Weight Bias in the Perinatal Period: An Integrative Review.

BACKGROUND: Weight bias toward individuals with higher body weights in healthcare settings is associated with adverse health behaviors, reduced healthcare utilization, and poor health outcomes. The purpose of this integrative review was to explore: (1) What has been measured and described regarding perinatal care providers' and students' weight bias toward pregnant, birthing, and postpartum individuals with higher body weights? (2) What has been measured and described regarding pregnant, birthing, and postpartum individuals' experiences of weight bias? (3) What is the association of experiences of weight bias with perinatal and mental health outcomes among pregnant, birthing, and postpartum individuals? METHODS: We conducted a systematic search in CINAHL, PubMed, and PsycINFO databases to identify relevant research publications related to the Medical Subject Headings (MeSH) terms weight prejudice (and related terms) and pregnancy (and related terms). The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Johns Hopkins Nursing Evidence-Based Practice model for study quality determination, and the Whittemore and Knafl integrative review framework for data extraction and analyses. RESULTS: Twenty-two publications met inclusion criteria, representing six countries and varying study designs. This review found pervasive sources of explicit weight bias in the perinatal period, including care providers and close relationships. Experiences of weight bias among pregnant and postpartum individuals are associated with adverse perinatal and mental health outcomes. DISCUSSION: The findings address a knowledge gap regarding a summary of literature on weight bias in the perinatal period and elucidate its prevalence as well as its negative influence on perinatal and mental health outcomes. Future research efforts on this topic must examine the nature and extent of perinatal care providers' weight bias by demographic factors and explore its association with clinical decision-making and perinatal and mental health outcomes.

Neonatal morbidity and mortality in birth centers in the United States 2018-2021: An observational study of low-risk birthing individuals.

BACKGROUND: Many studies reporting neonatal outcomes in birth centers include births with risk factors not acceptable for birth center care using the evidence-based CABC criteria. Accurate comparisons of outcomes by birth setting for low-risk patients are needed. METHODS: Data from the public Natality Detailed File from 2018 to 2021 were used. Logistic regression, including adjusted and unadjusted odds ratios, compared neonatal outcomes (chorioamnionitis, Apgar scores, resuscitation, intensive care, seizures, and death) between centers and hospitals. Covariates included maternal diabetes, body mass index, age, parity, and demographic characteristics. RESULTS: The sample included 8,738,711 births (8,698,432 (99.53%) in hospitals and 40,279 (0.46%) in birth centers). There were no significant differences in neonatal deaths (aOR 1.037; 95% CI [0.515, 2.088]; p-value 0.918) or seizures (aOR 0.666; 95% CI [0.315, 1.411]; p-value 0.289). Measures of morbidity either not significantly different or less likely to occur in birth centers compared to hospitals included chorioamnionitis (aOR 0.032; 95% CI [0.020, 0.052]; p-value < 0.001), Apgar score < 4 (aOR 0.814, 95% CI [0.638, 1.039], p-value 0.099), Apgar score < 7 (aOR 1.075, 95% CI [0.979, 1.180], p-value 0.130), ventilation >6 h (aOR 0.349; [0.281,0.433], p-value < 0.001), and intensive care admission (aOR 0.356; 95% CI [0.328, 0.386], p-value < 0.001). Birth centers had higher odds of assisted neonatal ventilation for <6 h as compared to hospitals (aOR 1.373; 95% CI [1.293, 1.457], p-value < 0.001). CONCLUSION: Neonatal deaths and seizures were not significantly different between freestanding birth centers and hospitals. Chorioamnionitis, Apgar scores < 4, and intensive care admission were less likely to occur in birth centers.

"I had no choice": A mixed-methods study on access to care for vaginal breech birth.

