Influence of Pregnancy Intention on Postpartum Contraceptive Choice at an Urban Academic Medical Center.

OBJECTIVE: This study aimed to describe postpartum contraception preferences in the context of pregnancy intention (PI). STUDY DESIGN: A prospective cohort study analyzing postpartum contraceptive choice (PCC) in 431 postpartum women who delivered at a single academic medical center. PCC in women with an unintended or mistimed pregnancy was compared to contraceptive choice in women with an intended pregnancy using the adapted National Survey of Family Growth categorization. Mistimed and unintended pregnancies were grouped for analysis. Generalized linear modeling estimated the relative influence of PI on PCC adjusting for maternal age, race, and parity. RESULTS: Nearly three out of four (71.9%) pregnancies were mistimed or unintended. These pregnancies were more likely in women who were non-Hispanic Black (62.3%), unmarried (86.3%), 18 to 24 years (51.3%), and insured by Medicaid or Medicare (82.1%), compared to women with an intended pregnancy, p-value <0.001. Women with mistimed or unintended pregnancy were 83% more likely to choose highly effective, user-independent methods compared to any other or no method, adjusted relative risk (aRR) = 1.83 (95% confidence interval [CI]: 1.36, 2.47), and more likely to desire voluntary sterilization, aRR = 2.70 (95% CI: 1.58, 4.59). Additionally, women with these pregnancies were 56% more likely to use user-independent methods compared to user-dependent methods, aRR = 1.56 (95% CI: 1.18, 2.06). CONCLUSION: Women with mistimed or unintended pregnancies are 83% more likely to choose highly effective postpartum contraception or voluntary sterilization, and thus initiatives are necessary to increase access and affordability to these methods before hospital discharge after delivery. KEY POINTS: · Nearly three out of four pregnancies in this study were mistimed or unintended.. · Women with mistimed or unintended pregnancies are more likely to choose highly effective postpartum contraception or voluntary sterilization.. · Public health initiatives to improve access to family planning services and postpartum contraception, including surgery for bilateral tubal ligation before discharge from the hospital postdelivery, are important areas of focus to help attenuate the rates of unintended pregnancy in the United States..

Maternal and newborn metabolomic changes associated with urinary polycyclic aromatic hydrocarbon metabolite concentrations at delivery: an untargeted approach.

INTRODUCTION: Prenatal exposure to polycyclic aromatic hydrocarbons (PAHs) has been associated with adverse human health outcomes. To explore the plausible associations between maternal PAH exposure and maternal/newborn metabolomic outcomes, we conducted a cross-sectional study among 75 pregnant people from Cincinnati, Ohio. METHOD: We quantified 8 monohydroxylated PAH metabolites in maternal urine samples collected at delivery. We then used an untargeted high-resolution mass spectrometry approach to examine alterations in the maternal (n = 72) and newborn (n = 63) serum metabolome associated with PAH metabolites. Associations between individual maternal urinary PAH metabolites and maternal/newborn metabolome were assessed using linear regression adjusted for maternal and newborn factors while accounting for multiple testing with the Benjamini-Hochberg method. We then conducted functional analysis to identify potential biological pathways. RESULTS: Our results from the metabolome-wide associations (MWAS) indicated that an average of 1% newborn metabolome features and 2% maternal metabolome features were associated with maternal urinary PAH metabolites. Individual PAH metabolite concentrations in maternal urine were associated with maternal/newborn metabolome related to metabolism of vitamins, amino acids, fatty acids, lipids, carbohydrates, nucleotides, energy, xenobiotics, glycan, and organic compounds. CONCLUSION: In this cross-sectional study, we identified associations between urinary PAH concentrations during late pregnancy and metabolic features associated with several metabolic pathways among pregnant women and newborns. Further studies are needed to explore the mediating role of the metabolome in the relationship between PAHs and adverse pregnancy outcomes.

Influence of social determinants of health on breastfeeding intent in the United States.

BACKGROUND: Breastfeeding rates in the United States are suboptimal despite public health recommendations that infants are fed breastmilk for their first year of life. This study aimed to characterize the influence of social determinants of health on intended breastfeeding duration. METHODS: This case-control study analyzed breastfeeding intent in 421 postpartum women. Data on social determinants and medical history were obtained from medical records and participant self-report. Logistic regression estimated the influence of demographic factors and social determinants on intent to breastfeed for durations of <6 months, 6-12 months, and at least 1 year. RESULTS: Thirty-five percent of mothers intended to breastfeed for at least 6 months, and 15% for 1 year. Social determinants that negatively predicted breastfeeding intent included not owning transportation and living in a dangerous neighborhood (p < 0.05). Women were more likely to intend to breastfeed for 12 months if they had knowledge of breastfeeding recommendations (adjusted odds ratio [aOR] 6.19, 95% confidence interval [CI 2.67-14.34]), an identifiable medical provider (aOR 2.64 [CI 1.22-5.72]), familial support (aOR 2.80 [CI 1.01-7.80]), or were married (aOR 2.55 [CI 1.01-6.46]). Sociodemographic factors that negatively influenced breastfeeding intent included non-Hispanic Black race, no high school diploma, cigarette use, income below $20,000, fewer than five prenatal visits, and WIC or Medicaid enrollment (p < 0.05). CONCLUSIONS: Women who lack familial support, an identifiable healthcare provider, or knowledge of breastfeeding guidelines are less likely to intend to breastfeed. Public health initiatives should address these determinants to improve breastfeeding and infant outcomes.

