Prevalence of hepatitis C among pregnant women in an Appalachian population.

The opioid crisis has adversely affected West Virginia's pregnant and infant populations. With high rates of opioid use disorder and neonatal abstinence syndrome, West Virginia has the highest rates of Hepatitis C (HCV) acute infection among pregnant women. To better understand how HCV impacts an already high-risk population, the study purpose was to (1) describe its prevalence among women receiving prenatal care at a single tertiary care clinic in Appalachia and compare with state and national rates, and (2) determine whether it is associated with preterm birth (gestation <37 weeks). Data were collected on a retrospective cohort of pregnant patients universally screened for HCV between 2017 and 2021. The study cohort had an HCV infection rate of 119/988 = 11.94% or 119.4 per 1000. This is five times the rate of 22.6 per 1000 live births in West Virginia in 2014 and 35 times the national rate of 3.4 per 1000 live births (MMWR Morb Mortal Wkly Rep 66, 2017 and 470). Viral loads were detected in 63 (6.38%) of patients. The study cohort with birth outcome data had high rates of tobacco use (326/720; 45.3%) and substance abuse (209/720; 29.0%). The preterm birth rate was 17.8% (128/720), almost double the national average (10.09%) (Natl Vital Stat Rep 70, 2021 and 1). There was no statistically significant difference in preterm birth between HCV-positive (15/92; 16.3%) and HCV-negative (113/628; 18.0%) patients. HCV infection in our population presents a significant public health issue and missed opportunity for treatment in a population with continuity of care challenges. These findings could be used to justify a pilot program for early postpartum referral for treatment.

Development of Artificial Intelligence Image Classification Models for Determination of Umbilical Cord Vascular Anomalies.

OBJECTIVE: The goal of this work was to develop robust techniques for the processing and identification of SUA using artificial intelligence (AI) image classification models. METHODS: Ultrasound images obtained retrospectively were analyzed for blinding, text removal, AI training, and image prediction. After developing and testing text removal methods, a small n-size study (40 images) using fastai/PyTorch to classify umbilical cord images. This data set was expanded to 286 lateral-CFI images that were used to compare: different neural network performance, diagnostic value, and model predictions. RESULTS: AI-Optical Character Recognition method was superior in its ability to remove text from images. The small n-size mixed single umbilical artery determination data set was tested with a pretrained ResNet34 neural network and obtained and error rate average of 0.083 (n = 3). The expanded data set was then tested with several AI models. The majority of the tested networks were able to obtain an average error rate of <0.15 with minimal modifications. The ResNet34-default performed the best with: an image-classification error rate of 0.0175, sensitivity of 1.00, specificity of 0.97, and ability to correctly infer classification. CONCLUSION: This work provides a robust framework for ultrasound image AI classifications. AI could successfully classify umbilical cord types of ultrasound image study with excellent diagnostic value. Together this study provides a reproducible framework to develop AI-specific ultrasound classification of umbilical cord or other diagnoses to be used in conjunction with physicians for optimal patient care.

Opioid Use Following Cesarean Delivery: A Pilot Study on Patterns of Use, Storage, and Disposal.

Objective The aim of this study was to describe various aspects related to opioid use and storage in the setting of at-home pain management after cesarean deliveries among an Appalachian population. Methods Women who underwent cesarean delivery (January-June 2019) at an Appalachian institution were prospectively enrolled and administered a telephone survey seven (± 3) days post-discharge. Results Of the 87 women enrolled, 40 (46%) completed the survey; 92.5% were prescribed an opioid medication, most commonly oxycodone/acetaminophen 5/325 mg. A Kruskal-Wallis H test revealed a significant association between the severity of pain that interfered with normal daily activities and the number of pills consumed [χ2(2)=6.75, p=0.034]. More than 70% of the participants (28/40) had not safely stored or disposed of their unused opioid medications. Conclusion Our findings highlight the need for interventions to educate patients on how to appropriately use, store, and dispose of unused opioids.

Prevalence and Spatial Distribution of Gastroschisis in an Industrial Watershed.