INTRODUCTION: Although current recommendations support vaginal breech birth as a reasonable option, access to breech birth in US hospitals is limited. This study explored the experiences of decision-making and perceptions of access to care in people who transferred out of the hospital system to pursue home breech birth. METHODS: We conducted a mixed methods study of people with a singleton, term breech fetus who transferred out of the US hospital system to pursue home breech birth. Twenty-five people completed an online demographic and psychosocial survey, and 23 (92%) participated in semi-structured interviews. We used an interpretive description approach informed by situational analysis to analyze qualitative data about participants' experiences and perceived access to care. RESULTS: Of 25 individuals who left the hospital system to pursue a home breech birth, most felt denied informed choice (64%) and threatened or coerced into cesarean (68%). The majority reported low or very low autonomy in decision-making (n = 20, 80%) and high decisional satisfaction using validated measures. Many participants felt safer in a hospital setting but were not able to access care for planned vaginal breech hospital birth, despite extensive efforts. Participants felt "backed into a corner" and "forced into homebirth," perceiving a lack of access to safe and respectful care in the hospital system. CONCLUSION: Some service users believe that home birth is their only option when they cannot access hospital-based care for vaginal breech birth. Current barriers to care for breech birth limit birthing people's autonomy and may be placing them and their infants at increased risk.

Comparing Cesarean Birth Utilization Between US Hospitals: A Demonstration of the Robson Ten-Group Classification System for Use in Quality Improvement and Benchmarking.

BACKGROUND: The World Health Organization-endorsed Robson Ten-Group Classification System (TGCS) is a standard reporting mechanism for cesarean birth, yet this approach is not widely adopted in the United States. OBJECTIVE: To describe the application and utility of the TGCS to compare hospital-level cesarean births rates, for use in quality improvement and benchmarking. METHODS: We conducted a descriptive, secondary data analysis of the Consortium on Safe Labor dataset using data from 228 438 women's births, from 2002 to 2008, in 12 sites across the United States. We stratified births into 10 mutually exclusive groups and calculated within-group proportions of group size and cesarean birth rates for between-hospital comparisons of cesarean birth, trial of labor after cesarean (TOLAC), and labor induction utilization. RESULTS: There is variation in use of cesarean birth, labor induction, and TOLAC across the 12 sites. CONCLUSION: The TGCS provides a method for between-hospital comparisons, particularly for revealing usage patterns of labor induction, TOLAC, and cesarean birth. Adoption of the TGCS in the United States would provide organizations and quality improvement leaders with an effective benchmarking tool to assist in reducing the use of cesarean birth and increasing the support of TOLAC.

Challenges in the Triage Care of Low-Risk Laboring Patients: A Comparison of 2 Models of Practice.

Triage and the timing of admission of low-risk pregnant women can affect the use of augmentation, epidural, and cesarean. The purpose of this analysis was to explore these outcomes in a community hospital by the type of provider staffing triage. This was a retrospective cohort study of low-risk nulliparous women with a term, vertex fetus laboring in a community hospital. Bivariate and multivariable statistics evaluated associations between triage provider type and labor and birth outcomes. Patients in this sample (N = 335) were predominantly White (89.5%), with private insurance (77.0%), and married (71.0%) with no significant differences in these characteristics by triage provider type. Patients admitted by midwives had lower odds of oxytocin augmentation (adjusted odds ratio [aOR] = 0.50, 95% confidence interval [CI] = 0.29-0.87), epidural (aOR = 0.29, 95% CI = 0.12-0.69), and cesarean birth (aOR = 0.308, 95% CI = 0.14-0.67), compared with those triaged by physicians after controlling for patient characteristics and triage timing. This study provides additional context to midwives as labor triage providers for healthy, low-risk pregnant individuals; however, challenges persisted with measurement. More research is needed on the specific components of care during labor that support low-risk patients to avoid medical interventions and poor outcomes.

The association between longer durations of the latent phase of labor and subsequent perinatal processes and outcomes among midwifery patients.

