Maternal Characteristics and Rates of Unexpected Complications in Term Newborns by Hospital.

Importance: The Joint Commission Unexpected Complications in Term Newborns measure characterizes newborn morbidity potentially associated with quality of labor and delivery care. Infant exclusions isolate relatively low-risk births, but unexpected newborn complications (UNCs) are not adjusted for maternal factors that may be associated with outcomes independently of hospital quality. Objective: To investigate the association between maternal characteristics and hospital UNC rates. Design, Setting, and Participants: This cohort study was conducted using linked 2016 to 2018 New York City birth and hospital discharge datasets among 254 259 neonates at low risk (singleton, ≥37 weeks, birthweight ≥2500 g, and without preexisting fetal conditions) at 39 hospitals. Logistic regression was used to calculate unadjusted hospital-specific UNC rates and replicated analyses adjusting for maternal covariates. Hospitals were categorized into UNC quintiles; changes in quintile ranking with maternal adjustment were examined. Data analyses were performed from December 2022 to July 2023. Main Outcomes and Measures: UNCs were classified according to Joint Commission International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) criteria. Maternal preadmission comorbidities, obstetric factors, social characteristics, and hospital characteristics were ascertained. Results: Among 254 259 singleton births at 37 weeks or later who were at low risk (125 245 female [49.3%] and 129 014 male [50.7%]; 71 768 births [28.2%] to Hispanic, 47 226 births [18.7%] to non-Hispanic Asian, 42 682 births [16.8%] to non-Hispanic Black, and 89 845 births [35.3%] to non-Hispanic White mothers and 2738 births [1.0%] to mothers with another race or ethnicity), 148 393 births (58.4%) were covered by Medicaid and 101 633 births (40.0%) were covered by commercial insurance. The 2016 to 2018 cumulative UNC incidence in New York City hospitals was 37.1 UNCs per 1000 births. Infants of mothers with preadmission risk factors had increased UNC risk; for example, among mothers with vs without preeclampsia, there were 104.4 and 35.8 UNCs per 1000 births, respectively. Among hospitals, unadjusted UNC rates ranged from 15.6 to 215.5 UNCs per 1000 births and adjusted UNC rates ranged from 15.6 to 194.0 UNCs per 1000 births (median [IQR] change from adjustment, 1.4 [-4.7 to 1.0] UNCs/1000 births). The median (IQR) change per 1000 births for adjusted vs unadjusted rates showed that hospitals with low (<601 deliveries/year; -2.8 [-7.0 to -1.6] UNCs) to medium (601 to <954 deliveries/year; -3.9 [-7.1 to -1.9] UNCs) delivery volume, public ownership (-3.6 [-6.2 to -2.3] UNCs), or high proportions of Medicaid-insured (eg, ≥90.72%; -3.7 [-5.3 to -1.9] UNCs), Black (eg, ≥32.83%; -5.3 [-9.1 to -2.2] UNCs), or Hispanic (eg, ≥6.25%; -3.7 [-5.3 to -1.9] UNCs) patients had significantly decreased UNC rates after adjustment, while rates increased or did not change in hospitals with the highest delivery volume, private ownership, or births to predominantly White or privately insured individuals. Among all 39 hospitals, 7 hospitals (17.9%) shifted 1 quintile comparing risk-adjusted with unadjusted quintile rankings. Conclusions and Relevance: In this study, adjustment for maternal case mix was associated with small overall changes in hospital UNC rates. These changes were associated with performance assessment for some hospitals, and these results suggest that profiling on this measure should consider the implications of small changes in rates for hospitals with higher-risk obstetric populations.

SARS-CoV-2 infection, inflammation and birth outcomes in a prospective NYC pregnancy cohort.

Associations between antenatal SARS-CoV-2 infection and pregnancy outcomes have been conflicting and the role of the immune system is currently unclear. This prospective cohort study investigated the interaction of antenatal SARS-CoV-2 infection, changes in cytokine and HS-CRP levels, birthweight and gestational age at birth. 2352 pregnant participants from New York City (2020-2022) were included. Plasma levels of interleukin (IL)-1ß, IL-6, IL-17A and high-sensitivity C-reactive protein (HS-CRP) were quantified in blood specimens obtained across pregnancy. Quantile and linear regression models were conducted to 1) assess the impact of antenatal SARS-CoV-2 infection, overall and by timing of detection of SARS-CoV-2 positivity (< 20 weeks versus ≥ 20 weeks), on birthweight and gestational age at delivery; 2) examine the relationship between SARS-CoV-2 infection and maternal immune changes during pregnancy. All models were adjusted for maternal demographic and obstetric factors and pandemic timing. Birthweight models were additionally adjusted for gestational age at delivery and fetal sex. Immune marker models were also adjusted for gestational age at specimen collection and multiplex assay batch. 371 (15.8%) participants were infected with SARS-CoV-2 during pregnancy, of which 98 (26.4%) were infected at < 20 weeks gestation. Neither SARS-CoV-2 infection in general nor in early or late pregnancy was associated with lower birthweight nor earlier gestational age at delivery. Further, we did not observe cytokine or HS-CRP changes in response to SARS-CoV-2 infection and thus found no evidence to support a potential association between immune dysregulation and the diversity in pregnancy outcomes following infection.

