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Background: While the Texas infant mortality rate (IMR) is below the Healthy People 2020 objective (5.7 per 1,000 live births), stark differences in IMR are seen across Texas communities. Health indicators for the state suggest important missed opportunities for improving maternal and infant outcomes. The Healthy Families initiative was a collaboration between a Texas state agency, community partners, and academic institutions to understand how evidence based interventions could be identified, adapted, and implemented to address community priorities and reduce disparities in pregnancy outcomes. Method: The Healthy Families initiative included two Texas counties, one with low utilization of prenatal care and one with persistent disparities in infant mortality. The model served to (1) identify community factors influencing IMR and maternal morbidity through stakeholder engagement and secondary data, (2) build community capacity to link pregnant women with existing and newly developed services, and (3) develop partnerships within the community and clinics to improve access to and sustainability of services. Results: A community-based participatory approach focused on stakeholder engagement was used to identify, design, and adapt strategies to address community-identified priorities. Conclusions: The Healthy Families initiative is a unique state-community-academic partnership aimed at improving pregnancy outcomes in vulnerable communities, with a focus on promotion of capacity building, maintenance, and sustainability of maternal and infant health programs

Objective To describe health burden and health service utilization from the prenatal period to 1 year postpartum among women with births covered by Texas Medicaid, focusing on the major contributors to maternal mortality after 60 days postpartum in Texas. Methods We analyzed diagnoses and health service utilization during the prenatal, early postpartum (5-60 days postpartum), and late postpartum (> 60 days to 1 year postpartum) periods, using administrative medical claims data for women ages 18-44 years with a Medicaid-paid delivery in 2017 residing in selected regions in Texas (n = 49,302). Results Overall, 12.6% and 17.5% of women had diagnoses of cardiovascular/coronary conditions and substance use disorder, respectively. Mental health conditions affected 30% of women, with anxiety (47.1%) and depression (34.3%) accounting for the greatest proportion of diagnosed mental health conditions. The prevalence of these conditions was higher during the late (19.4%) versus early (9.9%) postpartum period. About 47.8% of women had other chronic health conditions, including obesity, diabetes mellitus, and hypertension. Among women with the selected health conditions, utilization of any health services was higher during the prenatal period compared to early and late postpartum periods (e.g., any mental health service utilization: prenatal period (57.4%) versus early postpartum (26.9%) and late postpartum (25.5%) periods). However, among women with the selected health conditions, there was a high utilization of emergency room services during the late postpartum period [e.g., emergency room service utilization among those with mental health conditions: prenatal period (35.6%); postpartum period: early (5.5%) and late (30.1%)]. Conclusions for Practice Increasing access to the full range of recommended services during the prenatal period through 1 year postpartum has potential to help improve vulnerable women's birth outcomes., Author(s): Meliha Salahuddin [sup.1] [sup.2] [sup.3] , Krystin J. Matthews [sup.2] [sup.3] , Nagla Elerian [sup.2] , Patrick S. Ramsey [sup.4] , David L. Lakey [sup.1] [sup.2] , Divya A. [...]

Background: While the Texas infant mortality rate (IMR) is below the Healthy People 2020 objective (5.7 per 1,000 live births), stark differences in IMR are seen across Texas communities. Health indicators for the state suggest important missed opportunities for improving maternal and infant outcomes. The Healthy Families initiative was a collaboration between a Texas state agency, community partners, and academic institutions to understand how evidence-based interventions could be identified, adapted, and implemented to address community priorities and reduce disparities in pregnancy outcomes. Method: The Healthy Families initiative included two Texas counties, one with low utilization of prenatal care and one with persistent disparities in infant mortality. The model served to (1) identify community factors influencing IMR and maternal morbidity through stakeholder engagement and secondary data, (2) build community capacity to link pregnant women with existing and newly developed services, and (3) develop partnerships within the community and clinics to improve access to and sustainability of services. Results: A community-based participatory approach focused on stakeholder engagement was used to identify, design, and adapt strategies to address community-identified priorities. Conclusions: The Healthy Families initiative is a unique state–community–academic partnership aimed at improving pregnancy outcomes in vulnerable communities, with a focus on promotion of capacity building, maintenance, and sustainability of maternal and infant health programs. [ABSTRACT FROM AUTHOR]

