Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity.

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.

Assessing the neonatal health policy landscape in low- and middle-income countries: Findings from the 2018 WHO SRMNCAH policy survey.

Background: We aimed to describe the availability of newborn health policies across the continuum of care in low- and middle-income countries (LMICs) and to assess the relationship between the availability of newborn health policies and their achievement of global Sustainable Development Goal and Every Newborn Action Plan (ENAP) neonatal mortality and stillbirth rate targets in 2019. Methods: We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) Policy Survey and extracted key newborn health service delivery and cross-cutting health systems policies that align with the WHO health system building blocks. We constructed composite measures to represent packages of newborn health policies for five components along the continuum of care: antenatal care (ANC), childbirth, postnatal care (PNC), essential newborn care (ENC), and management of small and sick newborns (SSNB). We used descriptive analyses to present the differences in the availability of newborn health service delivery policies by World Bank income group in 113 LMICs. We employed logistic regression analysis to assess the relationship between the availability of each composite newborn health policy package and achievement of global neonatal mortality and stillbirth rate targets by 2019. Results: In 2018, most LMICs had existing policies regarding newborn health across the continuum of care. However, policy specifications varied widely. While the availability of the ANC, childbirth, PNC, and ENC policy packages was not associated with having achieved global NMR targets by 2019, LMICs with existing policy packages on the management of SSNB were 4.4 times more likely to have reached the global NMR target (adjusted odds ratio (aOR) = 4.40; 95% confidence interval (CI) = 1.09-17.79) after controlling for income group and supporting health systems policies. Conclusions: Given the current trajectory of neonatal mortality in LMICs, there is a dire need for supportive health systems and policy environments for newborn health across the continuum of care. Adoption and implementation of evidence-informed newborn health policies will be a crucial step in putting LMICs on track to meet global newborn and stillbirth targets by 2030.

Postpartum Opioid-Related Mortality in Patients With Public Insurance.

OBJECTIVE: To assess the incidence and risk factors for postpartum opioid overdose death and describe other causes of postpartum death in individuals with opioid use disorder (OUD). METHODS: We conducted a cohort study that used health care utilization data from the Medicaid Analytic eXtract linked to the National Death Index in the United States from 2006 to 2013. All pregnant individuals with live births or stillbirths and continuous enrollment for 3 months before delivery were eligible, including 4,972,061 deliveries. A subcohort of individuals with a documented history of OUD in the 3 months before delivery was identified. We estimated the cumulative incidence of death as occurring between delivery and 1 year postpartum among all individuals and individuals with OUD. Risk factors for opioid overdose death were assessed using odds ratios (ORs) and descriptive statistics, including demographics, health care utilization, obstetric conditions, comorbidities, and medications. RESULTS: The incidence of postpartum opioid overdose death per 100,000 deliveries was 5.4 (95% CI 4.5-6.4) among all individuals and 118 (95% CI 84-163) among individuals with OUD. Individuals with OUD had a sixfold higher incidence of all-cause postpartum death than all individuals. Common causes of death in individuals with OUD were other drug- and alcohol-related deaths (47/100,000), suicide (26/100,000), and other injuries, including accidents and falls (33/100,000). Risk factors strongly associated with postpartum opioid overdose death included mental health and other substance use disorders. Among patients with OUD, postpartum use of medication to treat OUD was associated with 60% lower odds of opioid overdose death (OR 0.4, 95% CI 0.1-0.9). CONCLUSION: Postpartum individuals with OUD have a high incidence of postpartum opioid overdose death and other preventable deaths, including nonopioid substance-related injuries, accidents, and suicide. Use of medications for OUD is strongly associated with lower opioid-related mortality.

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

BACKGROUND AND OBJECTIVE: The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. METHODS: In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. RESULTS: Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). CONCLUSIONS: Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Maternal health policy environment and the relationship with service utilization in low- and middle-income countries.

