Differences in Cesarean Rates for Nulliparous, Term, Singleton, Vertex Births Among Racial and Ethnic Groups and States Before and After Stay-at-Home Orders During the COVID-19 Pandemic, United States, 2017-2021.

OBJECTIVES: Evidence is limited on differences in cesarean rates for nulliparous, term, singleton, vertex (NTSV) births across racial and ethnic groups at the national and state level during the COVID-19 pandemic. We assessed changes in levels and trends of NTSV cesarean rates before and after stay-at-home orders (SAHOs) were implemented in the United States (1) overall, (2) by racial and ethnic groups, and (3) by 50 US states from January 2017 through December 2021. METHODS: We used birth certificate data from 2017 through 2021, restricted to hospital births, to calculate monthly NTSV cesarean rates for the United States and for racial and ethnic groups and to calculate quarterly NTSV cesarean rates for the 50 states. We used interrupted time-series analysis to measure changes in NTSV cesarean rates before and after implementation of SAHOs (March 1 through May 31, 2020). RESULTS: Of 6 022 552 NTSV hospital births, 1 579 645 (26.2%) were cesarean births. Before implementation of SAHOs, NTSV cesarean rates were declining in the United States overall; were declining among births to non-Hispanic Asian, non-Hispanic Black, Hispanic, and non-Hispanic White women; and were declining in 6 states. During the first month of implementation of SAHOs in May 2020, monthly NTSV rates increased in the United States by 0.55%. Monthly NTSV rates increased by 1.20% among non-Hispanic Black women, 0.90% among Hispanic women, and 0.28% among non-Hispanic White women; quarterly NTSV rates increased in 6 states. CONCLUSION: In addition to emergency preparedness planning, hospital monitoring, and reporting of NTSV cesarean rates to increase provider awareness, reallocation and prioritization of resources may help to identify potential strains on health care systems during public health emergencies such as the COVID-19 pandemic.

Adverse Maternal Experiences and Neonatal Abstinence Syndrome.

OBJECTIVES: To propose a measure for adverse maternal experiences (AMEs) and examine if AMEs are independently associated with delivery of a neonatal abstinence syndrome (NAS) diagnosed infant. METHODS: Using the Pregnancy Risk Assessment Monitoring System (PRAMS) stressful life events questions, we constructed a composite measure of AMEs. We conducted a retrospective analysis of linked Birth Certificate Data, Hospital Discharge Data and PRAMS data for 2012-2018 using the composite measure. Our analytic sample included 6358 singleton deliveries. We calculated prevalence of NAS and AMEs and prevalence odds ratio (POR) for delivery of an NAS-diagnosed infant adjusting for maternal sociodemographic characteristics, pre-pregnancy depression, prescription medicine 12 months prior to pregnancy, and smoking during pregnancy. RESULTS: The overall prevalence of NAS in Delaware during 2012-2018 was 2.2% (95% CI 1.8-2.6); 9.5% (95% CI 8.7-10.2) of women reported AMEs. After adjustment, women with AMEs had 1.1 times greater odds (aPOR 2.1; 95% CI 1.3-3.3) to deliver a NAS-diagnosed infant as compared with women without AMEs. CONCLUSIONS: Although the cross-sectional nature of the study limits drawing any causal inferences, there are co-occurring factors that support plausibility of an association between AMEs and delivering NAS-diagnosed infants. Addressing AMEs, mental health and substance use screening and treatment as part of preconception and prenatal care may mitigate risks.

Pre and Post-Lockdown Cesarean Deliveries and Perinatal Quality Indicators During the COVID-19 Pandemic.

We examined statewide perinatal quality indicators: nulliparous singleton term vertex cesarean births (NTSV) or low risk cesarean births, and non-medically indicated early term delivery (NMETD) rates during COVID-19 pandemic pre-lockdown (1/1/2019 to 3/23/2020) and post-lockdown (after 3/23/2020). Interrupted time-series analyses were used to examine the effects of the COVID-19 pandemic on these indicators. We observed a statistically significant increase in NTSV cesarean rates, 4.4% (95%CI: 1.3,7.4) immediately after lockdown, and a decrease in NMETD rate, 1.6% (95%CI: -2.5,-0.7). We observed an increase (0.3%; 95%CI: 0.0,0.6) in the slope (i.e., trend change) of NTSV rates post-lockdown and a decrease (-0.2%; 95%CI: -0.3,-0.1) in the slope of NMETD rates. Results suggest that the COVID-19 pandemic had an immediate effect on perinatal quality indicators in Delaware, with gradual return to pre-pandemic rates as the pandemic continued. In addition to emergency preparedness planning, hospital monitoring of perinatal quality indicators might improve obstetrical care during public health emergencies.