Association of Antenatal Corticosteroid Exposure and Infant Survival at 22 and 23 Weeks.

OBJECTIVE: In 2014, the leading obstetric societies published an executive summary of a joint workshop to establish obstetric interventions to be considered for periviable births. Antenatal corticosteroid administration between 220/7 and 226/7 weeks was not recommended given existing evidence. We sought to evaluate whether antenatal steroid exposure was associated with improved survival among resuscitated newborns delivered between 22 and 23 weeks of gestation. STUDY DESIGN: We conducted a population-based cohort study of all resuscitated livebirths delivered between 220/7 and 236/7 weeks of gestation in the United States during 2009 to 2014 utilizing National Center for Health Statistics data. The primary outcome was rate of survival to 1 year of life (YOL) between infant cohorts based on antenatal steroid exposure. Multivariable logistic regression estimated the association of antenatal steroid exposure on survival outcomes. RESULTS: In the United States between 2009 and 2014, there were 2,635 and 7,992 infants who received postnatal resuscitation after delivery between 220/7 to 226/7 and 230/7 to 236/7 weeks of gestation, respectively. Few infants born at 22 (15.9%) and 23 (26.0%) weeks of gestation received antenatal corticosteroids (ANCS). Among resuscitated neonates, survival to 1 YOL was 45.2 versus 27.8% (adjusted relative risk [aRR]: 1.6, 95% confidence interval [CI]: 1.2-2.1) and 57.9 versus 47.7% (aRR: 1.3, 95% CI: 1.1-1.5) for infants exposed to ANCS compared with those not exposed at 22 and 23 weeks of gestation, respectively. When stratified by 100 g birth weight category, ANCS were associated with survival among neonates weighing 500 to 599 g (aRR: 1.9, 95% CI: 1.3-2.9) and 600 to 699 g (aRR: 1.7, 95% CI: 1.1-2.6) at 22 weeks. CONCLUSION: Exposure to ANCS was associated with higher survival rates to 1 YOL among resuscitated infants born at 22 and 23 weeks. National guidelines recommending against ANCS utilization at 22 weeks should be re-evaluated given emerging evidence of benefit. KEY POINTS: · Exposure to antenatal steroids was associated with higher survival rates at 22 and 23 weeks of gestation.. · Women exposed to antenatal steroids were more likely to have an adverse outcome.. · The association between steroids and survival was observed among infants with birth weights > 500 g..

Acute histologic chorioamnionitis independently and directly increases the risk for brain abnormalities seen on magnetic resonance imaging in very preterm infants.

BACKGROUND: The independent risk for neurodevelopmental impairments attributed to chorioamnionitis in premature infants remains controversial. Delayed brain maturation or injury identified on magnetic resonance imaging at term-equivalent age can be used as a surrogate measure of neurodevelopmental impairments that is less confounded by postdelivery neonatal intensive care unit environmental factors to investigate this relationship more clearly. OBJECTIVE: This study aimed to determine whether preterm infants born with moderate to severe acute histologic chorioamnionitis would have a higher magnetic resonance imaging-determined global brain abnormality score, independent of early premature birth, when compared with preterm infants with no or mild chorioamnionitis. STUDY DESIGN: This was a prospective, multicenter cohort study involving infants born very prematurely ≤32 weeks' gestational age with acute moderate to severe histologic chorioamnionitis, graded using standard histologic criteria. Brain abnormalities were diagnosed and scored using a well-characterized, standardized scoring system captured using a high-resolution 3 Tesla magnetic resonance imaging research magnet. In secondary analyses, total brain volume and 4 magnetic resonance imaging metrics of cortical maturation (cortical surface area, sulcal depth, gyral index, and inner cortical curvature) were calculated using an automated algorithm and correlated with chorioamnionitis. The association of funisitis (any grade) with brain abnormalities was also explored. We investigated if premature birth mediated the relationship between histologic chorioamnionitis and brain abnormality score using mediation analysis. RESULTS: Of 353 very preterm infants, 297 infants had mild or no chorioamnionitis (controls), and 56 were diagnosed with moderate to severe acute histologic chorioamnionitis. The primary outcome brain abnormality score was significantly higher in histologic chorioamnionitis-exposed infants than in the controls (median, 4 vs 7; P<.001). Infants with acute histologic chorioamnionitis had significantly lower brain tissue volume (P=.03) and sulcal depth (P=.04), whereas other morphometric indices did not differ statistically. In the multiple regression analysis, we observed persistent significant relationships between moderate to severe acute histologic chorioamnionitis and brain abnormality scores (ß=2.84; 1.51-4.16; P<.001), total brain volume (P=.03), and sulcal depth (P=.02). Funisitis was also significantly associated with brain abnormality score after adjustment for clinical confounders (P=.005). Mediation analyses demonstrated that 50% of brain abnormalities was an indirect consequence of premature birth, and the remaining 50% was a direct effect of moderate to severe acute histologic chorioamnionitis when compared with preterm infants with no or mild chorioamnionitis exposure. Examining gestational age as a mediator, funisitis did not exert a significant direct effect on brain abnormalities after the significant indirect effects of preterm birth were accounted for. CONCLUSION: Acute histologic chorioamnionitis increases the risk for brain injury and delayed maturation, both directly and indirectly, by inducing premature birth.

