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To evaluate whether patient-prescriber racial and ethnic concordance is associated with postpartum opioid prescribing patterns and patient-reported pain scores.This is a retrospective cohort study of patients who delivered at a tertiary care center between December 1, 2015 and November 30, 2016. Self-identified non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic, or Asian patients were included. Patient-prescriber pairs were categorized as racially and ethnically concordant if they shared the same racial and ethnic identity; the prescriber was defined as the obstetrical provider who was responsible for the postpartum discharge of the patient. Multivariable regression models controlling for demographic and clinical confounders were used to assess the relationship of patient-prescriber racial and ethnic concordance with receipt of an opioid prescription and patient-reported pain score at discharge.Of 10,242 patients included in this analysis, 62.3% identified as NHW, 19.1% Hispanic, 9.7% NHB, and 8.9% Asian. About half (52.8%) of patients were discharged by a racially and ethnically concordant prescriber. Patient-prescriber racial and ethnic concordance was not associated with receipt of an opioid prescription (adjusted odds ratio [aOR] 0.82, confidence interval [95% CI] 0.67-1.00) or reporting a pain score ≥5 (aOR 0.90, 95% CI 0.69-1.16). However, NHB and Hispanic patients were less likely to receive an opioid prescription (aOR 0.73, 95% CI 0.56-0.95; aOR 0.73, 95% CI 0.57-0.92, respectively) and significantly more likely to report a pain score ≥5 (aOR 2.13, 95% CI 1.51-3.00; aOR 1.48 95% CI 1.08-2.01, respectively) than NHW patients, even when accounting for concordance.Disparities in postpartum opioid prescribing and pain perception are not ameliorated by patient-prescriber racial and ethnic concordance.

Gestational and pregestational diabetes during pregnancy are substantial and growing public health issues. Low-income individuals and individuals who identify as racial and ethnic minorities are disproportionately affected. Food security, which is defined as the degree to which individuals have capacity to access and obtain food, is at the center of nutritional resources and decisions for individuals with diabetes. While increasingly recognized as an important mediator of health disparities in the United States, food insecurity is understudied during pregnancy and specifically among pregnant individuals with diabetes, for whom the impact of food-related resources may be even greater. Previous research has suggested that food insecurity is associated with type 2 diabetes mellitus diagnoses and disease exacerbation in the general adult population. An emerging body of research has suggested that food insecurity during pregnancy is associated with gestational diabetes mellitus diagnoses and adverse diabetes-related outcomes. Additionally, food insecurity during pregnancy may be associated with adverse maternal and neonatal outcomes. Future research and clinical work should aim to further examine these relationships and subsequently develop evidence-based interventions to improve diabetes-related outcomes among pregnant individuals with food insecurity. The purpose of this article is to offer a working definition of food security, briefly review issues of food insecurity and diabetes, summarize research on food insecurity and diabetes-related pregnancy health, and discuss clinical recommendations and areas for future investigation. KEY POINTS: · Research on food insecurity and diabetes-related health is limited.. · The impact of food security on diabetes management and obstetric outcomes is likely significant.. · Future work to evaluate perinatal food security screening is warranted..

Objective The experience of an unplanned cesarean birth may be a risk factor for mood disorders and other challenges in the postpartum period, yet qualitative data on the patient experience are limited. We sought to understand individuals' experiences of having an unplanned cesarean birth. Study Design This was a secondary analysis of a prospective qualitative investigation among low-income postpartum individuals at a single-, tertiary-care center in which the primary aim was to evaluate patients' postpartum pain experience after a cesarean birth. Participants completed a 60-minute face-to-face interview on postpartum days 2 to 3. Only participants who labored prior to their cesarean birth were included in this analysis. Transcripts were analyzed by two separate authors using the constant comparative method. Themes are illustrated using direct quotes. Results A total of 22 individuals were included in this analysis; the majority (n=16, 72.7%) experienced a primary cesarean birth. Over half (n=12, 54.5%) identified as Hispanic and one-third (n=7, 31.8%) identified as non-Hispanic Black race and ethnicity. Four themes regarding the experience of a cesarean birth after labor were identified, including feelings of anguish, belief that vaginal birth is “normal,” poor experiences with care teams, and feelings of self-efficacy. Subthemes were identified and outlined. Conclusion In this cohort, individuals who experienced an unplanned cesarean birth after labor expressed feelings of self-blame, failure, and mistrust. Given the association of unplanned cesarean birth with mood disorders in the postpartum period, efforts to enhance communication and support may offer a means of improving individual experiences.Key Points