Assessing the Effect of School-Based Health Centers on Achievement of National Performance Measures.

BACKGROUND: We assess the impact of School-Based Health Centers (SBHCs) on National Performance Measures (NPMs) related to health care access and utilization among Medicaid-insured youth in Delaware. METHODS: Our retrospective analysis of Delaware's SBHC program data linked with Medicaid claims during 2014-2016 for 13 to 18-year-olds assessed achievement of NPMs and use of mental health services using propensity scores. We estimated crude and adjusted prevalence ratios (APR) for SBHC-enrolled compared with non-enrolled youth. RESULTS: Students enrolled in SBHCs had more health care visits (M = 8.7; 95% CI: 7.9-9.5) compared with non-SBHC-enrolled youth (M = 4.5; 95% CI: 4.3-4.7). Compared with non-SBHC, those enrolled in SBHCs were more likely to receive: well-child visits (APR = 1.2; 95% CI: 1.1-1.3); annual risk assessment (APR = 11.0; 95% CI: 6.9-17.5); BMI screening (APR = 5.6; 95% CI: 3.3-9.4); nutrition counseling (APR = 4.1; 95% CI: 2.8-6.0); physical activity counseling (APR = 6.3; 95% CI: 4.2-9.4); STIs and chlamydia screening (APR = 1.9; 95% CI: 1.3-2.8); mental health visits (APR = 2.6; 95% CI: 2.2-3.1). CONCLUSIONS: We found that among Medicaid-insured youth, those enrolled in SBHCs vs not enrolled in SBHCs had greater health care utilization as evident from NPMs and mental health services.

Assessing the relationship between neonatal abstinence syndrome and birth defects in Delaware.

BACKGROUND: Neonatal abstinence syndrome (NAS) is a withdrawal syndrome in newborns and is frequently caused by maternal opioid use during pregnancy. Our study examines whether NAS is associated with birth defects in Delaware. METHODS: We conducted a retrospective analysis of linked Delaware birth certificate data (BCD), hospital discharge data (HDD), and birth defects registry (BDR) data to examine the association between NAS and birth defects for all hospital births to Delaware residents from 2010 to 2017. Birth defects data were abstracted from medical records from Delaware's BDR. We used International Classification of Diseases Ninth and Tenth Revision Clinical Modification (ICD-9-CM/ICD-10-CM) 779.5 and P96.1 codes to determine NAS using HDD and excluded iatrogenic cases of NAS. We estimated crude and adjusted odds ratio with 95% confidence intervals (CIs). RESULTS: During 2010-2017, there were 2,784 cases of birth defects and 1,651 cases of NAS in Delaware. Among infants with a diagnosis of NAS, 56 also had a birth defect (3.4%), similar to 2,728 birth defects among 79,636 infants without a diagnosis of NAS (3.4%). We found no statistically significant association between an NAS diagnosis and birth defects (adjusted odds ratios = 1.0; 95% CI: 0.8-1.3). CONCLUSIONS: Our multiyear state-wide study using linked BCD, HDD, and BDR data for Delaware did not show a statistically significant association between infants diagnosed with NAS and birth defects, overall.

Condom and Contraceptive Use Among Sexually Active High School Students - Youth Risk Behavior Survey, United States, 2019.