Factors Associated with Receiving No Maternal or Neonatal Interventions among Periviable Deliveries.

OBJECTIVE: The aim of this study was to quantify the influence of maternal sociodemographic, medical, and pregnancy characteristics on not receiving maternal and neonatal interventions with deliveries occurring at 22 to 23 weeks of gestation. STUDY DESIGN: This was a case-control study of U.S. live births at 220/6 to 236/7 weeks of gestation using vital statistics birth records from 2012 to 2016. We analyzed births that received no interventions for periviable delivery. Births were defined as having no interventions if they did not receive maternal (cesarean delivery, maternal hospital transfer, or antenatal corticosteroid administration) or neonatal interventions (neonatal intensive care unit admission, surfactant administration, antibiotic administration, or assisted ventilation). Logistic regression estimated the influence of maternal and pregnancy factors on the receipt of no interventions when delivery occurred at 22 to 23 weeks. RESULTS: Of 19,844,580 U.S. live births in 2012-2016, 24,379 (0.12%) occurred at 22 to 23 weeks; 54.3% of 22-week deliveries and 15.7% of 23-week deliveries received no interventions. Non-Hispanic Black maternal race was associated with no maternal interventions at 22 and 23 weeks. Private insurance, singleton pregnancy, and small for gestational age were associated with receiving no neonatal interventions at 22 and 23 weeks of gestation. CONCLUSIONS: Withholding or refusing maternal and neonatal interventions occurs frequently at the threshold of viability. Our data highlight various sociodemographic, pregnancy, and medical factors associated with decisions to not offer or receive maternal or neonatal interventions when birth occurs at the threshold of viability. The data elucidate observed practices and may assist in the development of further research. KEY POINTS: · Non-Hispanic Black race was associated with receiving no maternal interventions.. · Indicators of high socioeconomic status were associated with no neonatal inventions.. · Patient-level factors influence the receipt of no interventions for periviable birth..

Factors Associated with Occurrence of Stillbirth before 32 Weeks of Gestation in a Contemporary Cohort.

OBJECTIVE: We sought to quantify the distribution of stillbirths by gestational age (GA) in a contemporary cohort and to determine identifiable risk factors associated with stillbirth prior to 32 weeks of gestation. STUDY DESIGN: Population-based case-control study of all stillbirths in the United States during the year 2014, utilizing vital statistics data, obtained from the National Center for Health Statistics. Distribution of stillbirths were stratified by 20 to 44 weeks of GA, in women diagnosed with stillbirth in the antepartum period. Pregnancy characteristics were compared between those diagnosed with stillbirth <32 versus ≥32 weeks of gestation. Multivariate logistic regression estimated the relative influence of various factors on the outcome of stillbirth prior to 32 weeks of gestation. RESULTS: There were 15,998 nonlaboring women diagnosed with stillbirth during 2014 in the United States between 20 and 44 weeks. Of them, 60.1% (n = 9,618) occurred before antenatal fetal surveillance (ANFS) is typically initiated (<32 weeks) and 39.9% (n = 6,380) were diagnosed at ≥32 weeks. Women with stillbirth prior to 32 weeks were more likely to be of non-Hispanic Black race (29.0 vs. 23.9%, p < 0.001), nulliparous (53.8 vs. 50.6%, p = 0.001), have chronic hypertension (CHTN; 6.0 vs. 4.3%, p < 0.001), and fetal growth restriction as evidenced by small for GA (SGA < 10th%) birth weight (44.8 vs. 42.1%, p < 0.001) as opposed to women with stillbirth after 32 weeks. After adjustment, SGA birth weight (adjusted odds ratio [aOR] = 1.2, 95% confidence interval [CI]: 1.1-1.3), Black race (aOR = 1.2, 95% CI: 1.1-1.3), and CHTN (aOR = 1.3, 95% CI: 1.1-1.5) were associated with stillbirth prior to 32 weeks of gestation as opposed to stillbirth after 32 weeks. CONCLUSION: More than 6 out of 10 stillbirths in this study occurred <32 weeks of gestation, before ANFS is typically initiated under American College of Obstetricians and Gynecologists recommendations. Among identifiable risk factors, CHTN, Black race, and fetal growth restriction were associated with higher risk of stillbirth before 32 weeks of gestation. Earlier ANFS may be warranted at in certain "at risk" women. KEY POINTS: · Six out of 10 stillbirths occur before 32 weeks of gestation.. · We evaluated factors associated with stillbirth <32 weeks.. · Hypertension and fetal growth restriction were associated with early stillbirth..

