Continuation of Reversible Contraception Following Enrollment in the Zika Contraception Access Network (Z-CAN) in Puerto Rico, 2016-2020.

The Zika Contraception Access Network (Z-CAN) provided access to high-quality client-centered contraceptive services across Puerto Rico during the 2016-2017 Zika virus outbreak. We sent online surveys during May 2017-August 2020 to a subset of Z-CAN patients at 6, 24, and 36 months after program enrollment (response rates: 55-60 percent). We described contraceptive method continuation, method satisfaction, and method switching, and we identified characteristics associated with discontinuation using multivariable logistic regression. Across all contraceptive methods, continuation was 82.5 percent, 64.2 percent, and 49.9 percent at 6, 24, and 36 months, respectively. Among continuing users, method satisfaction was approximately ≥90 percent. Characteristics associated with decreased likelihood of discontinuation included: using an intrauterine device or implant compared with a nonlong-acting reversible contraceptive method (shot, pills, ring, patch, or condoms alone); wanting to prevent pregnancy at follow-up; and receiving as their baseline method the same method primarily used before Z-CAN. Other associated characteristics included: receiving the method they were most interested in postcounseling (6 and 24 months) and being very satisfied with Z-CAN services at the initial visit (6 months). Among those wanting to prevent pregnancy at follow-up, about half reported switching to another method. Ongoing access to contraceptive services is essential for promoting reproductive autonomy, including supporting patients with continued use, method switching, or discontinuation.

Perceptions of the Zika Virus, Contraceptive Access, and Motivation to Participate in the Zika Contraception Access Network Program: Qualitative Analysis of Focusgroup Discussions with Puerto Rican Women.

OBJECTIVE: During the 2016-2017 Zika virus outbreak in Puerto Rico, the Zika Contraception Access Network (Z-CAN) provided client-centered contraceptive counseling and access to the full range of reversible contraceptive methods at no cost to prevent unintended pregnancies and thereby to reduce Zika-related birth outcomes. METHODS: To understand how Puerto Rican women's perceptions of the Zika virus affected contraceptive decisions and assess how they heard about the Z-CAN program and what influenced their participation, or lack thereof, 24 focus-group discussions were conducted among women of reproductive age who did and did not participate in Z-CAN. RESULTS: Women who participated in the discussions often had heard about Z-CAN from their physician or friends; non-participants had heard about Z-CAN from Facebook or friends. Women expressed satisfaction on finding a Z-CAN clinic and valued the same-day provision of contraceptives. When a preferred contraceptive method or a first appointment was not readily available, women reconsidered accessing the program. Women's perceptions and trust of reproductive healthcare providers, their engagement in social networks, and their ability to choose a contraceptive method that best meets their needs can influence participation in contraception-access programs. CONCLUSION: Focus groups can be used to understand women's knowledge of the Zika virus, barriers and facilitators to contraception access, and motivations for participation in the Z-CAN program.

Long-acting reversible contraception use and unmet desire among patients after the Zika Contraception Access Network Program in Puerto Rico.

OBJECTIVES: To describe unmet desire for long-acting reversible contraception (LARC) after the Zika Contraception Access Network (Z-CAN) in Puerto Rico during the 2016-2017 Zika outbreak. STUDY DESIGN: Z-CAN patients completed surveys about contraception experiences over a 3-year period. RESULTS: Of 1809 respondents, 3% never used LARC but reported wanting it since their initial visit. As reasons for not getting LARC, nearly 50% indicated a provider-related reason and 25% reported cost. CONCLUSIONS: Few Z-CAN patients who never used LARC had unmet desire. Provider training in contraception guidelines and strategies to address costs can expand access to the full range of reversible contraception. IMPLICATIONS: Three years after a short-term program provided reversible contraception in Puerto Rico, few respondents had never used but wanted a long-acting reversible contraception method. Nearly half reported provider-related reasons for not receiving long-acting reversible contraception, and 25% reported cost. Provider awareness of contraceptive guidance and method availability can support client-centered care.

Changes in Commercial Insurance Claims for Contraceptive Services During the Beginning of the COVID-19 Pandemic-United States, January 2019-September 2020.

