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ObjectiveTo identify characteristics associated with undergoing cell-free DNA (cfDNA) and multiple marker screening (MMS) simultaneously or redundantly (after receiving negative results from the first screening test) among women aged ⩾35 years.Study designParticipants presenting for prenatal testing completed a questionnaire that included measures of pregnancy worry and attitudes toward potential testing outcomes; data on prenatal test use was obtained via medical record review. We used multivariable logistic regression to identify factors associated with redundant or simultaneous screening.ResultsAmong 164 participants, 69 (42.1%) had cfDNA redundantly (n=51) to, or simultaneously (n=18) with, MMS. Compared with the 46 MMS-negative women who did not undergo further testing, those who underwent redundant or simultaneous cfDNA/MMS screening were more likely to have annual family incomes >$150 000, to feel having a miscarriage would be worse than having an intellectually disabled child, to desire comprehensive testing for intellectual disability and to have more pregnancy worry.ConclusionProviders who counsel patients on prenatal aneuploidy screening tests should explain the appropriate utilization of these screening tests to avoid unnecessary or minimally informative use of multiple tests.

Objective: To describe experiences of Latina women who were currently pregnant or recently gave birth around discrimination, anti-immigrant policies, and community violence during the early COVID-19 pandemic., Design: Qualitative secondary analysis., Setting: Online or phone interviews., Participants: Latina women who were currently pregnant or recently gave birth (N = 26)., Methods: We used reflexive thematic analysis to examine transcribed data from semistructured interviews conducted during the early COVID-19 pandemic with a subgroup of participants enrolled in a larger study related to prenatal care. Participants were English- or Spanish-speaking, Medicaid-eligible, Latina-identifying women who resided in Fresno County, California. We analyzed responses to questions about personal discrimination, the Black Lives Matter movement, and immigration policies using the theoretical frameworks of critical race theory and the political economy of health., Results: We identified four major themes: Avoidance of Community Engagement, Chronic Fear and Vigilance, The Role of Media, and Everyday Discrimination and Injustice., Conclusion: Participant experiences reflect the pervasiveness of fear and socioeconomic inequity and call attention to the racialized structures that affect health and health care access for Latina women. These exposures during the perinatal period may have intergenerational effects. These findings underscore the need for responsive and race-conscious perinatal nursing care for Latina women, assessment of the effect of the current sociopolitical environment on well-being, and policies that support equitable access to health and social care., Competing Interests: Conflict of Interest The authors report no conflicts of interest or relevant financial relationships., (Copyright © 2024 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Importance: Preterm birth (PTB) (gestational age <37 weeks) is a major cause of infant mortality and morbidity in the US and is marked by racial and ethnic and socioeconomic inequities. Further research is needed to elucidate the association of risk and protective factors with trends in PTB rates and with related inequities., Objective: To describe the association of PTB rates with inequities as well as related risk and protective factors over the past decade in a US population-based cohort., Design, Setting, and Participants: This retrospective cohort study of singleton live births in California from January 1, 2011, to December 31, 2022, was conducted using vital statistics records and hospital records. The cohort included births with a gestational age of 22 to 44 weeks., Main Outcomes and Measures: Preterm birth rates by racial and ethnic group and by public and nonpublic insurance (considered as a proxy for socioeconomic status) were studied across years. Log-linear regression (relative risks with 95% CIs) was used to evaluate risk and protective factors within groups. Associations of PTB rates with risk and protective factors were assessed., Results: This study included 5 431 018 singleton live births to individuals who identified as American Indian or Alaska Native (0.3%), Asian (14.2%), Black (4.9%), Hispanic (47.8%), or White (27.0%). A total of 43.1% of births were to individuals with public health insurance. From 2011 to 2022, the overall PTB rate increased from 6.8% to 7.5% (change [SE], 10.6% [0.6%]; z score of 18.5; P < .001). Differences in PTB rates and associated changes were observed for racial and ethnic groups and insurance groups. For example, 2022 PTB rates ranged from 5.8% among White individuals with nonpublic insurance to 11.3% among Black individuals with public health insurance. From 2011 to 2022, PTB rates decreased from 9.1% to 8.8% (change [SE], -3.5% [4.2]; z score of -0.8; P = .42) among Black individuals with nonpublic insurance, whereas they increased from 6.4% to 9.5% (change [SE], 49.8% [16.0%]; z score of 3.1; P = .002) among American Indian or Alaska Native individuals with nonpublic insurance. Increases in some risk factors (eg, preexisting diabetes, sexually transmitted infections, mental health conditions) were observed in most groups, and decreases in some protective factors (eg, participation in the California Women, Infants, and Children program) (P for trend < .001 from 2011 to 2021) were observed mostly in low-income groups., Conclusions and Relevance: In this cohort study of singleton live births in California, PTB rates increased in many groups. Persistent racial and ethnic and socioeconomic inequities were also observed. Changes in risk and protective factors provided clues to patterns of PTB. These data point to an urgent need to address factors associated with PTB at both the individual and population levels.