Background: Severe maternal morbidity (SMM) prevalence was 194.0 per 10 000 deliveries in Texas in 2015. Chronic, behavioral, and pregnancy‐induced conditions, as captured by a maternal comorbidity index, increase the risk for delivery‐related morbidity and mortality. The objective of the study was to examine the association between maternal comorbidity index and SMM among delivery hospitalizations in Texas. Methods: Delivery‐related hospitalizations among Texan women aged 15‐49 years were identified using the 2011‐2014 Texas all‐payer inpatient hospitalization public use data files (n = 1 434 441). The primary outcome of interest was SMM, based on the Alliance for Innovation on Maternal Health's coding scheme. The exposure of interest was a maternal comorbidity index. Multivariable logistic regression model was used to examine the association between maternal comorbidity index and SMM. Results: SMM prevalence remained consistent between 2011 and 2014 (196.0‐197.0 per 10 000 deliveries, P >.05; n = 1 434 441). Nearly 40% of delivery‐related hospitalizations had a maternal comorbidity index of at least 1, and the proportion of deliveries in the highest risk category of comorbidity index (≥5) increased by 12.0% from 2011 to 2014. SMM prevalence was highest among the youngest and oldest age groups. With each unit increase in maternal comorbidity index, the odds of SMM increase was 1.43 (95% CI 1.42‐1.43). Conclusions: Maternal comorbidity index is associated with SMM; however, the low predictive power of the model suggests that other, unmeasured factors may influence SMM in Texas. These findings highlight a need to understand broader contextual factors (practitioner, facility, systems of care, and community) that may be associated with SMM to reduce maternal morbidity and mortality in Texas. [ABSTRACT FROM AUTHOR]

Background: Cesarean delivery accounts for over one‐third of the ~400 000 annual births in Texas, with first‐time cesarean accounting for 20% of the overall cesareans. We examined associations of maternal medical comorbidities with cesarean delivery among nulliparous, term, singleton, vertex (NTSV) deliveries in Texas. Methods: Nulliparous, term, singleton, vertex deliveries to women aged 15‐49 years were identified using the 2015 Texas birth file (Center for Health Statistics, Texas Department of State Health Services). A risk factor index was constructed (score range 0‐4), including preexisting/gestational diabetes mellitus, preexisting/gestational hypertension/eclampsia, infertility treatment, smoking during pregnancy, and prepregnancy overweight/obesity, and categorized as 0, 1, 2, and 3+ based on the number of risk factors present. Multivariable logistic regression analyses were conducted to examine associations between the categorized risk factor index and cesarean delivery, overall and by maternal race and ethnicity. Results: Among the 114 535 NTSV deliveries in Texas in 2015, 27.2% were by cesarean. The most prevalent maternal risk among all deliveries was prepregnancy overweight/obesity (42.4%). The odds of cesarean delivery increased significantly with increasing number of risk factors [one risk factor: 1.72 (95% CI 1.67‐1.78); two risk factors: 2.58 (95% CI 2.46‐2.71); and three or more risk factors: 3.91 (95% CI 3.45‐4.44)]. Discussion: In Texas in 2015, nearly half of NTSV deliveries had at least one maternal risk factor and the odds of cesarean delivery were significantly elevated for women with a higher risk index score. The findings from this study highlight the need for intervening during the preconception and interconception period as intrapartum care practices have an important influence on birth outcomes. [ABSTRACT FROM AUTHOR]

Background: Induction of labor (IOL) is increasingly common in the United States, yet characteristics associated with IOL among primiparous women delivering at term are not well understood. Materials and Methods: Data from the Listening to Mothers III study, a survey of women aged 18–45 with singleton deliveries in U.S. hospitals in 2011–2012, were utilized. Weighted logistic regression models examined predictors of IOL among 924 primiparous women with term deliveries. Associations of maternal characteristics with delivery route (cesarean and vaginal delivery) were examined among primiparous women induced at term. Results: Four hundred twenty-three (45.8%) primiparous women with term deliveries underwent IOL; subjective reasons were reported by 53% of induced women. Women who were married (odds ratios [OR] = 1.8, 95% confidence intervals [CI] 1.2–2.9), felt pressure from a provider for IOL (OR = 3.5, 95% CI 2.0–6.2), and whose provider was concerned about the size of the baby (OR = 1.9, 95% CI 1.2–2.9) were significantly more likely to undergo IOL. Nearly 30% of primiparous women who underwent IOL at term had a cesarean delivery (CD). Among the induced women, those who were overweight/obese (OR = 4.9, 95% CI 2.5–10.0), felt pressure from a provider for CD (OR = 8.6, 95% CI 3.5–21.2), and whose provider suspected the baby might be getting large near end of pregnancy (OR = 2.7, 95% CI 1.1–7.0) were significantly more likely to have CD. Conclusions: In this study, nearly half of the primiparous women with term deliveries underwent IOL, with a sizeable proportion reporting subjective reasons for induction. A better understanding of the characteristics associated with IOL at term may help reduce unnecessary interventions and, ultimately, primary CD. [ABSTRACT FROM AUTHOR]