OBJECTIVE: We describe changes in commercial insurance claims for contraceptive services during the beginning of the COVID-19 pandemic. METHODS: We analyzed commercial insurance claims using IQVIA PharMetrics Plus data from more than 9 million U.S. females aged 15-49 years, enrolled during any month, January 2019 through September 2020. We calculated monthly rates of outpatient claims for intrauterine devices (IUDs), implants, and injectable contraception and monthly rates of pharmacy claims for contraceptive pills, patches, and rings. We used Joinpoint regression analysis to identify when statistically significant changes occurred in trends of monthly claims rates for each contraceptive method. We calculated monthly percentages of claims for contraceptive counseling via telehealth. RESULTS: Monthly claims rates decreased for IUDs (-50%) and implants (-43%) comparing February 2020 with April 2020 but rebounded by June 2020. Monthly claims rates for injectables decreased (-19%) comparing January 2019 with September 2020, and monthly claims rates for pills, patches, and rings decreased (-22%) comparing July 2019 with September 2020. The percentage of claims for contraceptive counseling occurring via telehealth was low (<1%) in 2019, increased to 34% in April 2020, and decreased to 9-12% in June-September 2020. CONCLUSIONS: Substantial changes in commercial insurance claims for contraceptive services occurred during the beginning of the COVID-19 pandemic, including transient decreases in IUD and implant claims and increases in telehealth contraceptive counseling claims. Contraceptive claims data can be used by decision makers to identify service gaps and evaluate use of interventions like telehealth to improve contraceptive access, including during public health emergencies.

Differences in delivery hospitalization experiences during the COVID-19 pandemic by maternal race and ethnicity, Pregnancy Risk Assessment Monitoring System, 2020.

OBJECTIVE: We investigated maternal COVID-19 related experiences during delivery hospitalizations, and whether experiences differed by maternal race and ethnicity. STUDY DESIGN: Data from the Pregnancy Risk Assessment Monitoring System among women with live births between April-December 2020 were used. Adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) estimated associations between maternal race and ethnicity and COVID-19 related delivery experiences. RESULTS: Among 12,879 women, 3.6% reported infant separation and 1.8% reported not being allowed support persons. Compared with non-Hispanic White women, American Indian/Alaska Native (AI/AN) (aPR = 2.7; CI: 1.2-6.2), Hispanic (aPR = 2.2; CI: 1.5-3.1), non-Hispanic Black (aPR = 2.4; CI: 1.7-3.6), and non-Hispanic Asian (aPR = 2.8; CI: 1.6-4.9) women reported more infant separation due to COVID-19. Not being allowed support persons was more common among AI/AN (aPR = 5.2; CI: 1.8-14.8) and non-Hispanic Black (aPR = 2.3; CI: 1.3-4.1) women. CONCLUSIONS: COVID-19 related delivery hospitalization experiences were unequally distributed among racial and ethnic minorities.

COVID-19 Vaccination Recommendations and Practices for Women of Reproductive Age by Health Care Providers - Fall DocStyles Survey, United States, 2022.

Pregnant and postpartum women are at increased risk for severe illness from COVID-19 compared with nonpregnant women of reproductive age. COVID-19 vaccination is recommended for all persons ≥6 months of age. Health care providers (HCPs) have a unique opportunity to counsel women of reproductive age, including pregnant and postpartum patients, about the importance of receiving COVID-19, influenza, and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines. Data from the Fall 2022 DocStyles survey were analyzed to examine the prevalence of COVID-19 vaccination attitudes and practices among HCPs caring for women of reproductive age, and to determine whether providers recommended and offered or administered COVID-19 vaccines to women of reproductive age, including their pregnant patients. Overall, 82.9% of providers reported recommending COVID-19 vaccination to women of reproductive age, and 54.7% offered or administered the vaccine in their practice. Among HCPs who cared for pregnant patients, obstetrician-gynecologists were more likely to recommend COVID-19 vaccination to pregnant patients (94.2%) than were family practitioners or internists (82.1%) (adjusted prevalence ratio [aPR] = 1.1). HCPs were more likely to offer or administer COVID-19 vaccination on-site to pregnant patients if they also offered or administered influenza (aPR = 5.5) and Tdap vaccines (aPR = 2.3). Encouraging HCPs to recommend, offer, and administer the COVID-19 vaccines along with influenza or Tdap vaccines might help reinforce vaccine confidence and increase coverage among women of reproductive age, including pregnant women.

Provider Perceptions of Facilitators of and Barriers to Implementation of the Zika Contraception Access Network: A Qualitative Evaluation.