Obstetrical clinical trials are the foundation of evidence-based medicine during pregnancy. As more obstetrical trials are conducted, understanding the publication characteristics of these trials is of utmost importance to advance obstetrical health.This study aimed to characterize the frequency of publication and trial characteristics associated with publication among obstetrical clinical trials in the United States. We additionally sought to examine time from trial completion to publication.This was a cross-sectional analysis of completed obstetrical trials with an intervention design and at least 1 site in the United States registered to ClinicalTrials.gov from 2007 to 2019. Trial characteristics were cross-referenced with PubMed to determine publication status up to 2021 using the National Clinical Trial identification number. Bivariable analyses were conducted to determine trial characteristics associated with publication. Multivariable logistic regression models controlling for prespecified covariates were generated to estimate the relationship between funding, primary purpose, and therapeutic foci with publication. Additional exploratory analyses of other trial characteristics were conducted. Time to publication was analyzed using Kaplan-Meier curves and Cox regression models.Of the 1879 obstetrical trials with registered completion, a total of 575 (30.6%) had at least 1 site in the United States, were completed before October 1, 2019, and were included in this analysis. Between October 2007 and October 2019, fewer than two-thirds (N=348, 60.5%) of trials reached publication. Annual rates of publication ranged from 46.4% in 2018 to 70.0% in 2007. No difference was observed in publication by funding, primary purpose, or therapeutic foci (all P.05). Trials with characteristics indicating high trial quality-including randomized allocation scheme, ≥50 participants enrolled, ≥2 sites, and presence of a data safety monitoring committee-had increased odds of publication compared with those without such characteristics (all P.05). For example, studies with randomized allocation of intervention had 2-fold greater odds of publication than nonrandomized studies (adjusted odds ratio, 2.09; 95% confidence interval, 1.30-3.37). Studies with ≥150 participants had nearly 8-fold odds of publication (adjusted odds ratio, 7.90; 95% confidence interval, 3.78-17.49) relative to studies with50 participants. Temporal analysis demonstrated variability in time to publication among obstetrical trials, with a median time of 20.1 months after trial completion, and with most trials that reached publication having been published by 40 months. No difference was observed in time to publication by funding, primary purpose, or therapeutic foci (all P.05).Publication of obstetrical trials remains suboptimal, with significant differences observed between trials with indicators of high quality and those without. Most trials that reach publication are published within 2 years of registered completion on ClinicalTrials.gov.

Objective The objective was to assess temporal trends in postpartum opioid prescribing, opioid use, and pain control satisfaction. Study Design This is a prospective observational study of postpartum patients who delivered at a large tertiary care center (May 2017–July 2019). Inpatient patients were screened for eligibility; those meeting eligibility criteria who used inpatient opioids were approached for prospective survey participation which probed inpatient and outpatient postpartum pain control. The amount of opioids used during inpatient hospitalization and the amount of opioids prescribed at discharge were obtained from medical records. The primary outcome was the difference in opioid prescribing at discharge over time, measured by (1) the proportion of participants who received an opioid prescription at discharge and (2) for those who received an opioid prescription, the total morphine milligram equivalents of the prescription. Additional outcomes were inpatient and outpatient opioid use and patient-reported satisfaction with postpartum pain control. Trends over time were evaluated using nonparametric tests of trend. Results Of 2,503 postpartum patients screened for eligibility, a majority (N = 1,425; 60.8%) did not use an opioid as an inpatient. Over the study period, there was a significant decline in the proportion of patients who used an opioid while inpatient (z-score = − 11.8; p Conclusion In this population, both the frequency and amount of opioid use in the postpartum period declined from 2017 to 2019. This decrease in opioid prescribing was not associated with changes in patient-reported satisfaction with pain control. Key Points