Background: The extent to which a favorable policy environment influences health care utilization and outcomes for pregnant and postpartum women is largely unknown. In this study, we aimed to describe the maternal health policy environment and examines its relationship with maternal health service utilization in low- and middle-income countries (LMICs). Methods: We used data from World Health Organization's 2018-2019 sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH) policy survey linked with key contextual variables from global databases, as well as UNICEF data on antenatal care (ANC), institutional delivery, and postnatal care (PNC) utilization in 113 LIMCs. We grouped maternal health policy indicators into four categories - national supportive structures and standards, service access, clinical guidelines, and reporting and review systems. For each category and overall, we calculated summative scores accounting for available policy indicators in each country. We explored variations of policy indicators by World Bank income group using χ2 tests and fitted logistic regression models for ≥85% coverage for each of four or more antenatal care visits (ANC4+), institutional delivery, PNC for the mothers, and for all ANC4+, institutional delivery, and PNC for mothers, adjusting for policy scores and contextual variables. Results: The average scores for the four policy categories were as follows: 3 for national supportive structures and standards (score range = 0-4), 5.5 for service access (score range = 0-7), 6. for clinical guidelines (score range = 0-10), and 5.7 for reporting and review systems (score range = 0-7), for an average total policy score of 21.1 (score range = 0-28) across LMICs. After adjusting for country context variables, for each unit increase in the maternal health policy score, the odds of ANC4+>85% increased by 37% (95% confidence interval (CI) = 1.13-1.64) and the odds of all ANC4+, institutional deliveries and PNC>85% by 31% (95% CI = 1.07-1.60). Conclusions: Despite the availability of supportive structures and free maternity service access policies, there is a dire need for stronger policy support for clinical guidelines and practice regulations, as well as national reporting and review systems for maternal health. A more favorable policy environment for maternal health can improve adoption of evidence-based interventions and increase utilization of maternal health services in LMICs.

Changes in the health systems and policy environment for maternal and newborn health, 2008-2018: An analysis of data from 78 low-income and middle-income countries.

BACKGROUND: Political, social, economic, and health system determinants play an important role in creating an enabling environment for maternal and newborn health. This study assesses changes in health systems and policy indicators for maternal and newborn health across 78 low- and middle-income countries (LMICs) during 2008-2018, and examines contextual factors associated with policy adoption and systems changes. METHODS: We compiled historical data from WHO, ILO, and UNICEF surveys and databases to track changes in ten maternal and newborn health systems and policy indicators prioritized for tracking by global partnerships. Logistic regression was used to examine the odds of systems and policy change based on indicators of economic growth, gender equality, and country governance with available data from 2008 to 2018. RESULTS: From 2008 to 2018, many LMICs (44/76; 57·9%) substantially strengthened systems and policies for maternal and newborn health. The most frequently adopted policies were national guidelines for kangaroo mother care, national guidelines for use of antenatal corticosteroids, national policies for maternal death notification and review, and the introduction of priority medicines in Essential Medicines Lists. The odds of policy adoption and systems investments were significantly greater in countries that experienced economic growth, had strong female labor participation, and had strong country governance (all p < 0·05). CONCLUSIONS: The widespread adoption of priority policies over the past decade is a notable step in creating an environment supportive for maternal and newborn health, but continued leadership and resources are needed to ensure robust implementation that translates into improved health outcomes.

Development of an instrument to measure awareness and mitigation of bias in maternal healthcare.

BACKGROUND: Implicit bias among maternal healthcare professionals contributes to disrespectful care and racial and ethnic disparities in patient outcomes, and there is growing consensus that implicit bias training is a key component of birth equity initiatives. A requirement for implicit bias training for healthcare professionals has become more widespread, but the impact training has is largely unknown, in part, because of a lack of validated instruments. Therefore, there is an urgent need for a psychometrically valid instrument for use in the evaluation of implicit bias training. OBJECTIVE: This study aimed to develop a valid and reliable instrument to assess implicit bias awareness and mitigation practices among maternal care professionals and that can be used to evaluate interventions aimed at mitigating such bias in clinical practice. STUDY DESIGN: We conducted an instrument development and validation study in 3 phases. In phase 1, item development, we generated a 43-item bank from literature and consultation and established content validity with subject matter experts. In phase 2, instrument development, we administered a revised set of 33 items to 307 nurses and midwives and conducted exploratory factor analysis to demonstrate construct validity and reliability. In phase 3, instrument evaluation, we confirmed the factor structure and compared the means of implicit bias training-exposed and -unexposed participants to further demonstrate construct validity with a representative state sample of 2096 maternal healthcare professionals (physicians, midwives, and nurses). RESULTS: Based on phase 2 results, we retained 23 items for the Bias in Maternal Health Care scale, which showed high internal consistency (Cronbach's alpha, 0.86). We identified 3 subscales, namely a 9-item Bias Awareness subscale (Cronbach's alpha, 0.86), a 7-item Bias Mitigation Practice subscale (Cronbach's alpha, 0.82), and a 7-item Bias Mitigation Self-Efficacy subscale (Cronbach's alpha, 0.81). Validation of the Bias Awareness and Bias Mitigation Practice subscales in phase 3 demonstrated the instrument's high reliability (Cronbach's alpha 0.86 and 0.83, respectively) and discriminating performance among maternal healthcare professionals. CONCLUSION: We developed a reliable and valid instrument for measuring awareness and mitigation of bias among maternal healthcare professionals. It can be used to evaluate implicit bias training and other bias mitigation interventions in maternal healthcare settings.