ScreenPlus: A comprehensive, multi-disorder newborn screening program.

The increasing availability of novel therapies highlights the importance of screening newborns for rare genetic disorders so that they may benefit from early therapy, when it is most likely to be effective. Pilot newborn screening (NBS) studies are a way to gather objective evidence about the feasibility and utility of screening, the accuracy of screening assays, and the incidence of disease. They are also an optimal way to evaluate the complex ethical, legal and social implications (ELSI) that accompany NBS expansion for disorders. ScreenPlus is a consented pilot NBS program that aims to enroll over 100,000 infants across New York City. The initial ScreenPlus panel includes 14 disorders and uses an analyte-based, multi-tiered screening platform in an effort to enhance screening accuracy. Infants who receive an abnormal result are referred to a ScreenPlus provider for confirmatory testing, management, and therapy as needed, along with longitudinal capture of outcome data. Participation in ScreenPlus requires parental consent, which is obtained in active and passive manners. Patient-facing documents are translated into the ten most common languages spoken at our nine pilot hospitals, all of which serve diverse communities. At the time of consent, parents are invited to receive a series of online surveys to capture their opinions about specific ELSI-related topics, such as NBS policy, residual dried blood spot retention, and the types of disorders that should be on NBS panels. ScreenPlus has developed a stakeholder-based, collective funding model that includes federal support in addition to funding from 14 advocacy and industry sponsors, all of which have a particular interest in NBS for at least one of the ScreenPlus disorders. Taken together, ScreenPlus is a model, multi-sponsored pilot NBS program that will provide critical data about NBS for a broad panel of disorders, while gathering key stakeholder opinions to help guide ethically sensitive decision-making about NBS expansion.

Development of a prediction model of postpartum hospital use using an equity-focused approach.

BACKGROUND: Racial inequities in maternal morbidity and mortality persist into the postpartum period, leading to a higher rate of postpartum hospital use among Black and Hispanic people. Delivery hospitalizations provide an opportunity to screen and identify people at high risk to prevent adverse postpartum outcomes. Current models do not adequately incorporate social and structural determinants of health, and some include race, which may result in biased risk stratification. OBJECTIVE: This study aimed to develop a risk prediction model of postpartum hospital use while incorporating social and structural determinants of health and using an equity approach. STUDY DESIGN: We conducted a retrospective cohort study using 2016-2018 linked birth certificate and hospital discharge data for live-born infants in New York City. We included deliveries from 2016 to 2017 in model development, randomly assigning 70%/30% of deliveries as training/test data. We used deliveries in 2018 for temporal model validation. We defined "Composite postpartum hospital use" as at least 1 readmission or emergency department visit within 30 days of the delivery discharge. We categorized diagnosis at first hospital use into 14 categories based on International Classification of Diseases-Tenth Revision diagnosis codes. We tested 72 candidate variables, including social determinants of health, demographics, comorbidities, obstetrical complications, and severe maternal morbidity. Structural determinants of health were the Index of Concentration at the Extremes, which is an indicator of racial-economic segregation at the zip code level, and publicly available indices of the neighborhood built/natural and social/economic environment of the Child Opportunity Index. We used 4 statistical and machine learning algorithms to predict "Composite postpartum hospital use", and an ensemble approach to predict "Cause-specific postpartum hospital use". We simulated the impact of each risk stratification method paired with an effective intervention on race-ethnic equity in postpartum hospital use. RESULTS: The overall incidence of postpartum hospital use was 5.7%; the incidences among Black, Hispanic, and White people were 8.8%, 7.4%, and 3.3%, respectively. The most common diagnoses for hospital use were general perinatal complications (17.5%), hypertension/eclampsia (12.0%), nongynecologic infections (10.7%), and wound infections (8.4%). Logistic regression with least absolute shrinkage and selection operator selection retained 22 predictor variables and achieved an area under the receiver operating curve of 0.69 in the training, 0.69 in test, and 0.69 in validation data. Other machine learning algorithms performed similarly. Selected social and structural determinants of health features included the Index of Concentration at the Extremes, insurance payor, depressive symptoms, and trimester entering prenatal care. The "Cause-specific postpartum hospital use" model selected 6 of the 14 outcome diagnoses (acute cardiovascular disease, gastrointestinal disease, hypertension/eclampsia, psychiatric disease, sepsis, and wound infection), achieving an area under the receiver operating curve of 0.75 in training, 0.77 in test, and 0.75 in validation data using a cross-validation approach. Models had slightly lower performance in Black and Hispanic subgroups. When simulating use of the risk stratification models with a postpartum intervention, identifying high-risk individuals with the "Composite postpartum hospital use" model resulted in the greatest reduction in racial-ethnic disparities in postpartum hospital use, compared with the "Cause-specific postpartum hospital use" model or a standard approach to identifying high-risk individuals with common pregnancy complications. CONCLUSION: The "Composite postpartum hospital use" prediction model incorporating social and structural determinants of health can be used at delivery discharge to identify persons at risk for postpartum hospital use.