The relationship between the congenital defect of gastroschisis and environmental toxins is poorly understood. We examined gastroschisis incidence, risk factors, and spatial association in a geographic region with known environmental pollution and hazardous waste sites. An observational study of fetal and neonatal gastroschisis diagnosed from 1/1/2006 to 12/31/2020 was conducted in a southern West Virginia (WV) tertiary care hospital. Emerging hot spot analysis and Ripley's K-Function examined the spatial relationship between gastroschisis cases and Environmental Protection Agency (EPA) Federal Registry Sites (FRS). A total of 63 gastroschisis cases provided a prevalence rate of 14.6 per 10000 live births. Gastroschisis was associated with younger maternal age, decreased pre-pregnancy BMI, and increased maternal tobacco use. Relative to FRS sites, spatial clusters were identified with emerging hot spot analysis. Observed Ripley K was higher at all measured bands. Results suggest a potential geographic association between gastroschisis cases and EPA-designated hazardous waste sites.

Residency Experience With Physical Examination- and Ultrasound-Indicated Cerclage: A Single Center Retrospective Study.

Background: Cervical insufficiency, the dilation of the cervix in the absence of contractions or labor, can cause second-trimester pregnancy loss or preterm birth. Cervical cerclage is a common treatment for cervical insufficiency and has 3 indications for placement: history, physical examination, and ultrasound. The purpose of this study was to compare pregnancy and birth outcomes for physical examination- and ultrasound-indicated cerclage. Methods: We conducted a retrospective observational descriptive review of second-trimester obstetric patients with transcervical cerclage performed by residents at a single tertiary care medical center from January 1, 2006, to January 1, 2020. We present data on all patients and compare outcomes between the 2 study groups: patients who received physical examination-indicated cerclage vs those who received ultrasound-indicated cerclage. Results: Cervical cerclage was placed on 43 patients at a mean gestational age of 20.4 ± 2.4 weeks (range, 14 to 25 weeks) and with a mean cervical length of 1.53 ± 0.5 cm (range, 0.4 to 2.5 cm). With a latency period of 11.8 ± 5.7 weeks, mean gestational age at delivery was 32.1 ± 6.2 weeks. Fetal/neonatal survival rates were comparable: 80% (16/20) for the physical examination group compared to 82.6% (19/23) for the ultrasound group. No differences were found between groups for gestational age at delivery-31.5 ± 6.8 in the physical examination group vs 32.6 ± 5.8 in the ultrasound group (P=0.581)-or for preterm birth <37 weeks-65.0% (13/20) in the physical examination group vs 65.2% (15/23) in the ultrasound group (P=1.000). Rates of maternal morbidity and neonatal intensive care unit morbidity were similar between the groups. No cases of immediate operative complications or maternal deaths occurred. Conclusion: Pregnancy outcomes for physical examination- and ultrasound-indicated cerclage placed by residents at a tertiary academic medical center were similar. Fetal/neonatal survival and preterm birth rates were favorable for physical examination-indicated cerclage when compared to other published studies.

A Scoping Review of Perinatal Palliative Care: Allowing Parents to Be Parents.

OBJECTIVE: Perinatal palliative care (PPC) is an option for patients who discover that their infant has a life-limiting fetal condition, which decreases the burden of the condition using a multidisciplinary approach. STUDY DESIGN: This review discusses the landmark literature in the past two decades, which have seen significant growth and development in the concept of PPC. RESULTS: The literature describes the background, quality, and benefits of offering PPC, as well as the ethical principles that support its being offered in every discussion of fetal life-limiting diagnoses. CONCLUSION: PPC shares a similar risk profile to other options after life-limiting diagnosis, including satisfaction with choice of continuation of pregnancy. The present clinical opinion closes by noting common barriers to establishing PPC programs and offers a response to overcome each one. KEY POINTS: · Perinatal palliative care serves patients who continue pregnancies with life-limiting fetal anomaly.. · Perinatal palliative care has a risk profile similar to other options such as termination.. · Health care providers can serve as champions to extend PPC to patients in their region..

Medication Abortion and Preterm Birth.