Understanding variation in person-centered maternity care: Results from a household survey of postpartum women in 6 regions of Ethiopia.

BACKGROUND: Effective communication, respect and dignity, and emotional support are critical for a positive childbirth experience that is responsive to the needs and preferences of women. OBJECTIVE: This study evaluated the performance of a person-centered maternity care scale in a large, representative household sample of postpartum women, and it describes differences in person-centered maternity care across individuals and communities in Ethiopia. STUDY DESIGN: The study used data from 2019 and 2020 from a representative sample of postpartum women in 6 regions of Ethiopia. It measured person-centered maternity care using a scale previously validated in other settings. To assess the scale validity in Ethiopia, we conducted cognitive interviews, measured internal consistency, and evaluated construct validity. Then, we fit univariable and multivariable linear regression models to test for differences in mean person-centered maternity care scores by individual and community characteristics. Lastly, multilevel modeling separated variance in person-centered maternity care scores within and between communities. RESULTS: Effective communication and support of women's autonomy scored lowest among person-centered maternity care domains. Of 1575 respondents, 704 (44.7%) were never asked their permission before examinations and most said that providers rarely (n=369; 23.4%) or never (n=633; 40.2%) explained why procedures were done. Person-centered maternity care was significantly higher for women with greater wealth, more formal education, and those aged >20 years. Variation in person-centered maternity care scores between individuals within the same community (τ2=58.3) was nearly 3 times greater than variation between communities (σ2=21.2). CONCLUSION: Ethiopian women reported widely varying maternity care experiences, with individuals residing within the same community reporting large differences in how they were treated by providers. Poor patient-provider communication and inadequate support of women's autonomy contributed most to poor person-centered maternity care.

Perinatal telemedicine at lower-level birthing hospitals in Maryland: lessons learned from a landscape analysis.

BACKGROUND: The aim of this study was to assess the current perinatal telemedicine (PTM) landscape and inform the design and implementation of a PTM network linking level I/II birthing hospitals with the two-level IV hospitals in Maryland, to improve access to maternal-fetal medicine (MFM) specialist care. METHODS: Qualitative in-depth interviews were conducted with 24 clinicians and telemedicine experts during July-September 2020. We obtained data on 12 level I/II and both level IV hospitals. RESULTS: Less than half of level I/II hospitals currently offer obstetric services through telemedicine, and both level IV hospitals have interest and technical capacity to support implementation of a PTM network in Maryland. The COVID-19 related shift to telehealth and telemedicine was identified as a facilitator for such PTM programs. Perceived barriers to provider adoption of PTM services and network in Maryland included hospital leadership buy-in, information technology (IT) literacy, and patient triage complexities. Perceived barriers to patient adoption of PTM were access to technology, IT literacy, and language. Key benefits of PTM services included overall improved patient access, convenience, cost-savings, and safety during the COVID-19 pandemic. Influential factors for implementing a PTM network in Maryland included buy-in and approval from hospital and health system administration, a streamlined telehealth platform allowing for electronic medical record integration and interoperability, program funding, and sustainability. CONCLUSIONS: Gaps in availability of MFM care at level I/II birth hospitals call for expanded telemedicine programming to improve high-risk patients' access to specialty obstetric care and support the development of a PTM network in Maryland.

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland.