Regional Contribution of Previable Infant Deaths to Infant Mortality Rates in the United States.

OBJECTIVE: Lack of standardization of infant mortality rate (IMR) calculation between regions in the United States makes comparisons potentially biased. This study aimed to quantify differences in the contribution of early previable live births (<20 weeks) to U.S. regional IMR. STUDY DESIGN: Population-based cohort study of all U.S. live births and infant deaths recorded between 2007 and 2014 using Centers for Disease Control and Prevention's (CDC's) WONDER database linked birth/infant death records (births from 17-47 weeks). Proportion of infant deaths attributable to births <20 vs. 20 to 47 weeks, and difference (ΔIMR) between reported and modified (births ≥20 weeks) IMRs were compared across four U.S. census regions (North, South, Midwest, and West). RESULTS: Percentages of infant deaths attributable to birth <20 weeks were 6.3, 6.3, 5.3, and 4.1% of total deaths for Northeast, Midwest, South, and West, respectively, p < 0.001. Contribution of < 20-week deaths to each region's IMR was 0.34, 0.42, 0.37, and 0.2 per 1,000 live births. Modified IMR yielded less regional variation with IMRs of 5.1, 6.2, 6.6, and 4.9 per 1,000 live births. CONCLUSION: Live births at <20 weeks contribute significantly to IMR as all result in infant death. Standardization of gestational age cut-off results in more consistent IMRs among U.S. regions and would result in U.S. IMR rates exceeding the healthy people 2020 goal of 6.0 per 1,000 live births.

Influence of periconception smoking behavior on birth defect risk.

BACKGROUND: Smoking is one of the most important modifiable risk factors for adverse maternal and neonatal outcomes. Smoking during pregnancy has been associated with fetal growth restriction, adverse pregnancy outcomes, and chronic adult diseases. Existing research has evaluated the risk of smoking on congenital defects. However, no studies have evaluated how periconception smoking affects birth defects. OBJECTIVE: The purpose of this study was to assess the association of maternal smoking and the timing of periconception exposure with congenital birth defects. STUDY DESIGN: This study was a population-based retrospective cohort of live births in Ohio from 2006-2015 with the use of data from birth certificates. Rates of cardiovascular, musculoskeletal, gastrointestinal, and neural tube birth defects were compared between a referent group of women who did not smoke and a group of women who smoked (1) during the preconception period of 3 months before conception only and not in the first trimester and (2) in the preconception period plus throughout the first trimester of pregnancy. Multivariate logistic regression was used to quantify the relationship between periconception smoking and the rate of birth defects after adjustment for maternal race, age, pregestational diabetes mellitus, and socioeconomic factors. RESULTS: Of the 1,436,036 live births in the study period, 75% of mothers did not smoke during the preconception period or during pregnancy. There were 334,156 women (23.3%) who smoked during pregnancy; 6.0% of the population smoked preconception only, and 17.3% of the population smoked both during the preconception period and through the first trimester. Smoking during the preconception period only, even without first trimester exposure, was associated with a 40% increased risk of gastroschisis. Smoking that was limited to preconception only was not associated with any other individual birth defects. However, smoking through the first trimester was associated with a statistically significant increased risk of several defects that included gastroschisis and limb reduction and a composite outcome of any defect, even after adjustment for coexisting factors. CONCLUSION: Smoking during the period of fetal organogenesis (during the first trimester of pregnancy) is associated with increased risk of some birth defects. In this study, we provide novel data that smoking during the few months before conception, even with cessation in the first trimester, may also pose a risk for fetal malformation such as gastroschisis. These findings highlight the importance of preconception women's public health education efforts and warrant further investigation.

Mode of Delivery in Previable Births.

OBJECTIVE: Preterm birth before 23 weeks of gestation typically results in neonatal death (5% survival). Society for Maternal-Fetal Medicine and American College of Obstetricians and Gynecologists published consensus guidelines recommending cesarean delivery (CD) not be performed for fetal indications between 20 and 226/7 weeks given the lack of proven benefit. We sought to quantify the previable CD rate and identify characteristics associated with previable CD. METHODS: We performed a population-based retrospective cohort study of all live births in Ohio (2006-2015). Frequency of previable CD was stratified by week of gestation, defined as delivery between 16 and < 23 weeks of gestation. Maternal, obstetric, and neonatal characteristics were compared between women who underwent vaginal delivery versus CD. Multivariable logistic regression estimated the relative influence of maternal and fetal factors on the outcome of CD among previable live births. RESULTS: Of 1,463,506 live births in Ohio during the 10-year study period, 2,865 births (0.2%) occurred during the previable period of 16 to 22 weeks. Nearly 1 in 10 live births at less than 23 weeks was delivered by cesarean (n = 273/2,865), CD rate 9.5% (95% confidence interval, 8.5-10.7). At 16 to 22 weeks of gestation, the CD rates were 0, 5.5, 7.6, 3.5, 5.4, 10.1, and 15.1%, respectively. Factors associated with CD included increasing parity, increasing birth weight, maternal corticosteroid administration, and fetal malpresentation. Previable neonates born by CD were more likely to be admitted to the NICU, receive ventilator support, and more likely to be living at the time of birth certificate filing. CONCLUSION: Nearly 1 out of 10 births during the previable period was delivered via cesarean. Factors associated with previable CD suggest intent for neonatal interventions, such as NICU admission and supportive therapies. Our findings support that education and adherence with guidelines for care of previable births are a potential area of focus for perinatal quality improvement efforts.