Considerable controversy exists about the effects of medication abortion on the incidence of preterm birth (PTB). Medication abortion of various types continues to be touted as a safe alternative to surgical abortion, and without increased risk for PTB. There is a paucity of evidence regarding medication abortion and PTB, but available papers are reviewed here. There is moderate-quality evidence that medication abortions which require surgical completion increase PTB rates more than surgical abortion alone.

Predicting perinatal outcomes with an obstructive sleep apnea screening tool.

The objective was to determine if a screening tool for obstructive sleep apnea could be used to predict adverse perinatal outcomes. This was a prospective observational study of patients receiving prenatal care and universally screened for obstructive sleep apnea with the STOP Questionnaire (four questions related to Snoring, Tiredness during daytime, Observed apnea, and high blood Pressure). Confounding variables were included in a backwards logistic regression model to predict adverse perinatal outcomes. The study population of 442 women had positive STOP screens (64; 14.5%) associated with preterm delivery and neonatal intensive care unit admissions. For preterm delivery, history of preterm delivery was the strongest predictor with odds ratios of 4.2 (95% confidence interval 2.0-8.8; p < 0.001), followed by STOP, odds ratios 2.8 (95% confidence interval 1.4-5.8; p = 0.004) and nulliparity, odds ratios 2.3 (95% confidence interval 1.2-4.4; p = 0.013). A positive STOP was the only significant predictor for neonatal intensive care unit admissions, odds ratios 2.5 (95% confidence interval 1.1-5.7; p = 0.036). STOP screening test performance indicated low sensitivity but high specificity: preterm delivery (28.3%, 87.4%), neonatal intensive care unit admissions (27.3%, 86.6%), low birth weight (25.0%, 86.9%), and preeclampsia (16.7%, 85.6%). As a stand-alone tool, the STOP Questionnaire has limited performance, but could be explored in combination with other factors that might increase sensitivity to predict preterm delivery and neonatal intensive care unit admission.

Autonomous Care Pathway to Patient Opioid Abstinence: Should All Programs Offer this Approach?

Introduction: The opioid epidemic resulted in vast increase in neonatal opioid withdrawal syndrome (NOWS). To mitigate NOWS and opioid dependency among women, staff established a gender specific, patient driven, autonomy based, outpatient therapeutic substitution program. Methods: Prospective observational study of obstetric patients receiving prenatal care 7/1/2016-12/31/2019. Patients underwent universal urine drug screens to identify illicit drug use with dependency and offered addiction counseling with voluntary outpatient therapeutic substitution in an obstetrical-addictions combined clinic to achieve abstinence with oral Buprenorphine tapering protocol. Urine substance screening and cord blood testing were obtained at delivery. Birth outcomes compared among groups who achieved abstinence at birth, were successful at tapering, or continued opioid use. Results: Of 783 births, 165 (20.9%) demonstrated opioid use with 91 (55.2%) participating at some point in pregnancy in therapeutic substitution program. At birth, 14/94 (14.9%) patients completed the program and achieved opioid abstinence, 22/94 (23.4%) still enrolled and actively tapering. 57/94 (34.5%) patients were lost to follow-up, relapsed, or terminated due to non-compliance. Seventy-four of 67 (44.3%) opioid positive mothers chose not to enroll. Of 14 women who completed the program, 0 babies born with NOWS, compared to 11/22 (50%) still enrolled in program and actively tapering, 29/57 (50.9%) lost to follow-up, relapsed, or terminated due to non-compliance, and 28/74 (37.8%) never enrolled in program. Conclusion/Implications: Outpatient therapeutic substitution with oral Buprenorphine with abstinence is possible in pregnant patients and results zero NOWS. More data are needed to confirm findings and explore methods for enhanced success in obtaining abstinence. Support: Appalachian Regional Commission and Prevention (ARC) 1st through Charleston Area Medical Center in cooperation with Charleston Health Education and Research Institute (CHERI).

Abdominal cerclage in a patient with a neocervix with planned cesarean hysterectomy at delivery.