Importance: In the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities. Objective: To examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland's SMM surveillance and review program. Design, Setting, and Participants: This cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records. Exposures: Hospitalization during pregnancy or within 42 days post partum. Main Outcomes and Measures: The main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care. Results: A total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals' readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such. Conclusions and Relevance: The findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.

Levels, Trends, and Risk Factors for Stillbirths in the United States: 2000-2017.

OBJECTIVE: This study documents 2000 to 2017 trends in stillbirth rates and changes in associations between known maternal and fetal risk factors and stillbirths for 2000 to 2002 versus 2015 to 2017 in the United States. STUDY DESIGN: We conducted a retrospective, population-based analysis of stillbirths and live-births using national vital statistics data. We calculated annual stillbirth rates overall and by gestational age; and examined stillbirth rates by maternal age, race-ethnicity, and state for 2000 to 2002 versus 2015 to 2017. We used Chi-squared tests to examine associations between maternal and fetal risk factors separately for early (20-27 weeks) and late (28+ weeks) stillbirths compared with live-births for 2000 to 2002 versus 2015 to 2017. RESULTS: Stillbirth rates declined by 7.5% (p < 0.001) during 2000 to 2006 but remained flat at approximately 6 stillbirths per 1,000 births thereafter. Throughout 2000 to 2017, there were significant improvements in stillbirth rates at 39+ weeks nationally (p < 0.001), but rates varied greatly between and within states. Sociodemographic (advanced maternal age, Black race, low education, unmarried status, and rural residence), obstetric, and other medical factors (>3 births, use of infertility treatment, maternal obesity, diabetes, chronic hypertension, eclampsia, no prenatal care, and tobacco use) were significantly more prevalent in women with late than early stillbirths or live births. Notably, late and total stillbirth rates were approximately 30% higher for women >35 years than for women <35 years and twice as high for non-Hispanic Black than non-Hispanic White women; American Indian/Alaska Native women represented the only racial-ethnic group with significantly higher late stillbirth rates in 2015 to 2017 than in 2000 to 2002. Pregnancy and fetal factors (multiple pregnancy, male fetus, and breech presentation) were more prevalent in women with early than late stillbirths or live births. CONCLUSION: U.S. stillbirth rates have plateaued since 2006. There are persistent differential risk profiles for early versus late stillbirths which can inform stillbirth prevention strategies (e.g., close observation of women with risk factors for stillbirth) and new research into the causes of stillbirths by gestational age. KEY POINTS: · U.S. stillbirth rates have plateaued since 2006.. · Stillbirth rates vary between and within U.S. states and by maternal and fetal factors.. · Early versus late stillbirths have different risk profiles which can guide stillbirth prevention strategies..

Maternal Warning Signs Education During Home Visiting: Results from a Formative Evaluation in Maryland.

Background: Maternal mortality rate reviews have identified the need for improved patient education regarding the warning signs of maternal complications to reduce preventable deaths. Maternal and child home visiting programs have the potential to deliver this education in communities. Aims: This study sought to evaluate the baseline provision of warning signs education among home visiting programs in Maryland and to assess the acceptability of and preferences for warning signs education materials among program staff. Materials and Methods: This sequential exploratory, mixed-methods study included qualitative interviews and focus group discussions followed by a web-based survey of all home visiting programs providing early postpartum visits in Maryland. Results: Twenty-five home visiting program staff took part in qualitative data collection, and survey responses were submitted by a manager from 40 of 58 eligible home visiting programs (69% response rate). All survey respondents agreed that home visiting programs should provide warning signs education and more than 80% of programs provided some warning signs education during pregnancy and the postpartum period. Printed pamphlets were provided by 68% of programs for pregnancy complications and 43% for postpartum complications. Only 33% of respondents were satisfied with their existing warnings signs education materials; 98% were interested in new illustrated pamphlets and 88% were interested in education videos. Qualitative participants considered pamphlets with simple designs, limited text, and visuals, as the most accessible for home visiting clients. Conclusions: There are opportunities to strengthen and expand warning signs education in Maryland through home visiting programs using new printed and video education materials.

Nativity-Related Disparities in Preterm Birth and Cardiovascular Risk in a Multiracial U.S. Cohort.