Health care personnel (HCP) caring for patients with Ebola virus disease (EVD) are at increased risk for infection with the virus. In 2014, a Texas hospital became the first U.S. community hospital to care for a patient with EVD; 2 nurses were infected while providing care. This article describes infection control measures developed to strengthen the hospital's capacity to safely diagnose and treat patients with EVD. After admission of the first patient with EVD, a multidisciplinary team from the Centers for Disease Control and Prevention (CDC) joined the hospital's infection preventionists to implement a system of occupational safety and health controls for direct patient care, handling of clinical specimens, and managing regulated medical waste. Existing engineering and administrative controls were strengthened. The personal protective equipment (PPE) ensemble was standardized, HCP were trained on donning and doffing PPE, and a system of trained observers supervising PPE donning and doffing was implemented. Caring for patients with EVD placed substantial demands on a community hospital. The experiences of the authors and others informed national policies for the care of patients with EVD and protection of HCP, including new guidance for PPE, a rapid system for deploying CDC staff to assist hospitals ("Ebola Response Team"), and a framework for a tiered approach to hospital preparedness. The designation of regional Ebola treatment centers and the establishment of the National Ebola Training and Education Center address the need for HCP to be prepared to safely care for patients with EVD and other high-consequence emerging infectious diseases. [ABSTRACT FROM AUTHOR]

In this article the author comments on the direction that all state agencies and institutions in Texas should reduce their 2010-2011 budgets to help maintain a constitutionally required balanced budget. He is critical on how the state insignificantly reduce budgets due to the economic downturn to maintain the required balanced budget. Also investigated are the steps to respond the budget challenges in the Health and Human Services agencies.

The mobile insertion sequence, IS 6110, is an important marker in tracking of Mycobacterium tuberculosis strains. Here, we demonstrate that IS 6110 can upregulate downstream genes through an outward-directed promoter in its 3′ end, thus adding to the significance of this element. Promoter activity was orientation dependent and was localized within a 110 bp fragment adjacent to the right terminal inverted repeat. Transcripts from this promoter, named OP6110, begin ≈ 85 bp upstream of the 3′ end of IS 6110. Use of green fluorescent protein (GFP) expression constructs showed that OP6110 was upregulated in M. tuberculosis during growth in human monocytes and in late growth phases in broth. Analysis of natural insertion sites in M. tuberculosis showed that IS 6110 upregulated expression of several downstream genes during growth in human monocytes, including Rv2280 in H37Rv and the PE-PGRS gene, Rv1468c, in the clinical strain 210, which is a member of the Beijing family. Transcription between IS 6110 and downstream genes was confirmed by reverse transcription polymerase chain reaction. The ability to activate genes during infection suggests that IS 6110 has the potential to influence growth characteristics of different strains, and indicates another mechanism by which IS 6110 can impact M. tuberculosis evolution. [ABSTRACT FROM AUTHOR]

The ability of Mycobacterium tuberculosis to grow in macrophages is central to its pathogenicity. We found previously that the widespread 210 strain of M. tuberculosis grew more rapidly than other strains in human macrophages. Because principal sigma factors influence virulence in some bacteria, we analysed mRNA expression of the principal sigma factor, sigA, in M. tuberculosis isolates during growth in human macrophages. Isolates of the 210 strain had higher sigA mRNA levels and higher intracellular growth rates, compared with other clinical strains and the laboratory strain H37Rv. SigA was also upregulated in the 210 isolate TB294 during growth in macrophages, compared with growth in broth. In contrast, H37Rv sigA mRNA levels did not change under these conditions. Overexpression of sigA enhanced growth of recombinant M. tuberculosis in macrophages and in lungs of mice after aerosol infection, whereas recombinant strains expressing antisense transcripts to sigA showed decreased growth in both models. In the presence of superoxide, sense sigA transformants showed greater resistance than vector controls, and the antisense sigA transformant did not grow. We conclude that M. tuberculosis sigA modulates the expression of genes that contribute to virulence, enhancing growth in human macrophages and during the early phases of pulmonary infection in vivo. This effect may be mediated in part by increased resistance to reactive oxygen intermediates. [ABSTRACT FROM AUTHOR]