Pregnancies complicated by congenital uterine anomalies (CUA) with a neocervix present a variety of challenges for the obstetrician. Abdominal cerclage can be utilized to help prevent preterm delivery in a patient with a neocervix. A 14-year-old female presented with right adnexal pain and was found to have a complex uterine anomaly resembling a noncommunicating unicornuate uterus with a cervix embedded in the rudimentary horn. A neocervix was created during surgical removal of the rudimentary horn. The patient became pregnant at age 24, and a transabdominal cerclage served an important role in the prevention of preterm delivery. Although limited data exists regarding the outcomes for the use of abdominal cerclage after the creation of a neocervix, term delivery is possible with said intervention.

Ecological study of effects of industrial watershed on Müllerian anomalies in an obstetric population.

OBJECTIVE: To ascertain the prevalence of Müllerian anomalies within an obstetrical population in relation to official hazardous waste sites designated by the Environmental Protection Agency (EPA) in West Virginia. METHODS: Observational study of obstetric patients in a tertiary care center with uterine ultrasounds from January 2006 to June 2017. An Optimized Hot Spot analysis and Ripley's K- Function was constructed to ascertain if there is an association with environmental exposures. RESULTS: The prevalence of Müllerian anomalies in our obstetric study sample was 0.9% (118/13,040). The most common were septate (47; 39.8%) and bicornuate (46; 39.0%). The distribution of Müllerian anomalies was non-random illustrated by Optimized Hot Spot Analysis locating several statistically significant zip codes of Müllerian anomalies in relation to zip codes that include EPA facilities. CONCLUSION: The distribution of Müllerian anomalies was clustered in watershed areas along the Kanawha River in West Virginia that have been designated as EPA FRS Sites and Superfund Sites.

Congenital heart defects in West Virginia: Preliminary findings from an ecological study of effects of an industrial watershed on increased incidence.

OBJECTIVE: Congenital anomalies are the leading cause of infant death, with congenital heart (CHD) defects the most common type. The study objective was to evaluate the incidence of fetal CHD in a tertiary care medical center's obstetric population in West Virginia and map areas of possible environmental exposure. METHODS: This was an observational study of patients with positive ultrasound screen for CHD from 1/1/2007-8/31/2016. An Optimized Hot Spot analysis and Ripley's K- Function was constructed to understand the effect of CHD in relation to proximity to chemical and coal extraction sites. RESULTS: Of the 16,871 obstetric pregnancies, 206 (1.2%) had fetal CHD with ventriculoseptal defects the most common (88; 42.7%). The majority of cases of CHD followed the industrial watershed of the Kanawha River in West Virginia. Direct point source exposure suggests a relationship in cases of CHD within Kanawha River and surrounding areas. The observed K was significantly above the expected K across all 10 distance bands. The fourth distance band exhibited the larger difference at (37914), between the expected verses the observed K function. CONCLUSION: Through spatial analysis, there appears to be a direct point source exposure for observed cases of f CHD along the industrial watershed of Kanawha County, West Virginia.

Inherited alterations of TGF beta signaling components in Appalachian cervical cancers.

PURPOSE: This study examined targeted genomic variants of transforming growth factor beta (TGFB) signaling in Appalachian women. Appalachian women with cervical cancer were compared to healthy Appalachian counterparts to determine whether these polymorphic alleles were over-represented within this high-risk cancer population, and whether lifestyle or environmental factors modified the aggregate genetic risk in these Appalachian women. METHODS: Appalachian women's survey data and blood samples from the Community Awareness, Resources, and Education (CARE) CARE I and CARE II studies (n = 163 invasive cervical cancer cases, 842 controls) were used to assess gene-environment interactions and cancer risk. Polymorphic allele frequencies and socio-behavioral demographic measurements were compared using t tests and χ2 tests. Multivariable logistic regression was used to evaluate interaction effects between genomic variance and demographic, behavioral, and environmental characteristics. RESULTS: Several alleles demonstrated significant interaction with smoking (TP53 rs1042522, TGFB1 rs1800469), alcohol consumption (NQO1 rs1800566), and sexual intercourse before the age of 18 (TGFBR1 rs11466445, TGFBR1 rs7034462, TGFBR1 rs11568785). Interestingly, we noted a significant interaction between "Appalachian self-identity" variables and NQO1 rs1800566. Multivariable logistic regression of cancer status in an over-dominant TGFB1 rs1800469/TGFBR1 rs11568785 model demonstrated a 3.03-fold reduction in cervical cancer odds. Similar decreased odds (2.78-fold) were observed in an over-dominant TGFB1 rs1800469/TGFBR1 rs7034462 model in subjects who had no sexual intercourse before age 18. CONCLUSIONS: This study reports novel associations between common low-penetrance alleles in the TGFB signaling cascade and modified risk of cervical cancer in Appalachian women. Furthermore, our unexpected findings associating Appalachian identity and NQO1 rs1800566 suggests that the complex environmental exposures that contribute to Appalachian self-identity in Appalachian cervical cancer patients represent an emerging avenue of scientific exploration.