ImportanceClinical trials guide evidence-based obstetrics and gynecology (OB-GYN) but often enroll nonrepresentative participants.ObjectiveTo characterize race and ethnicity reporting and representation in US OB-GYN clinical trials and their subsequent publications and to analyze the association of subspecialty and funding with diverse representation.Design and SettingCross-sectional analysis of all OB-GYN studies registered on ClinicalTrials.gov (2007-2020) and publications from PubMed and Google Scholar (2007-2021). Analyses included logistic regression controlling for year, subspecialty, phase, funding, and site number. Data from 332 417 studies were downloaded. Studies with a noninterventional design, with a registration date before October 1, 2007, without relevance to OB-GYN, with no reported results, and with no US-based study site were excluded.ExposuresOB-GYN subspecialty and funder.Main Outcomes and MeasuresReporting of race and ethnicity data and racial and ethnic representation (the proportion of enrollees of American Indian or Alaskan Native, Asian, Black, Latinx, or White identity and odds of representation above US Census estimates by race and ethnicity).ResultsAmong trials with ClinicalTrials.gov results (1287 trials with 591 196 participants) and publications (1147 trials with 821 111 participants), 662 (50.9%) and 856 (74.6%) reported race and ethnicity data, respectively. Among publications, gynecology studies were significantly less likely to report race and ethnicity than obstetrics (adjusted odds ratio [aOR], 0.54; 95% CI, 0.38-0.75). Reproductive endocrinology and infertility trials had the lowest odds of reporting race and ethnicity (aOR, 0.14; 95% CI, 0.07-0.27; reference category, obstetrics). Obstetrics and family planning demonstrated the most diverse clinical trial cohorts. Compared with obstetric trials, gynecologic oncology had the lowest odds of Black representation (ClinicalTrials.gov: aOR, 0.04; 95% CI, 0.02-0.09; publications: aOR, 0.06; 95% CI, 0.03-0.11) and Latinx representation (ClinicalTrials.gov: aOR, 0.05; 95% CI, 0.02-0.14; publications: aOR, 0.23; 95% CI, 0.10-0.48), followed by urogynecology and reproductive endocrinology and infertility. Urogynecology (ClinicalTrials.gov: aOR, 0.15; 95% CI, 0.05-0.39; publications: aOR, 0.24; 95% CI, 0.09-0.58) had the lowest odds of Asian representation.Conclusions and RelevanceRace and ethnicity reporting and representation in OB-GYN trials are suboptimal. Obstetrics and family planning trials demonstrate improved representation is achievable. Nonetheless, all subspecialties should strive for more equitably representative research.

Medicaid expansion under the Affordable Care Act (ACA) improved access to reproductive health care for low-income women and birthing people who were previously ineligible for Medicaid. We aimed to evaluate if the expansion affected the risk of having a short interpregnancy interval (IPI), a preventable risk factor for adverse pregnancy outcomes.We evaluated parous singleton births to mothers aged 19 or older from U.S. birth certificate data 2009-2018. We estimated the effect of residing in a state that expanded Medicaid access (expansion status determined at 60 days after the prior live birth) on the risk of having a short IPI (12 months) using difference-in-differences (DID) methods in linear probability models. We stratified the analyses by maternal characteristics and county-level reproductive health care access.Overall risk of short IPI was 14.9% in expansion states and 16.3% in non-expansion states. The expansion was not associated with a significant change in risk of having a short IPI (adjusted mean percentage point change 1.24 [-1.64, 4.12]). Stratified results also did not provide support for an association.ACA Medicaid expansion did not have an impact on risk of short IPI. Preventing short IPI may require more comprehensive policy interventions in addition to health care access.

Objective In 2012, recommendations for universal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination during pregnancy were released. Our objective was to determine if Tdap, influenza, and pneumococcal vaccine uptake during pregnancy changed after the release of the guidelines, and identify factors associated with receiving the Tdap and influenza vaccine after 2012. Methods We conducted a retrospective cohort study on pregnant individuals who initiated prenatal care before 20 weeks’ gestation between 11/2011-11/2012 (“pre-guideline”) and 12/2012-12/2015 (“post-guideline”). Vaccine uptake dates were abstracted from medical records. The pre and post-guideline cohorts were compared to determine if Tdap vaccine uptake and timing improved after the new Tdap guidelines. We additionally examined influenza and pneumococcal vaccine uptake before and after guidelines. Factors associated with receipt of the Tdap and influenza vaccine during pregnancy in the post-guideline cohort were evaluated using multivariable logistic regression models. Results Of 2,294 eligible individuals, 1,610 (70.2%) received care in the post-guideline cohort. Among the pre-guideline cohort, 47.4% received Tdap, whereas Tdap uptake increased to 86.1% after the guidelines (p Conclusions Receipt and timing of Tdap vaccine improved after implementation of the 2012 ACIP guidelines. Receipt of influenza vaccine uptake also improved during the study period, while uptake of the pneumococcal vaccine remained low. Significant racial disparities exist in receipt of Tdap and influenza vaccine during pregnancy.