Prior reports have suggested that CD14 mediates uptake of Mycobacterium tuberculosis into porcine alveolar macrophages and human fetal microglia, but the contribution of CD14 to cell entry in human macrophages has not been studied. To address this question, we used flow cytometry to quantify uptake by human monocytes and alveolar macrophages of M. tuberculosis expressing green fluorescent protein. Neutralizing anti-CD14 antibodies did not affect bacillary uptake and the efficiency of bacillary entry was similar in THP-1 cells expressing low and high levels of CD14. However, most internalized bacteria were found in CD14+ but not in CD14− monocytes because M. tuberculosis infection upregulated CD14 expression. We conclude that: (1) CD14 does not mediate cellular entry by M. tuberculosis; (2) M. tuberculosis infection upregulates CD14 expression on mononuclear phagocytes, and this may facilitate the pathogen’s capacity to modulate the immune response. [Copyright &y& Elsevier]

Evaluates the mRNA expression of multiple mycobacterial genes. Competitive reverse-transcriptase polymerase chain reaction; Hybridization of mycobacterial cDNA to Mycobacterium tuberculosis microarray; Primers used for amplification of mycobacterial genes.

Background. Histochemical staining of bone marrow biopsy samples for microorganisms may provide a presumptive diagnosis weeks before culture. Methods. To identify predictors of histochemical positivity, we reviewed 161 bone marrow biopsies from febrile patients with human immunodeficiency virus (HIV) infection. Results. By multivariate analysis, both hematocrit value <30% and white blood cell count <4,000/mm[sup 3] predicted biopsy positivity by culture or staining, but only anemia predicted histochemical stain positivity. Of cases with serum lactate dehydrogenase (LDH) levels >600 U/L, histoplasmosis was diagnosed in 31.6% versus 7.8% with lower LDH levels. Among histoplasmosis cases, staining showed fungi in all, with LDH levels >600 U/L versus 44.4% with lower levels. Conclusions. Bone marrow biopsy will most likely provide a rapid diagnosis in patients with anemia. Markedly elevated LDH levels suggest stain positivity for Histoplasma capsulatum . Histopathologic patterns may also guide empiric therapy. [ABSTRACT FROM AUTHOR]

The article discusses aspects of disaster management in Texas. The topics discussed include importance of being prepared for emergencies, Texas Department of State Health Services preparedness for dealing with emergencies, public health surveillance and investigations in Texas. Also discussed is the role of State Medical Operations Center (SMOC) in deployment of medical resources.

The author discusses the efforts of Texas state leaders to ensure that they provide preventive health care and family planning to low-income women. He states that Texas received $100 million in additional funds to expand Primary Health Care program. He notes that they continue to offer women's health services through the Family Planning program. He mentions that agencies such as hospital districts to local health departments have been awarded more than $45 million state funding.

The author discusses aspects of Texas' Sunset review, an intensive review of the operations on a timeline set y the Texas Legislature. He argues that the review is essential to oversee state agencies and ensure state government operates efficiently and effectively. He notes that the Texas Department of State Health Services is being reviewed by the Sunset Advisory Commission to determine if the agency needs to make recommendations for improvements.

The author reflects on the 83rd Legislative Session for public health in Texas. He says that the Texas Legislature has supported the Texas Department of State Health Services (DSHS) and the whole public health community for their objective to improve the health and well-being of the public. He mentions that the budget for DSHS has increased from $5.8 billion in 2012-2013 to $6.24 billion in 2014-2015.

In this article the author comments on the impact of disasters in Texas. The author mentions that Texas has experienced more disasters than other states in the country, affecting thousands of individuals. Moreover, he suggests that preparations and change in behavior are needed in minimizing the impact of disaster on the state.

In this article the author discusses the essence of time to act and prepare for public health concerns such epidemics and natural calamities in Texas. He cites the potential spread of the H1N1 virus during the fall and winter season, the potential for hurricane before the end of the year, and the possible floods and tornadoes in early spring. The author stresses that now is the time to get the seasonal flu vaccine and to help those priority groups understand the importance of immunization.