INTRODUCTION: Having a preterm birth is associated with future cardiovascular risk. Non-Hispanic Black women have higher rates of preterm birth than non-Hispanic White and Hispanic women, but nativity-related disparities in preterm birth are not well understood. METHODS: Data from 6,096 women in the Boston Birth Cohort: non-Hispanic Black (2,699), non-Hispanic White (997), or Hispanic (2,400), were analyzed in June 2021. Differences in cardiovascular risk factors were assessed. The association of preterm birth with nativity and duration of U.S. residence were investigated using multivariable logistic regression. RESULTS: U.S.-born women in all 3 racial-ethnic groups had a higher prevalence of obesity, smoking, and severe stress than foreign-born women. Foreign-born non-Hispanic Black and Hispanic women had lower odds of preterm birth than U.S.-born counterparts (non-Hispanic Black: AOR=0.79, 95% CI=0.65, 0.97; Hispanic: AOR=0.72, 95% CI=0.56, 0.93). In all the 3 groups, foreign-born women with shorter (<10 years) duration of U.S. residence had lower odds of preterm birth than the U.S.-born women (non-Hispanic Black: AOR=0.57, 95% CI=0.43, 0.75; Hispanic: AOR=0.72, 95% CI=0.55, 0.94; non-Hispanic White: AOR=0.46, 95% CI=0.25, 0.85), whereas the odds of preterm birth in foreign-born women with ≥10 years of residence were not significantly different. CONCLUSIONS: Foreign-born women had better cardiovascular risk profiles in all groups and lower odds of preterm birth in non-Hispanic Black and Hispanic groups. In all the 3 groups, a shorter duration of U.S. residence was associated with lower odds of preterm birth. Further studies are needed to understand the biological and social determinants underlying these nativity-related disparities and the impact of acculturation.

The Association of Preterm Birth With Maternal Nativity and Length of Residence Among Non-Hispanic Black Women.

Background: Preterm birth (PTB) is associated with future cardiovascular disease (CVD) risk and disproportionally affects non-Hispanic Black (NHB) women. Limited data exist on the influence of length of US residence on nativity-related disparities in PTB. We examined PTB by maternal nativity (US born vs foreign born) and length of US residence among NHB women. Methods: We analyzed data from 2699 NHB women (1607 US born; 1092 foreign born) in the Boston Birth Cohort, originally designed as a case-control study. Using multivariable logistic regression, we investigated the association of PTB with maternal nativity and length of US residence. Results: In the total sample, 29.1% of women delivered preterm (31.4% and 25.6% among US born and foreign born, respectively). Compared with foreign born, US-born women were younger (25.8 vs 29.5 years), had higher prevalence of obesity (27.6% vs 19.6%), smoking (20.5% vs 4.9%), alcohol use (13.2% vs 7.4%), and moderate to severe stress (73.5% vs 59.4%) (all P < 0.001). Compared with US-born women, foreign-born women had lower odds of PTB after adjusting for sociodemographic characteristics, alcohol use, stress, parity, smoking, body mass index, chronic hypertension, and diabetes (adjusted odds ratio [aOR], 0.79; 95% confidence interval [CI], 0.65-0.97). Foreign-born NHB women with < 10 years of US residence had 43% lower odds of PTB compared with US-born (aOR, 0.57; 95% CI, 0.43-0.75), whereas those with ≥ 10 years of US residence did not differ significantly from US-born women in their odds of PTB (aOR, 0.76; 95% CI, 0.54-1.07). Conclusions: The prevalence of CVD risk factors and proportion of women delivering preterm were lower in foreign-born than US-born NHB women. The "foreign-born advantage" was not observed with ≥ 10 years of US residence. Our study highlights the need to intensify public health efforts in exploring and addressing nativity-related disparities in PTB.