BACKGROUND/OBJECTIVE: To evaluate the association between the duration of the latent phase of labor and subsequent processes and outcomes. METHODS: Secondary analysis of prospectively collected data among 1,189 women with low-risk pregnancies and spontaneous labor. RESULTS: Longer latent phase duration was associated with labor dystocia (eg, nulliparous ≥ mean [compared with < mean] aOR 3.95 [2.70-5.79]; multiparous ≥ mean [compared with < mean] aOR 5.45 [3.43-8.65]), interventions to ameliorate dystocia, and epidurals to cope or rest (eg, oxytocin augmentation: nulliparous > 80th% [compared with < 80th%] aOR 6.39 [4.04-10.12]; multiparous ≥ 80th% [compared with < 80th%] aOR 6.35 [3.79-10.64]). Longer latent phase duration was also associated with longer active phase and second stage. There were no associations between latent phase duration and risk for cesarean delivery or postpartum hemorrhage in a practice setting with relatively low rates of primary cesarean. Newborns born to multiparous women with latent phase of labor durations at and beyond the 80th% were more frequently admitted to the NICU (≥80th% [compared with < 80th%] aOR 2.7 [1.22-5.84]); however, two-thirds of these NICU admissions were likely for observation only. CONCLUSIONS: Longer duration of the spontaneous latent phase of labor among women with low-risk pregnancies may signal longer total labor processes, leading to an increase in diagnosis of dystocia, interventions to manage dystocia, and epidural use. Apart from multiparous neonatal NICU admission, no other maternal or child morbidity outcomes were elevated with longer duration of the latent phase of labor.

Influence of midwifery presence in United States centers on labor care and outcomes of low-risk parous women: A Consortium on Safe Labor study.

BACKGROUND: Sixty percent of United States births are to multiparous women. Hospital-level policies and culture may influence intrapartum care and birth outcomes for this large population, yet have been poorly explored using a large, diverse sample. We sought to use national United States data to analyze the association between midwifery presence in maternity care teams and the birth processes and outcomes of low-risk parous women. METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk parous women in either interprofessional care (n = 12 125) or noninterprofessional care centers (n = 8996). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to assess processes and outcomes. RESULTS: There was concordance in outcome differences across regression models. With propensity score matching, women at interprofessional centers, compared with women at noninterprofessional centers, were 85% less likely to have labor induced (risk ratio [RR] 0.15; 95% CI 0.14-0.17). The risk for primary cesarean birth among low-risk parous women was 36% lower at interprofessional centers (RR 0.64; 95% CI 00.52-0.79), whereas the likelihood of vaginal birth after cesarean for this population was 31% higher (RR 1.31; 95% CI 1.10-1.56). There were no significant differences in neonatal outcomes. CONCLUSIONS: Parous women have significantly higher rates of vaginal birth, including vaginal birth after cesarean, and lower likelihood of labor induction when cared for in centers with midwives. Our findings are consistent with smaller analyses of midwifery practice and support integrated, team-based models of perinatal care to improve maternal outcomes.

Midwifery presence in United States medical centers and labor care and birth outcomes among low-risk nulliparous women: A Consortium on Safe Labor study.

BACKGROUND: The presence of midwives in a health system may affect perinatal outcomes but has been inadequately described in United States settings. Our objective was to compare labor processes and outcomes for low-risk nulliparous women birthing in United States medical centers with interprofessional care (midwives and physicians) versus noninterprofessional care (physicians only). METHODS: We conducted a retrospective cohort study using Consortium on Safe Labor data from low-risk nulliparous women who birthed in interprofessional (n = 7393) or noninterprofessional centers (n = 6982). Unadjusted, adjusted (age, race, health insurance type), propensity-adjusted, and propensity-matched logistic regression models were used to compare outcomes. RESULTS: There was concordance across logistic regression models, the most restrictive and conservative of which were propensity-matched models. With this approach, women at interprofessional medical centers, compared with women at noninterprofessional centers, were 74% less likely to undergo labor induction (risk ratio [RR] 0.26; 95% CI 0.24-0.29) and 75% less likely to have oxytocin augmentation (RR 0.25; 95% CI 0.22-0.29). The cesarean birth rate was 12% lower at interprofessional centers (RR 0.88; 95% CI 0.79-0.98). Adverse neonatal outcomes occurred in only 0.3% of births and were thus too rare to be modeled. CONCLUSIONS: The care processes and birth outcomes at interprofessional and noninterprofessional medical centers differed significantly. Nulliparous women receiving care at interprofessional centers were less likely to experience induction, oxytocin augmentation, and cesarean than women at noninterprofessional centers. Labor care and birth outcome differences between interprofessional and noninterprofessional centers may be the result of the presence of midwives and interprofessional collaboration, organizational culture, or both.