OBJECTIVE: From May 2016 through September 2017, the Zika Contraception Access Network (Z-CAN) program increased access to contraception during the Zika virus outbreak in Puerto Rico by providing no-cost client-centered contraceptive counseling and (same-day) access to the full range of US Food and Drug Administration-approved reversible contraceptives to women desirous of not becoming pregnant. The purpose of this study was to identify areas for programmatic improvement and enhance the sustainability of services from the perspectives of participating Z-CAN physicians and other staff. METHODS: From April through July 2017, 49 in-depth key-informant interviews were conducted with Z-CAN physicians and clinic staff. Twenty-five clinics participating in the Z-CAN program were selected through a cluster randomization process. A semi-structured interview guide was developed to explore the participants' perceptions of the Z-CAN program and examine facilitators of and barriers to said implementation. A thematic analysis of the emerging topics was conducted. RESULTS: Our analysis encountered 4 common overarching themes: facilitators of the Z-CAN program; barriers to Z-CAN implementation; the perceived impact of Z-CAN on providers and communities; and the sustainability of contraception access after the Z-CAN program ended. The key findings were that provider training, mentor support, and communication campaigns facilitated program implementation and that delays in the acquisition and distribution of contraceptives were obstacles. CONCLUSION: Lessons learned from the implementation of Z-CAN from the perspective of physicians and other staff can be used to work towards sustainable contraceptive services in Puerto Rico and inform other contraception-access programs' design and implementation strategies.

Severe acute respiratory syndrome coronavirus 2 seroprevalence and longitudinal antibody response following natural infection in pregnancy: A prospective cohort study.

BACKGROUND: Antenatal care provides unique opportunities to assess severe acute respiratory syndrome coronavirus 2 seroprevalence and antibody response duration after natural infection detected during pregnancy; transplacental antibody transfer may inform peripartum and neonatal protection. We estimated seroprevalence and durability of antibodies from natural infection (anti-nucleocapsid immunoglobulin G) among pregnant people, and evaluated transplacental transfer efficiency. OBJECTIVE AND DESIGN: We conducted a cross-sectional study to measure severe acute respiratory syndrome coronavirus 2 seroprevalence, and a prospective cohort study to longitudinally measure anti-nucleocapsid immunoglobulin G responses and transplacental transfer of maternally derived anti-nucleocapsid antibodies. METHODS: We screened pregnant people for the seroprevalence study between 9 December 2020 and 19 June 2021 for anti-nucleocapsid immunoglobulin G in Seattle, Washington. We enrolled anti-nucleocapsid immunoglobulin G positive people from the seroprevalence study or identified through medical records with positive reverse transcription polymerase chain reaction or antigen positive results in a prospective cohort between 9 December 2020 and 9 August 2022. RESULTS: In the cross-sectional study (N = 1284), 5% (N = 65) tested severe acute respiratory syndrome coronavirus 2 anti-nucleocapsid immunoglobulin G positive, including 39 (60%) without prior positive reverse transcription polymerase chain reaction results and 42 (65%) without symptoms. In the prospective cohort study (N = 107 total; N = 65 from the seroprevalence study), 86 (N = 80%) had anti-nucleocapsid immunoglobulin G positive results during pregnancy. Among 63 participants with delivery samples and prior anti-nucleocapsid positive results, 29 (46%) were anti-nucleocapsid immunoglobulin G negative by delivery. Of 34 remaining anti-nucleocapsid immunoglobulin G positive at delivery with paired cord blood, 19 (56%) had efficient transplacental anti-nucleocapsid immunoglobulin G antibody transfer. Median time from first anti-nucleocapsid immunoglobulin G positive to below positive antibody threshold was 19 weeks and did not differ by prior positive reverse transcription polymerase chain reaction status. CONCLUSIONS: Maternally derived severe acute respiratory syndrome coronavirus 2 antibodies to natural infection may wane before delivery. Vaccines are recommended for pregnant persons to reduce severe illness and confer protection to infants.

Pandemic-related stressors and mental health among women with a live birth in 2020.