Obstetric Outcomes Associated with Fetal Cyanotic Congenital Heart Disease.

OBJECTIVE: To characterize obstetric outcomes associated with cyanotic congenital heart disease (CCHD) in a contemporary population. STUDY DESIGN: We conducted a population-based retrospective cohort study of all livebirths in Ohio (2006-2015). Obstetric characteristics of pregnancies complicated by fetal CCHD were compared with those without CCHD, excluding those with other anomalies and aneuploidy. The primary objective was to determine the risk of cesarean delivery among CCHD affected pregnancies. Multivariate logistic regression estimated the influence of CCHD on these obstetric outcomes. RESULTS: Among 1,463,506 live births in Ohio, there were 863 (0.06%) CCHD affected births. The overall cesarean rate was 45.9 versus 31.0% (p< 0.001) in CCHD compared with non-CCHD pregnancies. After adjusting for various confounders, CCHD affected pregnancies were associated with a higher risk for cesarean delivery (adjusted relative risk [aRR]: 2.0, 95% confidence interval [CI]: 1.6-2.4), preterm birth (PTB) (aRR: 1.5, 95% CI: 1.1-2.0), induction of labor (aRR: 1.2, 95% CI: 1.04-1.4), small for gestational age (SGA) birthweight (aRR: 2.4, 95% CI: 2.0-2.9), and fetal intolerance of labor (FIOL; aRR: 2.0, 95% CI: 1.6-2.4). Women with CCHD affected pregnancies were also less likely to undergo a trial of labor (aRR: 0.4, 95% CI: 0.3-0.5) prior to cesarean delivery. CONCLUSION: Obstetric outcomes associated with CCHD include higher risk for cesarean delivery, PTB, SGA, and FIOL.

Influence of paternal age on perinatal outcomes.

BACKGROUND: There is an increasing trend to delay childbearing to advanced parental age. Increased risks of advanced maternal age and assisted reproductive technologies are widely accepted. There are limited data regarding advanced paternal age. To adequately counsel patients on risk, more research regarding advanced paternal age is necessary. OBJECTIVE: We sought to determine the influence of paternal age on perinatal outcomes, and to assess whether this influence differs between pregnancies achieved spontaneously and those achieved with assisted reproductive technology. STUDY DESIGN: A population-based retrospective cohort study of all live births in Ohio from 2006 through 2012 was completed. Data were evaluated to determine if advanced paternal age is associated with an increased risk of adverse outcomes in pregnancies. The analysis was stratified by status of utilization of assisted reproductive technology. Generalized linear regression models assessed the association of paternal age on pregnancy complications in assisted reproductive technology and spontaneously conceived pregnancies, after adjusting for maternal age, race, multifetal gestation, and Medicaid status, using Stata software (Stata, Release 12; StataCorp, College Station, TX). RESULTS: Paternal age was documented in 82.2% of 1,034,552 live births in Ohio during the 7-year study period. Paternal age ranged from 12-87 years, with a median of 30 (interquartile range, 26-35) years. Maternal age ranged from 11-62 years, with a median of 27 (interquartile range, 22-31) years. The use of assisted reproductive technology in live births increased as paternal age increased: 0.1% <30 years vs 2.5% >60 years, P < .001. After accounting for maternal age and other confounding risk factors, increased paternal age was not associated with a significant increase in the rate of preeclampsia, preterm birth, fetal growth restriction, congenital anomaly, genetic disorder, or neonatal intensive care unit admission. The influence of paternal age on pregnancy outcomes was similar in pregnancies achieved with and without assisted reproductive technology. CONCLUSION: Older paternal age does not appear to pose an independent risk of adverse perinatal outcomes, in pregnancies achieved either with or without assisted reproductive technology. However, small effect sizes such as very small risk increases or decreases may not be detectable despite the large sample size in this study of >830,000 births.

Modifying the risk of recurrent preterm birth: influence of trimester-specific changes in smoking behaviors.