Describing latent phase duration and associated characteristics among 1281 low-risk women in spontaneous labor.

BACKGROUND: Recent research suggests that latent phase of labor may terminate at 6 rather than 4 centimeters of cervical dilation. The objectives of this study were to: (a) characterize duration of the latent phase of labor among term, low-risk, United States women in spontaneous labor using the women's self-identified onset; and (b) quantify associations between demographic and maternal/newborn health characteristics and the duration of the latent phase. METHODS: This prospective study (n = 1281) described the duration of the latent phase of labor in hours, stratified by parity at the mean, median, and 80th, 90th, and 95th percentiles. The duration of the latent phase was compared for each characteristic using t tests or Wilcoxon rank-sum tests and regression models that controlled for confounders. RESULTS: In this sample of predominantly white, healthy women, duration of the latent phase of labor was longer than described in previous studies: The median duration was 9.0 hours and mean duration was 11.8 hours in nulliparous women. The median duration was 6.8 hours and mean duration was 9.3 hours in multiparous women. Among nulliparous women, longer duration was seen in women whose fetus was in a malposition. Among multiparous women, longer durations were noted in women with chorioamnionitis and those who gave birth between 41 and 41 + 6 weeks' gestation (vs between 40 and 40 + 6 weeks' gestation). CONCLUSIONS: The latent phase of labor may be longer than previously estimated. Contemporary estimates of latent phase of labor duration will help women and providers accurately anticipate, prepare, and cope during spontaneous labor.

Applying a physiologic partograph to Consortium on Safe Labor data to identify opportunities for safely decreasing cesarean births among nulliparous women.

BACKGROUND: The timing of hospital admission for women with spontaneous labor onset and the criteria used to assess active labor progress and diagnose labor dystocia may significantly influence women's risk for primary cesarean birth. Our aims were to assess associations of labor status at admission (i.e., preactive or active) and active labor progress (i.e., dystocic or physiologic) with oxytocin augmentation, cesarean birth, and adverse neonatal outcome rates. METHODS: A sample of low-risk, nulliparous women admitted to hospitals for spontaneous labor onset was extracted from the Consortium on Safe Labor (n = 27 077). Binomial logistic regression was used to assess associations between labor classifications and outcomes. RESULTS: At admission, 68.0% of women were in preactive labor and 32.0% were in active labor. Cesarean rates for these groups were 18.0% and 7.2%, respectively (adjusted odds ratio [AOR] 2.69; 95% CI 2.45-2.96). Oxytocin augmentation and adverse neonatal outcomes were more likely for women admitted in preactive labor. Among women admitted in active labor, 9.3% experienced labor dystocia and 90.7% progressed physiologically. Cesarean rates for these groups were 20.4% and 5.9%, respectively (AOR 3.02; 95% CI 2.45-3.73). Nearly half of the cesareans performed for dystocia among women admitted in active labor occurred when cervical dilation was physiologic. Oxytocin augmentation and adverse neonatal outcomes were more likely when active labor was dystocic. CONCLUSIONS: Adoption of evidence-based, standardized approaches for diagnosing active labor onset, assessing labor progress, and diagnosing dystocia may safely decrease oxytocin augmentation and cesarean birth rates in the United States.