The author discusses the aim of the Department of State Health Services (DSHS) to improve public health in Texas as he attended the Texas Legislature gathering on January 13, 2009. He reveals that he tackles the DSHS appropriations request during the hearing. The inclusion of state hospital services, family planning reimbursement, and department operational costs to maintain operational capacity of DSHS are also examined.

The article discusses the concept of the campaign called "Ready or Not? HAVE A PLAN. It features radio, television, newspaper and outdoor advertising, community outreach events and an interactive Website to encourage people in Texas to create an emergency plan. This has been funded by the Centers for Disease Control and Prevention for public health preparedness.

The article discusses the author's experience of participating in the 80th Texas Legislature session held in 2007. He was able to observe how policy and budgets are made through the legislative process. As commissioner of the Texas Department of State Health Services (DSHS), he was mostly involved in the budgetary process. The author realized the importance of support in the community during the process.

The article focuses on issues related to public health in Texas. The author mentions that his interest in public health has been drawn by his realization that the root causes of diseases can be avoided through prevention instead of a medical approach. He states that the Texas Department of State Health Services must use an extensive approach to the physical and behavioral health challenges being faced by the state.

The author discusses Texas government response to Ebola virus which highlights strength of public health in the state. Topics discussed include the diagnosis of Thomas Eric Duncan has set in motion to prevent the spread of the disease, the public health emergency needs the complete attention of local and state leadership, emergency responders, and the health care system, and the Governor's Task Force on Infectious Disease Preparedness and Response.

The article focuses on the healthcare services provided by the Baptist Child and Family Services (BCFS) and the U.S. Office of Refugee Resettlement (ORR) on children refugees in Texas Hill Country in Texas. It mentions that the medical services provided by the BCFS through its bilingual nurses and on-site pediatricians is thorough and excellent. It discusses the other services provided for to the said children.

The author highlights the importance of immunizations on serious illness as preventable measures and treatment of chronic illness in children in Texas. He mentions the vaccination for pertusis, an infectious and serious complication in infants which has increased in the state. He states the vaccinations for measles, an infection in the respiratory system for children. He also stresses out the importance of children and infant immunization to prevent the spread of pertusis and measles.

The author reflects on the opportunities for the improvement of public health in Texas in 2013.

The author discusses the efforts of the local healthcare sector in Texas in battling the spread of West Nile virus in the state. he states that the Department of State Health Services has teamed up with other health departments in identifying a way to fight the outbreak, which include aerial spraying. He adds that the department also carried out information about personal precautions such as the use of repellants and eliminating stagnant water.

The article comments on prevention of chronic diseases in Texas. It has been informed that Texas has a higher prevalence of most chronic diseases with heart disease and stroke are the first and fourth leading causes of death in Texas. It has been informed that by addressing risk factors like inadequate physical activity, tobacco use, poor nutrition and substance abuse, chronic diseases could be mitigated.

The author discusses his effort as president of the Association of State and Territorial Health Officials to make babies healthy through the program Healthy Texas Babies in Texas. He mentions that the Texas Legislature gave 4.1 million dollars as funds that will be used to tackle issues that lead to unhealthy birth outcomes. Furthermore, a treatment and screening of pregnant women, education regarding fatherhood, and nurse consultation will be conducted by the state's local health department.

The article presents the author's views regarding diagnosis and treatment of acquired immunodeficiency syndrome (AIDS). He discusses the role of local health departments in assessing risk, evaluation, epidemiologic assessment, research, planning and medical care for AIDS. He further reports that Texas has support from state legislature for raising awareness and providing medication for AIDS.

In this article the author discusses the need for communities, families, and individuals to prepare for natural calamities and make the appropriate response when they strike. The author notes the importance of community involvement and collaboration in disaster preparedness and the role of public health. He cites the Ready or Not public education campaign which will be launched by the Texas Department of State Health Services (DSHS) to teach Texans about emergency preparedness.

In this article, the author discusses the preparation for public health risks brought by H1N1 flu. He refers to the spread of the virus and how various state health agencies and organizations prepared to address the problem. He suggests to continue to follow precautions to reduce the risk of spreading the flu.

The article focuses on the recommendation of the Center of Dieses Control and Prevention about the screening for human immunodeficiency virus (HIV) in Texas. The medical center advocates that all citizens between 13-64 years old will be screened for HIV as part of medical practice. On the other hand, it mentions that one among the three people was diagnosed with AIDS within a year of getting their first diagnosis of HIV infection in previous five years.