Introduction: L'accouchement avant terme (AAT) est associé à un risque futur de maladie cardiovasculaire (MCV) et touche disproportionnellement les femmes noires non hispaniques (NNH). Les données sur l'influence de la durée de résidence aux É.-U. sur les disparités de l'AAT liées au lieu de naissance sont limitées. Nous avons examiné l'AAT en fonction du lieu de naissance de la mère (née aux É.-U. vs née à l'étranger) et la durée de résidence aux É.-U. chez les femmes NNH. Méthodes: Nous avons analysé les données de 2 699 femmes NNH (1 607 nées aux É.-U.; 1 092 nées à l'étranger) de la Boston Birth Cohort, conçue à l'origine comme une étude cas-témoins. À l'aide de la régression logistique multivariée, nous avons examiné l'association de l'AAT au lieu de naissance de la mère et à la durée de résidence aux É.-U. Résultats: Dans l'échantillon total, 29,1 % des femmes qui avaient accouché avant terme (soit 31,4 % des femmes nées aux É.-U. et 25,6 % des femmes nées à l'étranger). Comparativement aux femmes nées à l'étranger, les femmes nées aux É.-U. étaient plus jeunes (25,8 vs 29,5 ans), montraient une prévalence plus élevée d'obésité (27,6 % vs 19,6 %), du tabagisme (20,5 % vs 4,9 %), de la consommation d'alcool (13,2 % vs 7,4 %) et de stress modéré à important (73,5 % vs 59,4 %) (toutes les valeurs P < 0,001). Comparativement aux femmes nées aux É.-U., les femmes nées à l'étranger avaient un risque inférieur d'AAT après l'ajustement des caractéristiques sociodémographiques, de la consommation d'alcool, du stress, de la parité, du tabagisme, de l'indice de masse corporelle, de l'hypertension chronique et du diabète (ratio d'incidence approché ajusté [RIAa], 0,79; intervalle de confiance [IC] à 95 %, 0,65-0,97). Les femmes NNH nées à l'étranger de < 10 ans de résidence aux É.-U. avaient une probabilité 43 % plus faible d'AAT que les femmes nées aux É.-U. (RIAa, 0,57; IC à 95 %, 0,43-0,75), tandis que les femmes de ≥ 10 ans de résidence aux É.-U. ne montraient pas de différence significative dans leur probabilité d'AAT par rapport aux femmes nées aux É.-U. (RIAa, 0,76; IC à 95 %, 0,54-1,07). Conclusions: La prévalence des facteurs de risque de MCV et la proportion de femmes qui accouchent avant terme étaient plus faibles chez les femmes NNH nées à l'étranger que chez les femmes NNH nées aux É.-U. L'« avantage d'être nées à l'étranger ¼ n'était pas observé lors de ≥ 10 ans de résidence aux É.-U. Notre étude illustre la nécessité d'intensifier les efforts de santé publique pour explorer et remédier aux disparités liées au lieu de naissance dans l'AAT.

Disparities in cardiometabolic risk profiles and gestational diabetes mellitus by nativity and acculturation: findings from 2016-2017 National Health Interview Survey.

INTRODUCTION: Gestational diabetes mellitus (GDM) is a common complication of pregnancy with implications for cardiovascular health. Among reproductive-aged women, less is known about nativity-related disparities in cardiometabolic risk profiles and GDM history. We examined how cardiometabolic risk profiles and GDM history differed by nativity and explored associations between acculturation, cardiometabolic risk profiles and GDM history. RESEARCH DESIGN AND METHODS: We analyzed cross-sectional data from the 2016-2017 National Health Interview Survey among reproductive-aged women (18-49 years) who both reported ever being pregnant and answered the question on GDM history. Using multivariable logistic regression, we examined the percentage with GDM history and compared cardiometabolic profiles by nativity status and acculturation (duration of US residence). RESULTS: Of 9525 women, 22.5% were foreign-born. Also, 11.7% of foreign-born women had a GDM history vs 9.6% of US-born women. Foreign-born women with ≥10 years US residence had the highest age-standardized percentage with GDM history (11.0%) compared with US-born women (9.2%) and foreign-born women with <10 years US residence (6.7%). US-born women had a higher prevalence of hypertension, current smoking, and alcohol use than foreign-born women. Among foreign-born women, those with ≥10 years US residence had a higher prevalence of hypertension, current smoking, and alcohol use than those with <10 years US residence. In the fully adjusted model, foreign-born women with ≥10 years US residence had higher odds of GDM history than US-born women (OR 1.43; 95% CI 1.17 to 1.76) while foreign-born women with <10 years US residence and US-born women has similar odds of GDM history. CONCLUSIONS: Greater duration of US residence may be associated with nativity-related disparities in GDM. Acculturation, including changing health-related behaviors may explain the disparities among foreign-born women and should be further investigated to appropriately target interventions to prevent GDM and future cardiometabolic diseases.