Parental Depression and Anxiety Associated with Newborn Bloodspot Screening for Rare and Variable-Onset Disorders.

The ability to screen newborns for a larger number of disorders, including many with variable phenotypes, is prompting debate regarding the psychosocial impact of expanded newborn bloodspot screening (NBS) on parents. This study compares psychological outcomes of parents of children with a range of NBS/diagnostic experiences, with a particular focus on lysosomal storage disorders (LSDs) and X-linked adrenoleukodystrophy (X-ALD) as representative disorders with complex presentations. An online cross-sectional survey with six domains was completed in 2019 by a volunteer sample of parents with at least one child born between 2013 and 2018. Parents were classified in the analysis stage into four groups based on their child's rare disorder and means of diagnosis. Stress and depression were estimated using dichotomous measures of the depression subscale of the Hospital Anxiety and Depression Scale and the Parental Stress Scale. Logistic regression models were estimated for the relationship between the parent group and stress/depression, controlling for demographic variables (region of the US, income, education, major life events, relationship to the child, number of children, parent age, and race/ethnicity). One hundred seventy-four parents were included in this analysis. Parents of children with an LSD or X-ALD diagnosis clinically may have higher odds of depression (OR: 6.06, 95% CI: 1.64-24.96) compared to parents of children with the same disorders identified through NBS, controlling for covariates. Although a similar pattern was observed for parental stress (OR: 2.85, 95% CI: 0.82-10.37), this did not reach statistical significance. Ethically expanding NBS and genome sequencing require an understanding of the impacts of early detection for complex disorders on families. These initial findings are reassuring, and may have implications as NBS expands. Given our small sample size, it is difficult to generalize these findings to all families. These preliminary trends warrant further investigation in larger and more diverse populations.

Intimate partner violence (IPV) prevention using a cross-sectoral couple-based intervention: results from a cluster randomised control trial in Ibadan, Nigeria.

INTRODUCTION: Intimate partner violence (IPV) is the most common form of violence women experience globally. Economic empowerment interventions have been implemented across countries to prevent and address IPV, with mixed results. A sociological 'male-backlash' model suggests that addressing unequal gender norms is crucial to reduce IPV. This study evaluates the impact of a multipronged intervention among heterosexual couples in urban and periurban Ibadan that aimed at reducing IPV by increasing financial and reproductive literacy, fostering gender equality and improving relationship quality. METHODS: A four-arm mixed-methods cluster randomised control trial was employed. Baseline data and end line data six months postintervention were collected to estimate changes in key outcomes. In-depth interviews were conducted with 15 couples 2 years postintervention to explore the drivers of changes in outcomes. Difference-in-differences regression models were estimated to compare changes in IPV levels across the three intervention arms and control arm, and thematic analysis was conducted to understand drivers of change in IPV outcomes. RESULTS: Physical IPV decreased significantly in the gender socialisation (GS) (ß: -4.63 (SE: 2.12)) and GS and financial literacy (ß: -4.61 (SE: 2.02)) groups as compared with the control group. Changes in emotional and sexual IPV were marginally significant or insignificant, respectively, suggesting that the intervention did not have an impact on non-physical forms of IPV. In the in-depth interviews, couples reported improved communication and trust, enhanced conflict management skills, and increased mutual respect as a result of participation across intervention arms, which may have facilitated the reduction of violence in their relationships. CONCLUSION: This study highlights the potential utility of gender transformative interventions for improving physical IPV outcomes. Future research should seek to understand the mechanisms that influence sexual and emotional IPV as their aetiology may be different from physical violence. TRAIL REGISTRATION NUMBER: The study protocol was registered at ClinicalTrials.gov (ID: NCT03888495).

Impact of a family-centred early intervention programme in South India on caregivers of children with developmental delays.

BACKGROUND: This study evaluated the impact on caregiver strain and family empowerment among caregivers of children with disabilities who received training and education as part of a family-centred community-based early intervention programme in South India. METHODS: This prospective open cohort longitudinal study compared change from baseline to two years post-intervention among caregivers of the first cohort of children who were enrolled in the programme. Paired t-tests determined effect on the Modified Caregiver Strain Index (MCSI) and Family Empowerment Scale (FES), and p-values were adjusted for multiple comparisons using the False Discovery Rate approach. RESULTS: Of the 308 caregivers (91% women), 44% provided care to children with cerebral palsy and 56% to children with other developmental delays. The mean age of the children at baseline was 3.3 (±1.5 years). The overall mean change from baseline in the FES was 4.1 (95% CI: 3.3, 4.9; p < 0.001) representing improved empowerment. The mean change for the MCSI score was -3.7 (95% CI: -4.5, -2.9; p < 0.001) representing reduced caregiver strain. CONCLUSIONS: A family-centred early intervention programme that provides training and education to caregivers of children with developmental delays demonstrated positive change in caregiver strain and family empowerment.Implications for RehabilitationThe well-being of a child is influenced by the well-being of their caregiver.Improving caregiver well-being can help improve care and support for children with developmental delays.A family-centred early intervention therapy programme that includes training and education to caregivers can reduce strain and improve family empowerment.