Authorship grids: Practical tools to facilitate collaboration and ethical publication.

Publication of new findings and approaches in peer-reviewed journals is fundamental to advancing science. As interprofessional, team-based scientific publication becomes more common, authors need tools to guide collaboration and ethical authorship. We present three forms of authorship grids that are based on national and international author recommendations, including guidelines from the International Committee of Medical Journal Editors, the Committee on Publication Ethics, National Institutes of Health data sharing policies, common reporting guidelines, and Good Clinical Practice standards from the International Conference on Harmonization. The author grids are tailored to quantitative research, qualitative research, and literature synthesis. These customizable grids can be used while planning and executing projects to define each author's role, responsibilities, and contributions as well as to guide conversations among authors and help avoid misconduct and disputes. The grids also can be submitted to journal editors and published to provide public attribution of author contributions.

Likelihood of cesarean delivery after applying leading active labor diagnostic guidelines.

BACKGROUND: Friedman, the United Kingdom's National Institute for Health and Care Excellence (NICE), and the American College of Obstetricians and Gynecologists/Society for Maternal-Fetal Medicine (ACOG/SMFM) support different active labor diagnostic guidelines. Our aims were to compare likelihoods for cesarean delivery among women admitted before vs in active labor by diagnostic guideline (within-guideline comparisons) and between women admitted in active labor per one or more of the guidelines (between-guideline comparisons). DESIGN: Active labor diagnostic guidelines were retrospectively applied to cervical examination data from nulliparous women with spontaneous labor onset (n = 2573). Generalized linear models were used to determine outcome likelihoods within- and between-guideline groups. RESULTS: At admission, 15.7%, 48.3%, and 10.1% of nulliparous women were in active labor per Friedman, NICE, and ACOG/SMFM diagnostic guidelines, respectively. Cesarean delivery was more likely among women admitted before vs in active labor per the Friedman (AOR 1.75 [95% CI 1.08-2.82] or NICE guideline (AOR 2.55 [95% CI 1.84-3.53]). Between guidelines, cesarean delivery was less likely among women admitted in active labor per the NICE guideline, as compared with the ACOG/SMFM guideline (AOR 0.55 [95% CI 0.35-0.88]). CONCLUSION: Many nulliparous women are admitted to the hospital before active labor onset. These women are significantly more likely to have a cesarean delivery. Diagnosing active labor before admission or before intervention to speed labor may be one component of a multi-faceted approach to decreasing the primary cesarean rate in the United States. The NICE diagnostic guideline is more inclusive than Friedman or ACOG/SMFM guidelines and its use may be the most clinically useful for safely lowering cesarean rates.

Hyperemesis gravidarum: a holistic overview and approach to clinical assessment and management.

Hyperemesis gravidarum (HG) is a rare and severe form of nausea and vomiting of pregnancy associated with significant costs and psychosocial impacts. The etiology of HG remains largely unknown, although maternal genetics and placental factors are suspected. Prompt recognition and treatment of HG are essential to minimize associated maternal and fetal morbidity. Diagnosis is made on the basis of typical presentation, with exclusion of other causes of severe nausea and vomiting of pregnancy. Validated clinical tools are available to assess severity of symptoms and guide plans of care. Evidence to guide management of HG is limited, but many nonpharmacologic and pharmacologic interventions are available with published guidelines to inform implementation. Care of the woman with HG requires compassion and acknowledgement of individual needs and responses to interventions.

Acute Cystitis in a Transfeminine Patient: Assessment and Treatment of Urinary Tract Symptoms.

Management of acute cystitis in a transfeminine patient is discussed as an example of treatment of urinary tract infections (UTIs). The case is an introduction for clinicians who typically care for cisgender women and wish to expand the populations they serve to include care of gender-diverse individuals. This is supportive of the 2021 American College of Nurse-Midwives Position Statement on Health Care for Transgender and Gender Non-Binary People. Possible differential diagnoses for urinary symptoms in transfeminine patients are discussed, as well as relevant history taking, examination skills, and treatment guidelines for acute cystitis of patients with penises along with discussion of basic care for transgender individuals seeking midwifery or primary care services.

Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study.

OBJECTIVE: Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling). DESIGN: Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats). SETTING: Planned community birth (homes and birth centers), United States. SAMPLE: Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset. METHODS: Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes. MAIN OUTCOME MEASURES: Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death. RESULTS: One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded. CONCLUSIONS: All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.

Implicit and Explicit Weight Bias among Midwives: Variations Across Demographic Characteristics.

INTRODUCTION: Weight bias toward individuals with higher body weights is present in health care settings. However, there has been limited quantitative exploration into weight bias among perinatal care providers and its potential variations based on demographic characteristics. The aim of this study was to examine if the direction and extent of weight bias among midwives certified by the American Midwifery Certification Board (AMCB) varied across age, years since certification, body mass index (BMI), race, ethnicity, and US geographic region. METHODS: Through direct email listservs, postcard distribution, social media accounts, and professional networks, midwives were invited to complete an online survey of their implicit weight bias (using the Implicit Association Test) and their explicit weight bias using the Anti-Fat Attitudes Questionnaire (AFA), Fat Phobia Scale (FPS), and Preference for Thin People (PTP) measure. RESULTS: A total of 2106 midwives who identified as Black or White and resided in one of 4 US geographic regions participated in the survey. Midwives with a lower BMI expressed higher levels of implicit (P <.01) and explicit (P ≤.01) weight bias across all 4 measures except for the AFA Fear of Fat Subscale. Implicit weight bias levels also varied by age (P <.001) and years since certification (P <.001), with lower levels among younger midwives (vs older) and those with fewer years (vs more) since certification. Only age and BMI remained significant (P <.001) after adjusting for other demographic characteristics. Lower explicit weight bias levels were found among midwives who identified as Black (vs White) on 2 measures (FPS: adjusted ß = -0.07, P = .004; PTP: P = .01). DISCUSSION: This was the first quantitative study of how weight bias varies across demographic characteristics among a national sample of midwives. Further exploration is needed in more diverse samples. In addition, research to determine whether weight bias influences clinical decision-making and quality of care is warranted.

Weight Bias Among Certified Nurse-Midwives and Certified Midwives: Findings From a National Sample.

INTRODUCTION: Weight bias toward individuals with higher body weights permeates health care settings in the United States and has been associated with poor weight-related communication and quality of care as well as adverse health outcomes. However, there has been limited quantitative investigation into weight bias among perinatal care providers. Certified nurse-midwives (CNMs)/certified midwives (CMs) attend approximately 11% of all births in the United States. The aims of this study were to measure the direction and extent of weight bias among CNMs/CMs and compare their levels of weight bias to the US public and other health professionals. METHODS: Through direct postcard distribution, social media accounts, professional networks, and email listservs, American Midwifery Certification Board (AMCB)-certified midwives were solicited to complete an online survey of their implicit weight bias using the Implicit Association Test and their explicit weight bias using the Antifat Attitudes Questionnaire, Fat Phobia Scale, and Preference for Thin People measure. RESULTS: A total of 2257 midwives participated in the survey, yielding a completion rate of 17.7%. Participants were mostly White and female, with a median age of 46 years and 11 years since AMCB certification. More than 70% of midwives have some level of implicit weight bias, although to a lesser extent compared with previously published findings among the US public (P < .01) and other health professionals (P < .01). In a subsample comparison of female midwives to female physicians, implicit weight bias levels were similar (P > .05). Midwives also express explicit weight bias, but at lower levels than the US public and other health professionals (P < .05). DISCUSSION: This study provides the first quantitative research documenting weight bias among a national US sample of perinatal care providers. Findings can inform educational efforts to mitigate weight bias in the perinatal care setting and decrease harm.

Sex and Gender Variables in Data Set Creation and Data Cleaning for Inclusive and Accurate Reproductive Health Research and Quality Improvement.