Outcomes in an obstetrical population with hereditary thrombophilia and high tobacco use.

OBJECTIVE: The purpose of this study was to examine birth outcomes in women treated or untreated for thrombophilia during pregnancies affected or not by tobacco exposure. METHODS: This was a retrospective cohort study of consecutive women from a single maternal fetal medicine clinic who delivered between January 2009 and December 2013. We compared birth outcomes by four groups of thrombophilia and smoking combinations and then by treated or untreated groups. RESULTS: Of the 8889 pregnant women in this study, 113 had thrombophilia and 97 received treatment. Thromboprophylaxis included: low molecular weight heparin, aspirin, unfractionated heparin, folic acid, and combinations of these. Smokers with thrombophilia had significantly higher rates of preeclampsia, intrauterine growth restriction, preterm birth (<37 weeks gestation) and low birth weight (all p ≤ .001). Conversely, this group had significantly lower rates of hemolysis, elevated liver enzymes, low platelet count (HELLP syndrome) and placental abruption. Women with thrombophilia who received thromboprophylaxis had lower rates of adverse birth outcomes, reaching significance for preterm birth <32 weeks gestation (4.3% versus 21.1%, p = .026). CONCLUSION: Pregnant women who smoke and have thrombophilia may be more likely to experience adverse birth outcomes and receive more benefit from thromboprophylaxis than their nonsmoking counterparts.

Pulmonary hypertension: Clinical parameters of a difficult case in pregnancy.

Treatment of pulmonary hypertension in pregnancy with a prostacyclin analogue-iloprost and/or calcium channel antagonists appears to improve outcomes and survival. These medications could have been administered to the patient and the response monitored. If the patient did not respond to therapy, this patient may have had either a referral to or transfer to another high risk center with more experience in this type of pregnant patient. There is no literature to support termination of pregnancy improving maternal survival outcomes in these patients, even though termination is recommended by all obstetrical textbooks. Maternal survival, rather, appears to be related to response to therapy, type of therapy, and continuation of therapy. SUMMARY: A patient who is pregnant with pulmonary hypertension (increased right-sided heart pressures) may be managed with medications. There is no literature to support termination of pregnancy improving maternal survival outcomes in patients with pulmonary hypertension, even though termination is recommended by all obstetrical textbooks. Maternal survival, rather, appears to be related to response to therapy, type of therapy, and continuation of therapy.

Doppler screening and predictors of adverse outcomes in high risk pregnancies affected by tobacco.

OBJECTIVE: The purpose of this study was to investigate associations between Doppler measurements and adverse outcomes in an obstetric population with high tobacco use. METHODS: This retrospective study included patients with Doppler data (umbilical systolic/diastolic velocity ratios (S/D), uterine S/D, uterine left/right ratio index (RI)). Receiver operator characteristic curve analysis determined cut-off elevated Doppler indices. Stepwise logistic regression was used to predict adverse outcomes. RESULTS: 338 of 745 patients (45.4%) had adverse outcomes. Doppler artery indices identified significant associations with IUGR, preeclampsia, low birth weight, pre-term birth and composite adverse outcome variable. An elevated Umbilical S/D was 2.1 (95% Confidence Interval (CI): 1.5-2.9; p<0.001) times was more likely to have an adverse outcome. For left uterine artery S/D and nulliparity, the odds ratios were 1.8 (95% CI: 1.3-2.5) and 1.4 (95% CI: 1.0-1.9), respectively. CONCLUSION: Umbilical and uterine left S/D indices and nulliparity are significant independent predictors of adverse outcomes.