Preventing unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, among adolescents is a public health priority. This report presents prevalence estimates for condom and contraceptive use among sexually active U.S. high school students from the 2019 Youth Risk Behavior Survey. Behaviors examined included any condom use, primary contraceptive method use, and condom use with a more effective contraceptive method, all reported at last sexual intercourse. Analyses were limited to sexually active students (i.e., those who had sexual intercourse with one or more persons during the 3 months before the survey). Except for any condom use, students reporting only same-sex sexual contact were excluded from analyses. Weighted prevalence estimates were calculated, and bivariate differences in prevalence were examined by demographic characteristics (sex, race/ethnicity, and grade) and other sexual risk behaviors (age of sexual initiation, previous 3-month and lifetime number of sex partners, and substance use before last sexual intercourse). Nationwide, 27.4% of high school students reported being sexually active (n = 3,226). Among sexually active students who reported having had sexual contact with someone of the opposite sex (n = 2,698), most students (89.7%) had used a condom or a primary contraceptive method at last sexual intercourse. Prevalence of any condom use at last sexual intercourse was 54.3%, and condoms were the most prevalent primary contraceptive method (43.9% versus 23.3% for birth control pills; 4.8% for intrauterine device [IUD] or implant; and 3.3% for shot, patch, or ring). Approximately 9% had used condoms with an IUD, implant, shot, patch, ring, or birth control pills. Using no pregnancy prevention method was more common among non-Hispanic black (23.2%) and Hispanic (12.8%) students compared with non-Hispanic white students (6.8%); compared with Hispanic students, using no pregnancy prevention method was more common among non-Hispanic black students. Prevalence of condom use was consistently lower among students with other sexual risk behaviors. Results underscore the need for public health professionals to provide quality sexual and reproductive health education and clinical services for preventing unintended pregnancy and STDs/HIV and decreasing disparities among sexually active youths.

Evaluating the Health Outcomes of the Healthy Women Healthy Babies Program in Delaware.

OBJECTIVES: The Delaware Healthy Women Healthy Babies Program (HWHB) was developed in response to increasing rates of infant mortality (IMR) and widening racial disparity. The primary aim of this study was to examine birth outcomes of enrolled and non-enrolled black and Hispanic women in the program whose payer was Medicaid. METHODS: We utilized a retrospective cohort of linked birth certificate and HWHB program participant data during 2011-2015. Our primary outcome variables (dependent variables) of interest included cigarette use, low birth weight, preterm birth and neonatal mortality. We utilized inverse probability of treatment weighting (IPTW) and estimated crude odds ratios (COR) and adjusted odds ratio (AOR) with 95% confidence intervals (CI) using IPTW as a weight variable. RESULTS: HWHB enrolled women were 10% less likely to smoke during pregnancy COR 0.89 (95% CI 0.82-0.96); were 9% less likely to deliver a low birth weight infant (AOR 0.91; 95% CI 0.84-0.99; p = 0.023); were 15% less likely to deliver a preterm infant (AOR 0.85; 0.78-0.92; p < .0001) as compared with non-HWHB women. Infants delivered by HWHB enrolled women had 27% less likelihood (AOR 0.73; 95% CI 0.54-0.98; p = 0.035) of experiencing a neonatal death (i.e., < 28 days) as compared with infants of non-enrolled HWHB women. CONCLUSION: The primary goal of this evaluation was to assess the effectiveness of the HWHB program on modifiable risk factors of IMR among HWHB enrolled and non-enrolled women. We found that HWHB program is a promising practice in improving the outcomes of infants born to participating black and Hispanic mothers.

Neonatal Abstinence Syndrome (NAS) in Southwestern Border States: Examining Trends, Population Correlates, and Implications for Policy.

Introduction Neonatal abstinence syndrome (NAS) is withdrawal syndrome in newborns following birth and is primarily caused by maternal drug use during pregnancy. This study examines trends, population correlates, and policy implications of NAS in two Southwest border states. Materials and Methods A cross-sectional analysis of Hospital Inpatient Discharge Data (HIDD) was utilized to examine the incidence of NAS in the Southwest border states of Arizona (AZ) and New Mexico (NM). All inpatient hospital births in AZ and NM from January 1, 2008 through December 31, 2013 with ICD9-CM codes for NAS (779.5), cocaine (760.72), or narcotics (760.75) were extracted. Results During 2008-2013 there were 1472 NAS cases in AZ and 888 in NM. The overall NAS rate during this period was 2.83 per 1000 births (95% CI 2.68-2.97) in AZ and 5.31 (95% CI 4.96-5.66) in NM. NAS rates increased 157% in AZ and 174% in NM. NAS newborns were more likely to have low birth weight, have respiratory distress, more likely to have feeding difficulties, and more likely to be on state Medicaid insurance. AZ border region (border with Mexico) had NAS rates significantly higher than the state rate (4.06 per 1000 births [95% CI 3.68-4.44] vs. 2.83 [95% CI 2.68-2.97], respectively). In NM, the border region rate (2.09 per 1000 births [95% CI 1.48-2.69]) was significantly lower than the state rate (5.31 [95% CI 4.96-5.66]). Conclusions Despite a dramatic increase in the incidence of NAS in the U.S. and, in particular, the Southwest border states of AZ and NM, there is still scant research on the overall incidence of NAS, its assessment in the southwest border, and associated long-term outcomes. The Healthy Border (HB) 2020 binational initiative of the U.S.-Mexico Border Health Commission is an initiative that addresses several public health priorities that not only include chronic and degenerative diseases, infectious diseases, injury prevention, maternal and child health but also mental health and addiction. The growing opioid epidemic and rise in NAS cases in the Southwest border, as partially shown in this study, provides another opportunity to track health illnesses and outcomes in the Southwest border, especially because there are targeted resources through High Intensity Drug Trafficking Areas (HIDTA) funding.