BACKGROUND: Women with at least 1 prior occurrence of premature birth often have demographic and medical risk factors that are not modifiable. However, smoking cessation could be a targeted intervention in which a woman with a history of premature birth may be able to reduce her future risk of recurrence. OBJECTIVE: This study aims to assess how trimester-specific smoking patterns influence the risk of recurrent premature birth. STUDY DESIGN: This was a population-based retrospective cohort study of singleton nonanomalous live births in Ohio, 2006-2012 using vital statistics birth records. This analysis was limited to women with at least 1 prior premature birth. Rates of birth <37 weeks were compared among nonsmokers, women who smoked in the 3 months prior to pregnancy and quit in the first vs quit in the second vs quit in the third trimester. Multivariate logistic regression analyses assessed the association between smoking cessation at various time points in pregnancy and recurrent premature birth while adjusting for maternal race, education, Medicaid enrollment, and marital status. RESULTS: We analyzed the outcomes of 36,432 women with a prior premature birth who subsequently delivered at 20-42 weeks. One third of women with a prior premature birth smoked during pregnancy. Of smokers, 16% quit early in the first trimester, 7% quit in the second, 5% quit in the third trimester, and 72% smoked throughout pregnancy. The rate of recurrent premature birth in nonsmokers was high 28% in this cohort. Smoking in pregnancy with cessation in the first or second trimester was not significantly associated with an increase in recurrent premature birth rates (first trimester, 29% adjusted odds ratio, 0.97 [95% confidence interval, 0.9-1.1], and second trimester, 31% adjusted odds ratio, 1.10 [95% confidence interval, 0.9-1.3], respectively). However, quitting late in pregnancy (third trimester) was associated with a high rate (43%) of delivery <37 weeks, adjusted odds ratio, 1.81 (95% confidence interval, 1.48-2.21). Continued smoking throughout pregnancy was also associated with an increased recurrent premature birth (32%), adjusted odds ratio, 1.14 (95% confidence interval, 1.07-1.22), despite adjustment for concomitant premature birth risk factors. CONCLUSION: Smoking cessation in pregnancy and its relationship to preterm birth has been studied extensively, and it is widely accepted that smoking in pregnancy increases preterm birth rates. However, this study provides novel information quantifying the risk of recurrent preterm birth and stratifies the increased risk of recurrent preterm birth by trimester-specific smoking behavior. Although women with even 1 prior premature birth are at an inherently high risk of recurrence, women who stopped smoking early in the first 2 trimesters experienced similar preterm birth rates compared with nonsmokers. However, delayed smoking cessation or smoking throughout pregnancy significantly increased recurrent premature birth risk. Smoking cessation is a potential modifiable risk factor for recurrent preterm birth in high-risk pregnancies. This study highlights the importance of early pregnancy smoking cessation in those at especially high risk, women with a prior preterm birth.

Assessment of DHA on reducing early preterm birth: the ADORE randomized controlled trial protocol.

BACKGROUND: Preterm birth contributes to 0.5 million deliveries in the United States (one of eight pregnancies) and poses a huge burden on public health with costs in the billions. Of particular concern is that the rate of earliest preterm birth (<34 weeks) (ePTB), which has decreased little since 1990 and has the greatest impact on the overall infant mortality, resulting in the greatest cost to society. Docosahexaenoic acid (DHA) supplementation provides a potential high yield, low risk strategy to reduce early preterm delivery in the US by up to 75%. We propose a Phase III Clinical Trial (randomized to low or high dose DHA, double-blinded) to examine the efficacy and safety of high dose DHA supplementation to reduce ePTB. We also plan for a secondary pregnancy efficacy analysis to determine if there is a subset of pregnancies most likely to benefit from DHA supplementation. METHODS: Between 900 and 1200 pregnant women who are ≥ 18 years old and between 12 and 20 weeks gestation will be recruited from three trial experienced academic medical institutions. Participants will be randomly assigned to two daily capsules of algal oil (totaling 800 mg DHA) or soybean and corn oil (0 mg DHA). Both groups will receive a commercially available prenatal supplement containing 200 mg DHA. Therefore, the experimental group will receive 1000 mg DHA/d and the control group 200 mg DHA/d. We will then employ a novel Bayesian response adaptive randomization design that assigns more subjects to the "winning" group and potentially allows for substantially smaller sample size while providing a stronger conclusion regarding the most effective group. The study has an overall Type I error rate of 5% and a power of 90%. Participants are followed throughout pregnancy and delivery for safety and delivery outcomes. DISCUSSION: We hypothesize that DHA will decrease the frequency of ePTB <34 weeks. Reducing ePTB is clinically important as these earliest preterm deliveries carry the highest risk of neonatal morbidity, as well as contribute significant stress for families and post a large societal burden. TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov (identifier: NCT02626299 ) on December 8, 2015. Additional summary details may be found in Table 1.

Racial Differences in the Influence of Interpregnancy Interval on Fetal Growth.