Healthy management of very early adolescent pregnancy.

BACKGROUND: Very Early Pregnancy (< 15 years at delivery) is suggested as a risk factor for adverse pregnancy outcome including low birth weight (LBW), preterm birth (PTB), small for gestational age (SGA) infants, stillbirth, and neonatal mortality. OBJECTIVE: To systematically review the risk of an infant being born LBW/ PTB/SGA/stillbirth or neonatal mortality among patients < 15 years of age. Search strategy: Medline, Embase, CINAHL, and bibliographies of identified articles were searched for English language studies. SELECTION CRITERIA: Selection criteria: Studies reporting birth outcomes to mothers < 15 years of age with an appropriate control group of older gravidas. Data collection and analysis: A single reviewer collected data and assessed the quality of the studies for biases in sample selection, correct age cohorts, confounder adjustment, analytical, outcome assessments, and attrition. Main results: Forty-six studies were located with very early adolescent pregnancy. Of these, only 21 papers had the correct age group (< 15 years) with a comparison cohort. The studies found in the very early adolescent pregnancy: Increased risk of SGA; Increased risk of LBW < 2,500 gms; Increased risk of PTD < 37 weeks; Decreased risk of DM; Decreased risk of cesarean section; Decreased risk of use of pitocin/active phase length; Conflicting risks for Preeclampsia/VLBW/Episiotomy/instrumental delivery rates. SELECTION CRITERIA: Very early adolescent pregnancies (< 15 years) do not have universally grim outcomes as normally quoted. Very early adolescent pregnancies have decreased risk of cesarean delivery, DM, and of active phase disorders. Further, many of the adverse outcomes may be ameliorated with earlier, adolescent-focused, and improved antenatal care.

Transvaginal cervical length and tobacco use in Appalachian women: association with increased risk for spontaneous preterm birth.

Currently ACOG recommends that a mid-term screening strategy may be considered to identify short cervix in low risk populations in an effort to prevent preterm birth. Vaginal progesterone is recommended for women with a cervical length ≤20 mm. Cerclage is recommended for women with prior spontaneous preterm birth who are already receiving progesterone supplementition and CL is <25 mm. This study examined risk factors for spontaneous preterm birth (SPB) <35 weeks among a general obstetrical population prior to these ACOG recommendations. However, cervical cerclage was a possible intervention. Study population included 1,074 patients from 1 Jan 2007-30 Jun 2008 receiving mid-trimester transvaginal ultrasounds during prenatal care at a tertiary medical center clinic. Receiver operator characteristic (ROC) curve cutoff optimal value was ≤34 mm, (n=224), corresponding to 8.9% SPB with shortened cervices compared to 1.4% in patients with normal cervices (>34 mm; n=850; p<0.001 (Area Under the Curve (AUC) 76.6, p<0.001). Cervical lengths <30 mm had 12 times the risk of SPB (p<0.001) while 30-34 mm had 5 times (p=0.005). Tobacco use (≥10 cigarettes per day), p=0.030, and low BMI, p=0.034, had additive effect. Shortened cervical length during routine screening independently predicted SPB while heavy smoking with shortened cervix during pregnancy doubled risk compared to shortened cervix alone.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states.

OBJECTIVE: To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. DESIGN: Population-based natural experiment. SETTING AND DATA SOURCES: Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. MAIN OUTCOMES: Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). INDEPENDENT VARIABLES: Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence. MAIN RESULTS: Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (ß-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (ß=-0.061 to -1.100), skilled attendance at birth (ß=-0.032 to -0.427), low birth weight (ß=0.149 to 2.166), all-abortion hospitalisation ratio (ß=-0.566 to -0.962), clean water (ß=-0.048 to -0.730), sanitation (ß=-0.052 to -0.758) and intimate-partner violence (ß=0.085 to 0.755). TFR showed an inverse association with MMR (ß=-14.329) and MMRAO (ß=-1.750) and a direct association with iAMR (ß=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates. CONCLUSIONS: Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.