The objective of this analysis was to assess the associations between pandemic-related stressors and feeling more anxious/depressed, among women with a live birth. We analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS) COVID-19 maternal experiences supplement, implemented in 29 U.S. jurisdictions from October 2020-June 2021, among women with a live birth during April-December 2020. We examined stressors by type (economic, housing, childcare, food insecurity, partner, COVID-19 illness) and score (number of stressor types experienced [none, 1-2, 3-4, or 5-6]). Outcomes were feeling 1) more anxious and 2) more depressed than usual due to the pandemic. We calculated adjusted prevalence ratios estimating associations between stressors and outcomes. Among 12,525 respondents, half reported feeling more anxious and 28% more depressed than usual. The prevalence of stressor types was 50% economic, 41% childcare, 18% partner, 17% food insecurity, 12% housing, and 10% COVID-19 illness. Respondents who experienced partner stressors (anxious aPR: 1.81, 95% CI: 1.73-1.90; depressed aPR: 3.01, 95% CI: 2.78-3.25) and food insecurity (anxious aPR: 1.79, 95% CI: 1.71-1.88; depressed aPR: 2.32, 95% CI: 2.13-2.53) had the largest associations with feeling more anxious and depressed than usual. As stressor scores increased, so did the aPRs for feeling more anxious and more depressed due to the pandemic. COVID-19 stressors, not COVID-19 illness, were found to be significantly associated with feeling more anxious and depressed. Pregnant and postpartum women might benefit from access to supports and services to address pandemic-related stressors/social-determinants and feelings of anxiety and depression.

Contraceptive Sabotage and Contraceptive Use at the Time of Pregnancy: An Analysis of People with a Recent Live Birth in the United States.

Contraceptive sabotage and other forms of intimate partner violence (IPV) can interfere with contraceptive use. We used 2012 to 2015 Pregnancy Risk Assessment Monitoring System data from 8,981 people residing in five states who reported that when they became pregnant, they were not trying to get pregnant. We assessed the relationships between ever experiencing contraceptive sabotage and physical IPV 12 months before pregnancy (both by the current partner) and contraceptive use at the time of pregnancy using multivariable logistic regression. We also assessed the joint associations between physical IPV 12 months before pregnancy and ever experienced contraceptive sabotage with contraceptive use at the time of pregnancy. Few people ever experienced contraceptive sabotage (1.8%; 95% confidence interval [CI]: 1.4, 2.3) or physical IPV 12 months before pregnancy (2.8%; 95% CI: 2.3, 3.3). In models adjusted for age, race/ethnicity, marital status, education, and state of residence, ever experiencing contraceptive sabotage was associated with contraceptive use at the time of pregnancy (adjusted odds ratio [aOR]: 1.73; 95% CI: 1.06, 2.82), but not with physical IPV 12 months before pregnancy (aOR: 0.69; 95% CI: 0.46, 1.02). When examining the joint association, compared to not ever experiencing contraceptive sabotage or physical IPV 12 months before pregnancy, ever experiencing contraceptive sabotage was significantly related to contraceptive use at the time of pregnancy (aOR: 1.72; 95% CI: 1.00, 2.95). However, it was not associated with experiencing physical IPV 12 months before pregnancy (aOR: 0.68; 95% CI: 0.45, 1.04) or with experiencing both contraceptive sabotage and physical IPV 12 months before pregnancy (aOR: 1.21; 95% CI: 0.42, 3.50), compared to not ever experiencing contraceptive sabotage or physical IPV 12 months before pregnancy. Our study highlights that current partner contraceptive sabotage may motivate those not trying to get pregnant to use contraception; however, all people in our sample still experienced a pregnancy.

Maternal and Newborn Hospital Outcomes of Perinatal SARS-CoV-2 Infection: A National Registry.

OBJECTIVES: The American Academy of Pediatrics National Registry for the Surveillance and Epidemiology of Perinatal coronavirus disease 2019 (COVID-19) (NPC-19) was developed to provide information on the effects of perinatal severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. METHODS: National Registry for the Surveillance and Epidemiology of Perinatal COVID-19 participating centers entered maternal and newborn data for pregnant persons who tested positive for SARS-CoV-2 infection between 14 days before and 10 days after delivery. Incidence of and morbidities associated with maternal and newborn SARS-CoV-2 infection were assessed. RESULTS: From April 6, 2020 to March 19, 2021, 242 centers in the United States centers reported data for 7524 pregnant persons; at the time of delivery, 78.1% of these persons were asymptomatic, 18.2% were symptomatic but not hospitalized specifically for COVID-19, 3.4% were hospitalized for COVID-19 treatment, and 18 (0.2%) died in the hospital of COVID-related complications. Among 7648 newborns, 6486 (84.8%) were tested for SARS-CoV-2, and 144 (2.2%) were positive; the highest rate of newborn infection was observed when mothers first tested positive in the immediate postpartum period (17 of 125, 13.6%). No newborn deaths were attributable to SARS-CoV-2 infection. Overall, 15.6% of newborns were preterm: among tested newborns, 30.1% of polymerase chain reaction-positive and 16.2% of polymerase chain reaction-negative were born preterm (P < .001). Need for mechanical ventilation did not differ by newborn SARS-CoV-2 test result, but those with positive tests were more likely to be admitted to a NICU. CONCLUSIONS: Early in the pandemic, SARS-CoV-2 infection was acquired by newborns at variable rates and without apparent short-term effects. During a period that preceded widespread availability of vaccines, we observed higher than expected numbers of preterm births and maternal in-hospital deaths.