The article discusses the implications the active hurricane season in 2008 in Texas. According to the author, this season has called into play all the planning and response resources that the state can muster. The article also discusses topics on public health preparedness and response including emergency management, disaster coordination, and community volunteers.

The author reflects on the failure of access to mental health and substance abuse services and the effort of the Department of Social and Health Services (DSHS) to address the issue in Texas. He argues that the need, scope and delivery of health service continues to grow. He cites that DSHS is leading a statewide campaign to transform mental health service delivery, which will make it easier for consumers and their families to gain access to the service.

The article focuses on the importance of planning for an influenza pandemic. It says that the Great Influenza Pandemic of 1918 and the influenza pandemics of 1957 and 1968 illustrate that a pandemic can be worse than natural disasters so pandemic influenza planning is not only about health but also about societal issues. Accordingly, the Texas Department of State Health Services (DSHS) and other local health departments have already started pandemic influenza planning several years ago.

Background: Severe maternal morbidity (SMM) prevalence was 194.0 per 10 000 deliveries in Texas in 2015. Chronic, behavioral, and pregnancy-induced conditions, as captured by a maternal comorbidity index, increase the risk for delivery-related morbidity and mortality. The objective of the study was to examine the association between maternal comorbidity index and SMM among delivery hospitalizations in Texas., Methods: Delivery-related hospitalizations among Texan women aged 15-49 years were identified using the 2011-2014 Texas all-payer inpatient hospitalization public use data files (n = 1 434 441). The primary outcome of interest was SMM, based on the Alliance for Innovation on Maternal Health's coding scheme. The exposure of interest was a maternal comorbidity index. Multivariable logistic regression model was used to examine the association between maternal comorbidity index and SMM., Results: SMM prevalence remained consistent between 2011 and 2014 (196.0-197.0 per 10 000 deliveries, P > .05; n = 1 434 441). Nearly 40% of delivery-related hospitalizations had a maternal comorbidity index of at least 1, and the proportion of deliveries in the highest risk category of comorbidity index (≥5) increased by 12.0% from 2011 to 2014. SMM prevalence was highest among the youngest and oldest age groups. With each unit increase in maternal comorbidity index, the odds of SMM increase was 1.43 (95% CI 1.42-1.43)., Conclusions: Maternal comorbidity index is associated with SMM; however, the low predictive power of the model suggests that other, unmeasured factors may influence SMM in Texas. These findings highlight a need to understand broader contextual factors (practitioner, facility, systems of care, and community) that may be associated with SMM to reduce maternal morbidity and mortality in Texas., (© 2019 Wiley Periodicals, Inc.)

Background: Cesarean delivery accounts for over one-third of the ~400 000 annual births in Texas, with first-time cesarean accounting for 20% of the overall cesareans. We examined associations of maternal medical comorbidities with cesarean delivery among nulliparous, term, singleton, vertex (NTSV) deliveries in Texas., Methods: Nulliparous, term, singleton, vertex deliveries to women aged 15-49 years were identified using the 2015 Texas birth file (Center for Health Statistics, Texas Department of State Health Services). A risk factor index was constructed (score range 0-4), including preexisting/gestational diabetes mellitus, preexisting/gestational hypertension/eclampsia, infertility treatment, smoking during pregnancy, and prepregnancy overweight/obesity, and categorized as 0, 1, 2, and 3+ based on the number of risk factors present. Multivariable logistic regression analyses were conducted to examine associations between the categorized risk factor index and cesarean delivery, overall and by maternal race and ethnicity., Results: Among the 114 535 NTSV deliveries in Texas in 2015, 27.2% were by cesarean. The most prevalent maternal risk among all deliveries was prepregnancy overweight/obesity (42.4%). The odds of cesarean delivery increased significantly with increasing number of risk factors [one risk factor: 1.72 (95% CI 1.67-1.78); two risk factors: 2.58 (95% CI 2.46-2.71); and three or more risk factors: 3.91 (95% CI 3.45-4.44)]., Discussion: In Texas in 2015, nearly half of NTSV deliveries had at least one maternal risk factor and the odds of cesarean delivery were significantly elevated for women with a higher risk index score. The findings from this study highlight the need for intervening during the preconception and interconception period as intrapartum care practices have an important influence on birth outcomes., (© 2018 Wiley Periodicals, Inc.)