INTRODUCTION: Existing data is often used for reproductive research and quality improvement. Electronic health records (EHRs) with a single data field for sex and gender conflate sex assigned at birth, genotype, gender identity, and the presence of anatomic tissue and organs. This is problematic for inclusion of transgender and gender-diverse populations in research. This article discusses considerations with a single-item sex and gender variable drawn from EHR records and describes an audit to determine variable validity as a criterion for inclusion or exclusion in perinatal research. METHODS: Individuals with a live birth at a large academic medical center from 2010 to 2022 were identified via electronic query, and records with male demographic information were reviewed to validate (1) the patient's date of birth and delivery date in the EHR matched the medical record number, (2) male sex and gender demographic information, and (3) male gender terms in EHR notes. RESULTS: All health records of male birthing individuals (n = 8) had EHR evidence of giving birth within the health system during the timeframe, and the date of birth matched the medical record number of the EHR. All had male gender in the EHR demographic information. Six patients did not have any male gender terms in available EHR notes, only female gender terms. Two records had recent notes using male gender terms. DISCUSSION: Current EHRs may not have reliable data on the gender and sex of gender-diverse individuals. A single sex and gender variable drawn from EHRs should not be used as inclusion or exclusion criteria for health research or quality improvement without additional record review. EHRs can be updated to collect more data on sex, gender identity, and other relevant variables to improve research and quality improvement.

Performance of Phenotype Algorithms for the Identification of Opioid-Exposed Infants.

OBJECTIVE: Observational studies examining outcomes among opioid-exposed infants are limited by phenotype algorithms that may under identify opioid-exposed infants without neonatal opioid withdrawal syndrome (NOWS). We developed and validated the performance of different phenotype algorithms to identify opioid-exposed infants using electronic health record data. METHODS: We developed phenotype algorithms for the identification of opioid-exposed infants among a population of birthing person-infant dyads from an academic health care system (2010-2022). We derived phenotype algorithms from combinations of 6 unique indicators of in utero opioid exposure, including those from the infant record (NOWS or opioid-exposure diagnosis, positive toxicology) and birthing person record (opioid use disorder diagnosis, opioid drug exposure record, opioid listed on medication reconciliation, positive toxicology). We determined the positive predictive value (PPV) and 95% confidence interval for each phenotype algorithm using medical record review as the gold standard. RESULTS: Among 41 047 dyads meeting exclusion criteria, we identified 1558 infants (3.80%) with evidence of at least 1 indicator for opioid exposure and 32 (0.08%) meeting all 6 indicators of the phenotype algorithm. Among the sample of dyads randomly selected for review (n = 600), the PPV for the phenotype requiring only a single indicator was 95.4% (confidence interval: 93.3-96.8) with varying PPVs for the other phenotype algorithms derived from a combination of infant and birthing person indicators (PPV range: 95.4-100.0). CONCLUSIONS: Opioid-exposed infants can be accurately identified using electronic health record data. Our publicly available phenotype algorithms can be used to conduct research examining outcomes among opioid-exposed infants with and without NOWS.

Expanding primary care opportunities: simulation for clinical reasoning.

Many nurse practitioner specialties are requiring that basic primary care be included in their curricula. However, some experienced faculty within the specialty lack primary care experience. With a national shortage of nursing faculty, it is more important than ever to maximize available resources without overtaxing faculty workloads. Revision of our primary care practicum allowed nurse-midwifery faculty to lead a primary care clinical conference, using Family Nurse Practitioner (FNP) faculty as primary care experts. We revamped the clinical conference time to simulate clinical visits to guide the students through the clinical reasoning process. Low-fidelity simulation allowed students time to take a systematic approach to patient assessment, planning, and charting. The FNP "experts" were used to critique student chart notes prior to grading. This collaborative approach to the primary care clinical conference was well received by students, faculty, and preceptors and was quick and inexpensive to implement.