COVID-19 vaccination recommendations and practices for women of reproductive age, U.S. Physicians, Fall 2021.

Pregnant people with COVID-19 are at increased risk for severe illness and adverse pregnancy outcomes. COVID-19 vaccinations are safe and effective, including for pregnant and recently pregnant people. The objective of this analysis was to describe the extent to which primary care physicians across the United States report confidence in talking with female patients of reproductive age about COVID-19 vaccination, recommending COVID-19 vaccinations to pregnant patients, and offering COVID-19 vaccinations at their practices in fall 2021. We analyzed cross-sectional data from the Fall 2021 DocStyles survey, a web-based panel survey of U.S. primary healthcare providers (64% response rate). Family practitioners/internists, obstetrician-gynecologists, and pediatricians were asked about confidence in talking with female patients of reproductive age about COVID-19 vaccination, vaccination practices regarding pregnant patients, and offering COVID-19 vaccinations. We describe results overall and by select physician characteristics. Among 1501 respondents, most were family practitioners/internists (67%), 17% were obstetrician-gynecologists, and 17% were pediatricians. Overall, 63% were very confident talking with female patients of reproductive age about COVID-19 vaccination, 80% recommended pregnant patients get vaccinated as soon as possible, and 50% offered COVID-19 vaccinations at their current practice. Obstetrician-gynecologists were most confident in talking with female patients, but only one-third offered the vaccine at their practices. This analysis found that most physicians felt confident talking about COVID-19 vaccinations and recommended pregnant patients get vaccinated as soon as possible. Provider recommendation for vaccination remains a key strategy for achieving high vaccination coverage, and consistent recommendations may improve vaccine acceptance among pregnant and postpartum people.

Is the COVID-19 Pandemic Continuing to Impact Sexual and Reproductive Health Services for Adolescents? Findings From a 2021 Survey of US Physicians.

PURPOSE: We examined the impact of the COVID-19 pandemic in Fall 2021 on sexual and reproductive health (SRH) services among physicians whose practice provided these services to adolescents just before the pandemic. METHODS: Data were from the DocStyles online panel survey administered September-November 2021 to US physicians who reported their practice provided SRH services to adolescent patients before the pandemic (n = 948). We calculated prevalence of service delivery challenges (e.g., limited long-acting reversible contraception services) and use of strategies to support access (e.g., telehealth) in the month prior to survey completion, compared these estimates with prevalence "at any point during the COVID-19 pandemic", and examined differences by physician specialty and adolescent patient volume. RESULTS: Fewer physicians reported their practice experienced service delivery challenges in the month prior to survey completion than at any point during the pandemic. About 10% indicated limited long-acting reversible contraception and sexually transmitted infection testing services in the prior month overall; prevalence varied by physician specialty (e.g., 26% and 17%, respectively by service, among internists). Overall, about 25% of physicians reported reductions in walk-in hours, weekend/evening hours, and adolescents seeking care in the prior month. While most practices that initiated strategies supporting access to services during the pandemic used such strategies in the prior month, some practices (22%-37% depending on the strategy) did not. DISCUSSION: Findings suggest some physicians who serve adolescents continued to experience challenges providing SRH services in the Fall 2021, and some discontinued strategies to support access that had been initiated during the pandemic.

Impact of a Health Communication Campaign on Uptake of Contraceptive Services during the 2016-2017 Zika Virus Outbreak in Puerto Rico.