Objective: To compare the model-predicted benefits, harms, and cost-effectiveness of cytology, cotesting, and primary HPV screening in U.S. women living with HIV (WLWH)., Design: We adapted a previously published Markov decision model to simulate a cohort of U.S. WLWH., Setting: United States., Subjects, Participants: A hypothetical inception cohort of WLWH., Intervention: We simulated five screening strategies all assumed the same strategy of cytology with HPV triage for ASCUS for women aged 21 to 29 years. The different strategies noted are for women aged 30 and older as the following: continue cytology with HPV triage, cotesting with repeat cotesting triage, cotesting with HPV16/18 genotyping triage, primary hrHPV testing with cytology triage, and primary hrHPV testing with HPV16/18 genotyping triage., Main Outcome Measures: The outcomes include colposcopies, false-positive results, treatments, cancers, cancer deaths, life-years and costs, and lifetime quality-adjusted life-years., Results: Compared with no screening, screening was cost-saving, and > 96% of cervical cancers and deaths could be prevented. Cytology with HPV triage dominated primary HPV screening and cotesting. At willingness-to-pay thresholds under $250,000, probabilistic sensitivity analyses indicated that primary HPV testing was more cost-effective than cotesting in over 98% of the iterations., Conclusions: Our study suggests the current cytology-based screening recommendation is cost-effective, but that primary HPV screening could be a cost-effective alternative to cotesting. To improve the cost-effectiveness of HPV-based screening, increased acceptance of the HPV test among targeted women is needed, as are alternative follow-up recommendations to limit the harms of high false-positive testing., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Financial Disclosure Kara Ayers is the co-investigator on two grants related to pregnancy and parenting. Brandeis University is the PI. She is a Cincinnati Children's Faculty member. She is a PCORI Board of Governor's member and owns her own consulting firm called Mind Ramps, LLC, not related to this work. The other authors did not report any potential conflicts of interest.