Interpregnancy intervals and the risk for infant mortality: a case control study of Arizona infants 2003-2007.

There is well-documented evidence on how interpregnancy interval (IPI) is associated with adverse perinatal outcomes and how short and long IPIs are associated with increased risk for preterm birth, low birth weight, and intra-uterine growth restriction. However, the extremes of IPI on infant mortality are less well documented. The current study builds on the existing evidence on IPI to examine if extremes of IPI are associated with infant mortality, and also examines if IPI is associated with both neonatal and post-neonatal mortality after adjusting for several known confounders. Matched birth and death certificate data for Arizona resident infants was drawn for 2003-2007 cohorts. The analysis was restricted to singleton births among resident mothers with a previous live birth (n = 1,466) and a randomly selected cohort of surviving infants during the same time-frame was used as a comparison group (n = 2,000). Logistic regression models were utilized to assess the odds for infant mortality at monthly interpregnancy intervals (<6, 6-11, 12-17, 18-23, 24-59, ≥60), while adjusting for established predictors of infant mortality (i.e., preterm birth, low birth weight, and small for gestational age), and other potential confounders. Unadjusted analysis showed greater clustering at extreme IPIs of <6 months and ≥60 months for infants that died (32%) compared to infants that survived (24.7%). Shorter IPI (i.e., <6 months, 6-11 months, and 12-17 months) compared to 'ideal' IPI (i.e., 18-23 months), were associated with infant mortality even after adjusting for confounders. Short intervals were significantly associated with neonatal, but not post-neonatal deaths. IPI above 23 months were not associated with infant mortality in our analyses. Shorter IPIs (18 months or less) significantly increases the risk for neonatal infant mortality even after controlling for known confounders, and our study adds to the existing evidence on adverse perinatal outcomes. Counseling women of reproductive age on the benefits of spacing pregnancies to at least 18 months addresses one preventable risk for early infant mortality.

Using community-based participatory mixed methods research to understand preconception health in African American communities of Arizona.

The article discusses Arizona's strategic implementation and evaluation of the first time motherhood initiative grant (FTMI) to understand preconception health among African American men and women in Arizona. Longitudinal focus groups assessed whether African American men and women in the targeted areas comprehended and recalled the messages related to preconception health. Matched pre and posttests assessed community members' knowledge of preconception as well as physicians' perceptions on preconception health and care. Focus-group data were transcribed and coded by independent coders to conduct content analyses. Inter-rater reliability and agreement among coders, bivariate and multivariate statistics were conducted for quantitative matched pre and posttests data using SAS v9.2 (SAS Institute, Cary, NC). The social marketing campaign had limited impact in recall and comprehension of the preconception health message among African American men and women. Data from focus groups revealed that African American men and women perceived preconception health to be vital. And results from the pretest and posttests of community-based presentations, further supported this finding. Evidence from Grand Round presentations indicated that practitioners and health care providers had diverging views on preconception health. Use of community-based participatory mixed methods research can facilitate better understanding of the efficacy of strategic interventions such as FTMI and can provide valuable information on preconception health. Cost limitations often prohibit extensive evaluation of social marketing campaigns, hence, evaluators and researchers should assess the feasibility of conducting an efficacy study versus an effectiveness study in evaluating social marketing campaigns.