The Zika Contraception Access Network (Z-CAN) was established during the 2016-2017 Zika virus outbreak in Puerto Rico as a short-term emergency response program providing client-centered contraceptive counseling and same-day access to the full range of reversible contraceptive methods at no cost to women wishing to delay pregnancy. An evidence-based communication campaign, Ante La Duda, Pregunta (ALDP), was launched to encourage utilization of Z-CAN services. We assessed the effectiveness of campaign tactics in increasing awareness of Z-CAN among women in Puerto Rico. Data on campaign exposure and awareness were obtained through a self-administered online survey approximately two weeks after an initial Z-CAN visit, while the number of searches for participating clinics were obtained from monitoring the campaign website. Findings demonstrated that the most common ways survey respondents learned about Z-CAN were through friends or family (38.3%), social media (23.9%), a clinical encounter (12.7%), and website (11.7%). Nearly two-thirds (61.1%) of respondents had heard of the ALDP campaign. Over the campaign's duration, there were 27,273 searches for Z-CAN clinics. Findings suggest that evidence-based communication campaigns may increase awareness of needed public health services during emergencies. Word of mouth, social media, and digital engagement may be appropriate communication tactics for emergency response mobilization.

Intrauterine Device Training, Attitudes, and Practices Among U.S. Health Care Providers: Findings from a Nationwide Survey.

BACKGROUND: Provider training in intrauterine device (IUD) procedures is a key strategy for improving evidence-based IUD care. We examined the influence of IUD training on IUD attitudes and practices among U.S. family planning providers. METHODS: In 2019, we conducted a cross-sectional survey of U.S. family planning providers. We performed logistic regression to examine associations between training in routine IUD placement and specific IUD safety attitudes, confidence performing IUD procedures, and specific IUD practices. RESULTS: Among 1,063 physicians and advanced practice clinicians, 85.1% reported training in routine IUD placement. Overall, IUD training was associated with accurately stating IUDs are safe for queried groups, including patients immediately postpartum (prevalence ratio [PR] 4.22; 95% confidence interval [CI] 1.29-13.85). Trained providers reported higher confidence in routine IUD placement for parous (PR 7.71; 95% CI 1.31-45.3) and nulliparous (PR 7.12; 95% CI 1.17-43.5) women and in IUD removal (PR 2.06; 95% CI 1.12-3.81). Among providers with IUDs available onsite, IUD training was associated with frequent same-day IUD provision for adults (PR 7.32; 95% CI 2.16-24.79) and adolescents (PR 7.63; 95% CI 2.22-26.24). Trained providers were also less likely to routinely use misoprostol before IUD placement for nulliparous (PR 0.19; 95% CI 0.11-0.33) and parous women (PR 0.07; 95% CI 0.03-0.16). CONCLUSION: Training in routine IUD placement was associated with evidence-based IUD safety attitudes, confidence in performing IUD procedures, and clinical practices aligned with Centers for Disease Control and Prevention contraception guidance. Expanding IUD training might increase evidence-based care and patient access to the full range of contraception, including IUDs.

Characteristics and treatment of hospitalized pregnant women with COVID-19.

BACKGROUND: Pregnant women less frequently receive COVID-19 vaccination and are at increased risk for adverse pregnancy outcomes from COVID-19. OBJECTIVE: This study aimed to first, describe the vaccination status, treatment, and outcomes of hospitalized, symptomatic pregnant women with COVID-19, and second, estimate whether treatment differs by pregnancy status among treatment-eligible (ie, requiring supplemental oxygen per National Institutes of Health guidelines at the time of the study) women. STUDY DESIGN: From January to November 2021, the COVID-19-Associated Hospitalization Surveillance Network completed medical chart abstraction for a probability sample of 2715 hospitalized women aged 15 to 49 years with laboratory-confirmed SARS-CoV-2 infection. Of these, 1950 women had symptoms of COVID-19 on admission, and 336 were pregnant. We calculated weighted prevalence estimates of demographic and clinical characteristics, vaccination status, and outcomes among pregnant women with symptoms of COVID-19 on admission. We used propensity score matching to estimate prevalence ratios and 95% confidence intervals of treatment-eligible patients who received remdesivir or systemic steroids by pregnancy status. RESULTS: Among 336 hospitalized pregnant women with symptomatic COVID-19, 39.6% were non-Hispanic Black, 24.8% were Hispanic or Latino, and 61.9% were aged 25 to 34 years. Among those with known COVID-19 vaccination status, 92.9% were unvaccinated. One-third (32.7%) were treatment-eligible. Among treatment-eligible pregnant women, 74.1% received systemic steroids and 61.4% received remdesivir. Among those that were no longer pregnant at discharge (n=180), 5.4% had spontaneous abortions and 3.5% had stillbirths. Of the 159 live births, 29.0% were preterm. Among a propensity score-matched cohort of treatment-eligible hospitalized women of reproductive age, pregnant women were less likely than nonpregnant women to receive remdesivir (prevalence ratio, 0.82; 95% confidence interval, 0.69-0.97) and systemic steroids (prevalence ratio, 0.80; 95% confidence interval, 0.73-0.87). CONCLUSION: Most hospitalized pregnant patients with symptomatic COVID-19 were unvaccinated. Hospitalized pregnant patients were less likely to receive recommended remdesivir and systemic steroids compared with similar hospitalized nonpregnant women. Our results underscore the need to identify opportunities for improving COVID-19 vaccination, implementation of treatment of pregnant women, and the inclusion of pregnant women in clinical trials.