Background: Improving perinatal mental health and care experiences and preventing adverse maternal and infant outcomes are essential prenatal care components, yet existing services often miss the mark, particularly for low-income populations. An enhanced group prenatal care program, "Glow! Group Prenatal Care and Support," was developed in California's Central Valley in response to poor perinatal mental health, disrespectful care experiences, and high rates of adverse birth outcomes among families with low incomes., Methods: Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) is a pragmatic, two-arm, randomized, comparative-effectiveness study designed to assess depression (primary outcome), the experience of care (secondary outcome), and preterm birth (exploratory outcome) among Medi-Cal (California's Medicaid program)-eligible pregnant and birthing people, comparing those assigned to Glow! Group Prenatal Care and Support (Glow/GC) with those assigned to enhanced, individual prenatal care through the California Department of Public Health's Comprehensive Perinatal Services Program (CPSP/IC). Participating clinical practices offer the two comparators, alternating between comparators every 6 weeks, with the starting comparator randomized at the practice level. Participant-reported outcomes are assessed through interviewer-administered surveys at study entry, during the participant's third trimester, and at 3 months postpartum; preterm birth and other clinical outcomes are abstracted from labor and delivery records. Patient care experiences are further assessed in qualitative interviews. The protocol complies with the Standard Protocol Items for Randomized Trials., Conclusions: This comparative-effectiveness study will be used to determine which of two forms of enhanced prenatal care is more effective, informing future decisions regarding their use., Trial Registration: ClinicalTrials.gov: NCT04154423., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To pilot test and assess the feasibility and acceptability of chaplain-led decision coaching alongside the GOALS (Getting Optimal Alignment around Life Support) decision support tool to enhance decision-making in threatened periviable delivery., Methods: Pregnant people admitted for threatened periviable delivery and their 'important other' (IO) were enrolled. Decisional conflict, acceptability, and knowledge were measured before and after the intervention. Chaplains journaled their impressions of training and coaching encounters. Descriptive analysis and conventional content analysis were completed., Results: Eight pregnant people and two IOs participated. Decisional conflict decreased by a mean of 6.7 (SD = 9.4) and knowledge increased by a mean of 1.4 (SD = 1.8). All rated their experience as "good" or "excellent," and the amount of information was "just right." Participants found it "helpful to have someone to talk to" and noted chaplains helped them reach a decision. Chaplains found the intervention a valuable use of their time and skillset., Conclusion: This is the first small-scale pilot study to utilize chaplains as decision coaches. Our results suggest that chaplain coaching with a decision support tool is feasible and well-accepted by parents and chaplains., Innovations: Our findings recognize chaplains as an underutilized, yet practical resource in value-laden clinical decision-making., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier B.V.)

Objectives: To assess psychometric properties of two scales developed to measure the quality of person-centered care during pregnancy and childbirth in the United States-the Person-Centered Prenatal Care (PCPC-US) and Person-Centered Maternity Care (PCMC-US) scales-in a low-income predominantly Latinx population in California., Methods: Data were collected from July 2020 to June 2023 from surveys of low-income pregnant and birthing people in Fresno, California, participating in the "Engaging Mothers and Babies; Reimagining Antenatal Care for Everyone" (EMBRACE) trial. Research staff administered the 26-item PCPC-US scale at 30-34 weeks' gestation (n = 315) and the 35-item PCMC-US scale at 10-14 weeks after birth (n = 286), using the language preferred by the participant (English or Spanish). We assessed construct, criterion, and known group validity and internal consistency of the scales., Results: 78% of respondents identified as Latinx. Factor analysis identified one dominant factor for each scale that accounted for over 60% of the cumulative variance, with most items loading at > 0.3. The items also loaded adequately on sub-scales for "dignity and respect," "communication and autonomy," and "responsive and supportive care." Cronbach's alpha for the full scales were > 0.9 and between 0.70 and 0.87 for the sub-scales. Summative scores range from 0 to 100, with higher scores indicating higher person-centered care. Correlations with scores on scales measuring prenatal care quality and birth experience provided evidence for criterion validity, while associations with known predictors provided evidence for known-group validity., Conclusions: The PCPC-US and PCMC-US scales, which were developed using a community-engaged process and found to have good psychometric properties in a largely high-income sample of Black women, were shown to also have good psychometric properties in a sample of low-income primarily Latinx women. Both scales provide valid and reliable tools to measure person-centered care experiences among minoritized communities to support efforts to reduce existing birth inequities., (© 2023. The Author(s).)

