Families and Child Well-Being Study data (age 3 N = 3288 and 49% Black, 26% Hispanic, 22% non-Hispanic White; age 5 N = 3001 and 51% Black, 25% Hispanic, 21% non-Hispanic White; age 9 N = 3630 and 50% Black, 25% Hispanic, 21% non-Hispanic White) and ordinal logistic regression to model problem behavior at ages 3, 5, and 9 on maternal depression status during year 2. RESULTS: At age 9, children whose mother was depressed during year 2 were significantly more likely to have higher internalizing (AOR = 1.92, 95% CI: 1.42,2.61) and externalizing (AOR = 1.65, 95% CI: 1.10,2.48) problem behavior scores. In our secondary analysis, race/ethnicity did not have moderating effects, potentially due to a limitation of the data that required use of maternal self-reported race/ethnicity as a proxy for child race/ethnicity. DISCUSSION: Exposure to maternal depression after the prenatal and perinatal periods may have a negative association with children's behavioral development through age 9. Interventions that directly target maternal depression during this time should be developed. Additional research is needed to further elucidate the role of race/ethnicity in the relationship between maternal depression and child problem behavior.

Pregnancy complications and maternal birth outcomes in women with intellectual and developmental disabilities in Wisconsin Medicaid.

BACKGROUND: Women with intellectual and developmental disabilities (IDD) may face greater risk for poor pregnancy outcomes. Our objective was to examine risk of maternal pregnancy complications and birth outcomes in women with IDD compared to women without IDD in Wisconsin Medicaid, from 2007-2016. METHODS: Data were from the Big Data for Little Kids project, a data linkage that creates an administrative data based cohort of mothers and children in Wisconsin. Women with ≥1 IDD claim the year before delivery were classified as having IDD. Common pregnancy complications and maternal birth outcomes were identified from the birth record. We calculated risk ratios (RR) using log-linear regression clustered by mother. We examined outcomes grouped by IDD-type and explored interaction by race. RESULTS: Of 177,691 women with live births, 1,032 (0.58%) had an IDD claim. Of 274,865 deliveries, 1,757 were to mothers with IDD (0.64%). Women with IDD were at greater risk for gestational diabetes (RR: 1.28, 95% CI: 1.0, 1.6), gestational hypertension (RR: 1.22, 95% CI: 1.0, 1.5), and caesarean delivery (RR 1.32, 95% CI: 1.2, 1.4) compared to other women. Adjustment for demographic covariates did not change estimates. Women with intellectual disability were at highest risk of gestational hypertension. Black women with IDD were at higher risk of gestational hypertension than expected under a multiplicative model. CONCLUSIONS: Women with IDD have increased risk of pregnancy complications and adverse outcomes in Wisconsin Medicaid. Results were robust to adjustment. Unique patterns by IDD types and Black race warrant further exploration.

Infant Mortality in Rural and Nonrural Counties in the United States.

BACKGROUND AND OBJECTIVES: Rural counties have the highest infant mortality rates across the United States when compared with rates in more urban counties. We use a social-ecological framework to explain infant mortality disparities across the rural-urban continuum. METHODS: We created a cohort of all births in the United States linked to infant death records for 2014 to 2016. Records were linked to county-level data from the Area Health Resources File and the American Community Survey and classified using the National Center for Health Statistics Urban-Rural Classification Scheme. Using multilevel generalized linear models, we investigated the association of infant mortality with county urban-rural classification, considering county health system resources and measures of socioeconomic advantage, net of individual-level characteristics, and controlling for US region and county centroid. RESULTS: Infant mortality rates were highest in noncore (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.26-1.39) and micropolitan counties (OR = 1.26, 95% CI: 1.20-1.32) when compared with large metropolitan fringe counties, controlling for geospatial measures. Inclusion of county health system characteristics did little to attenuate the greater odds of infant mortality in rural counties. Instead, a composite measure of county-level socioeconomic advantage was highly protective (adjusted OR = 0.84; 95% CI: 0.82-0.86) and eliminated any difference between the micropolitan and noncore counties and the large metropolitan fringe counties. CONCLUSIONS: Higher infant mortality rates in rural counties are best explained by their greater socioeconomic disadvantage than more-limited access to health care or the greater prevalence of mothers' individual health risks.

Food Insecurity and Housing Instability Partially Mediate the Association Between Maternal Depression and Child Problem Behavior.

Maternal depression is a risk factor for the development of problem behavior in children. Although food insecurity and housing instability are associated with adult depression and child behavior, how these economic factors mediate or moderate the relationship between maternal depression and child problem behavior is not understood. The purpose of this study was to determine whether food insecurity and housing instability are mediators and/or moderators of the relationship between maternal depression when children are age 3 and children's problem behaviors at age 9 and to determine whether these mechanisms differ by race/ethnicity. We used data from the Fragile Families and Child Wellbeing Study. Food insecurity and housing instability at age 5 were tested as potential mediators and moderators of the relationship between maternal depression status at age 3 and problem behavior at age 9. A path analysis confirmed our hypothesis that food insecurity and housing instability partially mediate the relationship between maternal depression when children are age 3 and problem behavior at age 9. However, housing instability was only a mediator for externalizing problem behavior and not internalizing problem behavior or overall problem behavior. Results of the moderation analysis suggest that neither food insecurity nor housing instability were moderators. None of the mechanisms explored differed by race/ethnicity. While our findings stress the continued need for interventions that address child food insecurity, they emphasize the importance of interventions that address maternal mental health throughout a child's life. Given the central role of maternal health in child development, additional efforts should be made to target maternal depression.