Coronavirus Disease 2019 (COVID-19) Severity Among Women of Reproductive Age With Symptomatic Laboratory-Confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection by Pregnancy Status-United States, 1 January 2020-25 December 2021.

BACKGROUND: Information on the severity of coronavirus disease 2019 (COVID-19) attributable to the Delta variant in the United States among pregnant people is limited. We assessed the risk for severe COVID-19 by pregnancy status in the period of Delta variant predominance compared with the pre-Delta period. METHODS: Laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections among symptomatic women of reproductive age (WRA) were assessed. We calculated adjusted risk ratios for severe disease including intensive care unit (ICU) admission, receipt of invasive ventilation or extracorporeal membrane oxygenation (ECMO), and death comparing the pre-Delta period (1 January 2020-26 June 2021) and the Delta period (27 June 2021-25 December 2021) for pregnant and nonpregnant WRA. RESULTS: Compared with the pre-Delta period, the risk of ICU admission during the Delta period was 41% higher (adjusted risk ratio [aRR], 1.41 [95% confidence interval {CI}, 1.17-1.69]) for pregnant WRA and 9% higher (aRR, 1.09 [95% CI, 1.00-1.18]) for nonpregnant WRA. The risk of invasive ventilation or ECMO was higher for pregnant (aRR, 1.83 [95% CI, 1.26-2.65]) and nonpregnant (aRR, 1.34 [95% CI, 1.17-1.54]) WRA in the Delta period. During the Delta period, the risk of death was 3.33 (95% CI, 2.48-4.46) times the risk in the pre-Delta period among pregnant WRA and 1.62 (95% CI, 1.49-1.77) among nonpregnant WRA. CONCLUSIONS: Compared with the pre-Delta period, pregnant and nonpregnant WRA were at increased risk for severe COVID-19 in the Delta period.

The influence of structural racism, pandemic stress, and SARS-CoV-2 infection during pregnancy with adverse birth outcomes.