Objectives Assess the influence of maternal race on the association between interpregnancy interval (IPI) and risk of small for gestational age (SGA) and large for gestational age (LGA) births. Methods Statewide population-based cohort study of 380,520 singleton births. We calculated risk of SGA and LGA births following IPIs of 0 to <6, 6 to <12, 12 to <24 (referent), 24 to <60 months, and ≥60 months, by maternal race after adjustment for confounding influences. Results The highest risk for SGA among white women followed short IPI of 0 to <6 months [adjRR 1.14 (95 % CI 1.08-1.21)], and long IPI ≥ 60 months [adjRR 1.37 (95 % CI 1.31-1.43)]. Only long IPI ≥ 60 months increased SGA risk in black women [adjRR 1.22 (95 % CI 1.13-1.32)]. LGA risk in white women was lowest with shortest and longest IPIs, 0 to <6 [adjRR 0.80 (95 % CI 0.76-0.84)] and ≥60 months [adjRR 0.68 (95 % CI 0.66-0.70)]. The crude risk of LGA was directly proportional to longer IPIs in black women. However, after adjusting for confounding effects of age, obesity, excessive gestational weight gain, and gestational diabetes, the effect was reversed to reduced risk following long IPI ≥ 60 months [adjRR 0.82 (95 % CI 0.74-0.91)], similar to that of white women. Conclusions In black and white women, an interpregnancy interval of 1-2 years is associated with optimal fetal growth. In addition to birth spacing, addressing modifiable factors such as pre-pregnancy BMI, monitoring gestational weight gain, and control of gestational diabetes in black women may help optimize fetal growth.

Effect of Modifiable Risk Factors on Preterm Birth: A Population Based-Cohort.

Objectives The purpose of this study is to evaluate the prevalence, impact, and interaction of short interpregnancy interval (IPI), pre-pregnancy body mass index (BMI) category, and pregnancy weight gain (PWG) on the rate of preterm birth. Methods This is a population-based retrospective cohort study using vital statistics birth records from 2006 to 2011 in OH, US, analyzing singleton live births to multiparous mothers with recorded IPI (n = 393,441). Preterm birth rate at <37 weeks gestational age was compared between the referent pregnancy (defined as normal pre-pregnancy maternal BMI, IPI of 12-24 months, and Institute of Medicine (IOM) recommended PWG) and those with short or long IPI, abnormal BMI (underweight, overweight, and obese), and high or low PWG (under or exceeding IOM recommendations). Results Only 6 % of the women in this study had a referent pregnancy, with a preterm birth rate of 7.6 % for this group. Short IPIs of <6 and 6-12 months were associated with increased rates of preterm birth rate to 12.9 and 10.4 %, respectively. Low PWG compared to IOM recommendations for pre-pregnancy BMI class was also associated with increased preterm birth rate of 13.2 % for all BMI classes combined. However, the highest rate of preterm birth of 25.2 % occurred in underweight women with short IPI and inadequate weight gain with adjOR 3.44 (95 % CI 2.80, 4.23). The fraction of preterm births observed in this cohort that can be attributed to short IPIs is 5.9 %, long IPIs is 8.3 %, inadequate PWG is 7.5 %, and low pre-pregnancy BMI is 2.2 %. Conclusions Our analysis indicates that a significant proportion of preterm births in Ohio are associated with potentially modifiable risk factors. These data suggest public health initiatives focused on preterm birth prevention could include counseling and interventions to optimize preconception health and prenatal nutrition.

Racial disparity in previable birth.

BACKGROUND: Extremely preterm birth of a live newborn before the limit of viability is rare but contributes uniformly to the infant mortality rate because essentially all cases result in neonatal death. OBJECTIVE: The objective of the study was to quantify racial differences in previable birth and their contribution to infant mortality and to estimate the relative influence of factors associated with live birth occurring before the threshold of viability. STUDY DESIGN: This was a population-based retrospective cohort of all live births in Ohio over a 7 year period, 2006-2012. Demographic, pregnancy, and delivery characteristics of previable live births at 16 0/7 to 22 6/7 weeks of gestation were compared with a referent group of live births at 37 0/7 to 42 6/7 weeks. Rates of birth at each week of gestation were compared between black and white mothers, and relative risk ratios were calculated. Logistic regression estimated the relative risk of factors associated with previable birth, with adjustment for concomitant risk factors. RESULTS: Of 1,034,552 live births in Ohio during the study period, 2607 (0.25% of all live births) occurred during the previable period of 16-22 weeks. There is a significant racial disparity in the rate and relative risk of previable birth, with a 3- to 6-fold relative risk increase in black mothers at each week of previable gestational age. The incidence of previable birth for white mothers was 1.8 per 1000 and for black mothers, 6.9 per 1000. Factors most strongly associated with previable birth, presented as adjusted relative risk ratio (95% confidence interval [CI]), were maternal characteristics of black race adjusted relative risk 2.9 (95% CI, 2.6-3.2), age ≥ 35 years 1.3 (95% CI, 1.1-1.6), and unmarried 2.1 (95% CI, 1.8-2.3); fetal characteristics including congenital anomaly, 5.4 (95% CI, 3.4-8.1) and genetic disorder, 5.1 (95% CI, 2.5-10.1); and pregnancy characteristics including prior preterm birth 4.4 (95% CI, 3.7-5.2) and multifetal gestation, twin, 16.9 (95% CI, 14.4-19.8) or triplet, 65.4 (95% CI, 32.9-130.2). The majority, 80%, of previable births (16-22 weeks) were spontaneous in nature, compared with 73% in early preterm births (23-33 weeks), 72% in late preterm births (34-36 weeks), and 65% of term births (37-42 weeks) (P < .001). Previable births constituted approximately 28% of total infant mortalities in white newborns and 45% of infant mortalities in black infants in Ohio during the study period. CONCLUSION: There is a significant racial disparity in previable preterm births, with black mothers incurring a 3- to 6-fold increased relative risk compared with white mothers, most of which are spontaneous in nature. This may explain much of the racial disparity in infant mortality because all live-born previable preterm births result in death. Focused efforts on the prevention of spontaneous previable preterm birth may help to reduce the racial disparity in infant mortality.