Beyond Birth Control: Noncontraceptive Benefits of Hormonal Methods and Their Key Role in the General Medical Care of Women.

Contraceptives that contain estrogen and/or progestins are used by millions of women around the world to prevent pregnancy. Owing to their unique physiological mechanism of action, many of these medications can also be used to prevent cancer and treat multiple general medical conditions that are common in women. We performed a comprehensive literature search. This article will describe the specific mechanisms of action and summarize the available data documenting how hormonal contraceptives can prevent ovarian and uterine cancer and be used to treat women with a variety of gynecological and nongynecological conditions such as endometriosis, uterine fibroids, heavy menstrual bleeding, polycystic ovary syndrome, acne, and migraines. Contraceptive methods containing estrogen and progestin can be used for a wide variety of medical issues in women.

Peripartum Blood Transfusion Among Rural Women in the United States.

OBJECTIVE: To evaluate the peripartum transfusion rates for rural women compared with urban women in the United States. METHODS: In this population-based retrospective cohort study, geocoded birth records from 2014 to 2016 from the National Center for Health Statistics were used to examine the rural-urban differences in blood transfusion among nulliparous women delivering singleton, vertex pregnancies at term. We compared transfusion rates across the counties on a continuum from urban to rural. We generated a multivariable logistic regression model controlling for age, race, nativity, education, insurance, prenatal care, maternal health, gestational age, intrapartum care, mode of delivery, peripartum factors, and county of delivery. RESULTS: Among 3,346,816 births, the transfusion rates based on maternal county of residence increased as the counties became more rural: large metropolitan-center (1.9/1,000 live births); large metropolitan-fringe (2.4); medium metropolitan (2.6); small metropolitan (2.6); micropolitan (4.5); and noncore rural (5.3). Rural women living and delivering in a rural county had more transfusions (8.5/1,000 live births) than women in more urban counties (2.5/1,000). After adjusting for key covariates, the odds of transfusion were higher among women living in micropolitan (adjusted odds ratio [aOR] 2.25, 95% CI 2.09-2.43) and noncore rural (aOR 2.59, 95% CI 2.38-2.81) counties when compared with women living in large metropolitan counties. County of delivery had a higher association with transfusion than resident county. After adding delivery county to the regression model, the association of transfusion and living in a micropolitan (aOR 1.39, 95% CI 1.19-1.63) or noncore rural (aOR 1.32, 95% CI 1.12-1.55) county diminished. CONCLUSION: The odds of blood transfusion were higher for women in rural areas. The results indicate that the rurality of the county where the birth occurred was associated with more transfusion. This may reflect differences in maternity and blood banking services in rural hospitals and warrants further study to identify opportunities for intervention.

Associations of perceived prenatal stress and adverse pregnancy outcomes with perceived stress years after delivery.

Maternal stress is a risk factor for adverse pregnancy outcomes (APOs). This study evaluates the associations of prenatal stress and APOs with maternal stress years after pregnancy. The 10-item Perceived Stress Scale (PSS) (0-40 range) was completed in the first and third trimesters, and 2-7 years after delivery among a subsample (n = 4161) of nulliparous women enrolled at eight US medical centers between 2010 and 2013 in a prospective, observational cohort study. Demographics, medical history, and presence of APOs (gestational diabetes (GDM), hypertensive disorders of pregnancy (HDP), preeclampsia (PE), and medically indicated or spontaneous preterm birth (miPTB, sPTB)) were obtained. The associations of prenatal PSS and the presence of APOs with PSS scores years after delivery were estimated using multivariable linear regression. Mean PSS scores were 12.5 (95% CI 12.3, 12.7) and 11.3 (95% CI 11.1, 11.5) in the first and third trimesters respectively and 14.9 (95% CI 14.7, 15.1) 2-7 years later, an average increase of 2.4 points (95% CI 2.2, 2.6) from the start of pregnancy. Regressing PSS scores after delivery on first-trimester PSS and PSS increase through pregnancy showed positive associations, with coefficients (95% CI) of 2.8 (2.7, 3.0) and 1.5 (1.3, 1.7) per 5-point change, respectively. Adding APO indicator variables separately showed higher PSS scores for women with HDP (0.7 [0.1, 1.3]), PE (1.3 [0.6, 2.1]), and miPTB (1.3 [0.2, 2.4]), but not those with GDM or sPTB. In this geographically and demographically diverse sample, prenatal stress and some APOs were positively associated with stress levels 2-7 years after pregnancy.ClinicalTrials.gov Registration number NCT02231398.