BACKGROUND: Structural racism and pandemic-related stress from the COVID-19 pandemic may increase the risk of adverse birth outcomes. OBJECTIVE: Our objective was to examine associations between neighborhood measures of structural racism and pandemic stress with 3 outcomes: SARS-CoV-2 infection, preterm birth, and delivering small-for-gestational-age newborns. Our secondary objective was to investigate the joint association of SARS-CoV-2 infection during pregnancy and neighborhood measures with preterm birth and delivering small-for-gestational-age newborns. STUDY DESIGN: We analyzed data of 967 patients from a prospective cohort of pregnant persons in New York City, comprising 367 White (38%), 169 Black (17%), 293 Latina (30%), and 87 Asian persons (9%), 41 persons of other race or ethnicity (4%), and 10 of unknown race or ethnicity (1%). We evaluated structural racism (social/built structural disadvantage, racial-economic segregation) and pandemic-related stress (community COVID-19 mortality, community unemployment rate increase) in quartiles by zone improvement plan code. SARS-CoV-2 serologic enzyme-linked immunosorbent assay was performed on blood samples from pregnant persons. We obtained data on preterm birth and small-for-gestational-age newborns from an electronic medical record database. We used log-binomial regression with robust standard error for clustering by zone improvement plan code to estimate associations of each neighborhood measure separately with 3 outcomes: SARS-CoV-2 infection, preterm birth, and small-for-gestational-age newborns. Covariates included maternal age, parity, insurance status, and body mass index. Models with preterm birth and small-for-gestational-age newborns as the dependent variables additionally adjusted for SARS-CoV-2 infection. RESULTS: A total of 193 (20%) persons were SARS-CoV-2-seropositive, and the overall risks of preterm birth and small-for-gestational-age newborns were 8.4% and 9.8%, respectively. Among birthing persons in neighborhoods in the highest quartile of structural disadvantage (n=190), 94% were non-White, 50% had public insurance, 41% were obese, 32% were seropositive, 11% delivered preterm, and 12% delivered a small-for-gestational-age infant. Among birthing persons in neighborhoods in the lowest quartile of structural disadvantage (n=360), 39% were non-White, 17% had public insurance, 15% were obese, 9% were seropositive, 6% delivered preterm, and 10% delivered a small-for-gestational-age infant. In adjusted analyses, structural racism measures and community unemployment were associated with both SARS-CoV-2 infection and preterm birth, but not small-for-gestational-age infants. High vs low structural disadvantage was associated with an adjusted relative risk of 2.6 for infection (95% confidence interval, 1.7-3.9) and 1.7 for preterm birth (95% confidence interval, 1.0-2.9); high vs low racial-economic segregation was associated with adjusted relative risk of 1.9 (95% confidence interval, 1.3-2.8) for infection and 2.0 (95% confidence interval, 1.3-3.2) for preterm birth; high vs low community unemployment increase was associated with adjusted relative risk of 1.7 (95% confidence interval, 1.2-1.5) for infection and 1.6 (95% confidence interval, 1.0-2.8) for preterm birth. COVID-19 mortality rate was associated with SARS-CoV-2 infection but not preterm birth or small-for-gestational-age infants. SARS-CoV-2 infection was not independently associated with birth outcomes. We found no interaction between SARS-CoV-2 infection and neighborhood measures on preterm birth or small-for-gestational-age infants. CONCLUSION: Neighborhood measures of structural racism were associated with both SARS-CoV-2 infection and preterm birth, but these associations were independent and did not have a synergistic effect. Community unemployment rate increases were also associated with an increased risk of preterm birth independently of SARS-CoV-2 infection. Mitigating these factors might reduce the impact of the pandemic on pregnant people.

Association of Prepregnancy Substance Use and Substance Use Disorders with Pregnancy Timing and Intention.

Background: Limited research exists on the association between substance use disorders (SUDs) and dimensions of pregnancy intention. This study sought to examine the independent relationships between prepregnancy substance use and SUDs with pregnancy timing and intentions. Materials and Methods: Secondary analysis of data from three prenatal care sites in Connecticut, Massachusetts, and Michigan, 2016-2017. Associations were estimated using modified Poisson regression with robust error variance to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs), controlling for relevant covariates. Results: The total sample size was 1115 women. Respectively, 61.1% and 15.5% of women used any substance in the 30 days prepregnancy or had any SUD in the past 12 months. After adjustment, any prepregnancy substance use was associated with a reduced likelihood of a well-timed (aPR 0.85; 95% CI: 0.77-0.93) and intended (aPR 0.80; 95% CI: 0.72-0.89) pregnancy; similarly, any SUD was associated with a reduced likelihood of a well-timed (aPR 0.66; 95% CI: 0.55-0.80) and intended (aPR 0.79; 95% CI: 0.67-0.93) pregnancy. Conclusions: Women with prepregnancy substance use or SUD have decreased prevalence of well-timed and intended pregnancies. Greater efforts are needed to address substance use and family planning in routine, well-woman, prenatal, and postpartum care.

Changes in rates of adverse pregnancy outcomes during the COVID-19 pandemic: a cross-sectional study in the United States, 2019-2020.

OBJECTIVE: Our objective was to assess differences in pregnancy outcomes during the COVID-19 pandemic compared to the previous year. STUDY DESIGN: In a cross-sectional study of delivery hospitalizations in the Premier Healthcare Database Special COVID-19 Release, we assessed differences in selected maternal and pregnancy outcomes occurring April-December in 2019 and 2020 in the United States. RESULT: Among 663,620 deliveries occurring in 2019 and 614,093 deliveries occurring in 2020, we observed an increase in in-hospital maternal death from 2019 to 2020, which was no longer statistically significant after excluding deliveries with a COVID-19 diagnosis. Intensive care unit admission and preterm birth decreased from 2019 to 2020. There was no difference in the prevalence of most other outcomes examined. CONCLUSION: The full impact of the COVID-19 pandemic on maternal and pregnancy outcomes remains to be understood. Most outcomes investigated experienced minimal change from 2019 to 2020.