Relationship of trimester-specific smoking patterns and risk of preterm birth.

BACKGROUND: In 2011, the US national rate of smoking early in pregnancy was 11.5%. Unfortunately, our home state of Ohio had a rate twice as high at 23%. Smoking in pregnancy remains one of the most important modifiable risk factors for pregnancy complications, specifically preterm birth. OBJECTIVE: The objective of the study was to quantify the preterm birth risk to various trimester-specific smoking behaviors. STUDY DESIGN: The study was a population-based, retrospective cohort study of singleton non-anomalous live births, using Ohio birth records 2006 to 2012. Preterm birth rates were compared between non-smokers and women who smoked in the preconception period only, those who quit smoking after the 1st and 2nd trimesters, and those who smoked throughout pregnancy. Multivariate logistic regression quantified the risk of smoking with cessation at various times in pregnancy and preterm birth risk, adjusted for maternal race, education, age, Medicaid use, marital status, and parity. A stratified analysis was performed on the basis of preterm birth subtype: spontaneous preterm birth versus indicated preterm birth. We also performed an additional analysis stratifying for maternal race using the 2 largest categories of race (non-Hispanic white and non-Hispanic black). RESULTS: Of the 913,757 birth records analyzed, nearly 25% of the women reported some smoking behavior on the birth certificate data. Of smokers, less than half quit during pregnancy (38.8% vs 61.2% smoked throughout pregnancy). Early quitters had a similar preterm birth rate compared with non-smokers. Women who smoked through the 1st trimester only did not have a significant increase in their overall preterm birth odds ratio <37 weeks; however, it did increase the odds of extreme preterm birth <28 weeks by 20% (adjusted odds ratio, 1.20; 95% confidence interval [CI], 1.02, 1.40). Quitting late in pregnancy resulted in the highest odds ratio increase: 70% for preterm birth <37 weeks (adjusted odds ratio 1.70; CI, 1.60, 1.80), even after adjustment for the confounding influences. Quitting smoking early in pregnancy after the 1st trimester did not increase the overall risk of spontaneous or indicated preterm birth <37 weeks significantly. However, quitting after the 1st trimester was associated with a significant increase in risk of extreme spontaneous preterm birth <28 weeks, an effect not seen with indicated preterm birth <28 weeks. Delaying cessation until late in pregnancy-after the 2nd trimester-was associated with the highest risk increases, 65% increased odds of spontaneous and 78% increase in odds of indicated preterm births. The rate of preterm births to non-Hispanic black mothers was increased in all categories over those of non-Hispanic white mothers. The relative influence of smoking cessation in pregnancy was similar in black compared with white mothers. The effect modification in the regression model was analyzed and revealed no significant interaction between race and smoking patterns on preterm birth risk. CONCLUSION: Smoking throughout pregnancy is associated with an increased risk of preterm birth. However, quitting early in pregnancy negates this risk. Widespread programs aimed at smoking cessation early in pregnancy could have a significant impact on reducing the rate of preterm birth nationally.

Factors Associated with Smoking Cessation in Pregnancy.

Objective The objective of this study was to quantify the influence of various patient characteristics on early smoking cessation to better identify target populations for focused counseling and interventions. Study Design This study was a population-based retrospective cohort study of 1,003,532 Ohio live births more than 7 years (2006-2012). Women who quit smoking in the first trimester were compared with those who smoked throughout pregnancy. Logistic regression estimated the strength of association between patient factors and smoking cessation. Results The factors most strongly associated with early smoking cessation were non-white race and Hispanic ethnicity, at least some college education, early prenatal care, marriage, and breastfeeding. Numerous factors commonly associated with adverse perinatal outcomes were found to have a negative association with smoking cessation: low educational attainment, limited or late prenatal care, prior preterm birth, age < 20 years, age ≥ 35 years, and indicators of low SES. In addition, the heaviest smokers (≥ 20 cigarette/day) were least likely to quit (adjusted relative risk [RR], 0.35; 95% confidence interval 0.34, 0.36). Conclusion Early prenatal care and initiation of breastfeeding before discharge from the hospital are associated with increased RR of quitting early in pregnancy by 52 and 99%, respectively. Public health initiatives and interventions should focus on the importance of early access to prenatal care and education regarding smoking cessation for these particularly vulnerable groups of women who are at inherently high risk of pregnancy complications.