BACKGROUND Compared to women with a live birth, women with a stillbirth are more likely to have maternal complications during pregnancy and at birth, but risk factors related to their postpartum health are uncertain. OBJECTIVE This study aimed to identify patient-level risk factors for postpartum hospital readmission among women after having a stillbirth. STUDY DESIGN This was a population-based cohort study of 29,654 women with a stillbirth in California from 1997 to 2011. Using logistic regression models, we examined the association of maternal patient-level factors with postpartum readmission among women after a stillbirth within 6 weeks of hospital discharge and between 6 weeks and 9 months after delivery. RESULTS Within 6 weeks after a stillbirth, 642 women (2.2%) had a postpartum readmission. Risk factors for postpartum readmission after a stillbirth were severe maternal morbidity excluding transfusion (adjusted odds ratio, 3.02; 95% confidence interval, 2.28–4.00), transfusion at delivery but no other indication of severe maternal morbidity (adjusted odds ratio, 1.95; 95% confidence interval, 1.35–2.81), gestational hypertension or preeclampsia (adjusted odds ratio, 1.93; 95% confidence interval, 1.54–2.42), prepregnancy hypertension (adjusted odds ratio, 1.80; 95% confidence interval, 1.36–2.37), diabetes mellitus (adjusted odds ratio, 1.78; 95% confidence interval, 1.33–2.37), antenatal hospitalization (adjusted odds ratio, 1.78; 95% confidence interval, 1.43–2.21), cesarean delivery (adjusted odds ratio, 1.73; 95% confidence interval, 1.43–2.21), long length of stay in the hospital after delivery (>2 days for vaginal delivery and >4 days for cesarean delivery) (adjusted odds ratio, 1.59; 95% confidence interval, 1.33–1.89), non-Hispanic black race and ethnicity (adjusted odds ratio, 1.38; 95% confidence interval, 1.08–1.76), and having less than a high school education (adjusted odds ratio, 1.35; 95% confidence interval, 1.02–1.80). From 6 weeks to 9 months, 1169 women (3.90%) had a postpartum readmission; significantly associated risk factors were largely similar to those for earlier readmission. CONCLUSION Women with comorbidities, with birth-related complications, of non-Hispanic black race and ethnicity, or with less education had increased odds of postpartum readmission after having a stillbirth, highlighting the importance of continued care for these women after discharge from the hospital.

OBJECTIVE Our objective was to conduct a systematic review of the published literature on housing instability during pregnancy and adverse pregnancy outcomes and perinatal healthcare utilization. DATA SOURCES We performed a systematic search in November 2020 using Embase, MEDLINE, Cochrane Library, and Scopus using terms related to housing instability during pregnancy, adverse pregnancy outcomes, and perinatal healthcare utilization. The search was limited to the United States. STUDY ELIGIBILITY CRITERIA Studies examining housing instability (including homelessness) during pregnancy and adverse pregnancy outcomes (including preterm birth, low birthweight neonates, and maternal morbidity) and perinatal healthcare utilization were included. METHODS Two authors screened abstracts and full-length articles for inclusion. The final cohort consisted of 14 studies. Two authors independently extracted data from each article and assessed the study quality using the Grading of Recommendations, Assessment, Development, and Evaluation tool. Risk of bias was assessed using the National Institutes of Health Study Quality Assessment Tools. RESULTS All included studies were observational, including retrospective cohort (n=10, 71.4%), cross-sectional observational (n=3, 21.4%), or prospective cohort studies (n=1, 7.1%). There was significant heterogeneity in the definitions of housing instability and homelessness. Most of the studies only examined homelessness (n=9, 64.3%) and not lesser degrees of housing instability. Housing instability and homelessness during pregnancy were significantly associated with preterm birth, low birthweight neonates, neonatal intensive care unit admission, and delivery complications. Among studies examining perinatal healthcare utilization, housing instability was associated with inadequate prenatal care and increased hospital utilization. All studies exhibited moderate, low, or very low study quality and fair or poor internal validity. CONCLUSION Although data on housing instability during pregnancy are limited by the lack of a standardized definition, a consistent relationship between housing instability and adverse pregnancy outcomes has been suggested by this systematic review. The evaluation and development of a standardized definition and measurement of housing instability among pregnant individuals is warranted to address future interventions targeted to housing instability during pregnancy.