Background: The largest poverty alleviation program in the US is the earned income tax credit (EITC), providing $60 billion to over 25 million families annually. While research has shown positive impacts of EITC receipt in pregnancy, there is little evidence on whether the timing of receipt may lead to differences in pregnancy outcomes. We used a quasi-experimental difference-in-differences design, taking advantage of EITC tax disbursement each spring to examine whether trimester of receipt was associated with perinatal outcomes., Methods: We conducted a difference-in-differences analysis of California linked birth certificate and hospital discharge records. The sample was drawn from the linked CA birth certificate and discharge records from 2007-2012 (N = 2,740,707). To predict eligibility, we created a probabilistic algorithm in the Panel Study of Income Dynamics and applied it to the CA data. Primary outcome measures included preterm birth, small-for-gestational age (SGA), gestational diabetes, and gestational hypertension/preeclampsia., Results: Eligibility for EITC receipt during the third trimester was associated with a lower risk of preterm birth compared with preconception. Eligibility for receipt in the preconception period resulted in improved gestational hypertension and SGA., Conclusion: This analysis offers a novel method to impute EITC eligibility using a probabilistic algorithm in a data set with richer sociodemographic information relative to the clinical and administrative data sets from which outcomes are drawn. These results could be used to determine the optimal intervention time point for future income supplementation policies. Future work should examine frequent income supplementation such as the minimum wage or basic income programs., (© 2023. The Author(s).)

In response to disproportionately high rates of infant mortality and preterm birth among women of color and women in poverty in Fresno County, California, community and academic partners coordinated a community-based participatory research (CBPR) project with local residents. Social isolation and stress, inaccessible prenatal care, and dissatisfaction with care experiences were identified as leading predictors of poor birth outcomes. The PRECEDE-PROCEED framework was used to lead the CBPR effort that resulted in the development of a model of group prenatal care, named Glow! Group Prenatal Care Program (Glow! Program). Group prenatal care (GPNC), which focuses on pregnancy health assessments, education, and peer support, has the potential to address the health and social priorities of women during pregnancy. As a result of the employed CBPR process and the extensive participation from stakeholders, this modified GPNC model responds to the unique needs of the at-risk community members, the agencies aiming to improve maternal-child health experiences and outcomes, and the prenatal care providers offering it to their patients. The methods from this study can be applied in the design and implementation of community-based health care interventions. Returning to community partners throughout the design, implementation, and evaluation phases underscored that health care interventions cannot be designed in silos, and require flexibility to respond to factors that promote improved maternal and infant outcomes, which affect the end goal for the intervention.

Introduction: In the United States, adverse birth outcomes are most prevalent among Black women and birthing people, who are known to experience increased mistreatment and disrespect in care. The purpose of this paper is to describe findings from a study that used two validated scales to examine factors associated with experiences of person-centered care during pregnancy and birth among Black birthing people in California., Methods: We used data from 234 Black women and birthing people who were recruited between January and September 2020 as part of a validation study for the Person-Centered Prenatal Care (PCPC) and the Person-Centered Maternity Care (PCMC-US) scales. Bivariate and multivariate analyses were conducted to examine the associations between PCPC and PCMC-US scores and sociodemographic, health-related, and care-related factors., Results: The factors associated with lower PCPC scores were having foreign-born parents, having public or no insurance, part-time employment, unstable housing, late start of prenatal care (in the second or third trimester), poorer self-rated health (less than very good), and lack of continuity of care with prenatal providers. Factors associated with lower PCMC-US scores were having public insurance, late start of prenatal care, longer length of stay in facility following birth, poorer self-rated health, lack of continuity of care between prenatal care and birth providers, and racial discordance with birth provider., Conclusions: Our analysis highlights the contributions of intersecting identities as well as health-related and care-related factors to Black birthing people's experiences of care in California. Continuity of care and provider racial concordance, in particular, were shown to improve pregnancy and birth experiences., (© 2022 Wiley Periodicals LLC.)

Background: Racial inequities in maternal and child health outcomes persist: Black women and birthing people experience higher rates of adverse outcomes than their white counterparts. Similar inequities are seen in coronavirus disease (COVID-19) mortality rates. In response, we sought to explore the intersections of racism and the COVID-19 pandemic impact on the daily lives and perinatal care experiences of Black birthing people., Methods: We used an intrinsic case study approach grounded in an intersectional lens to collect stories from Black pregnant and postpartum people residing in Fresno County (July-September 2020). All interviews were conducted on Zoom without video and were audio recorded and transcribed. Thematic analysis was used to group codes into larger themes., Results: Of the 34 participants included in this analysis, 76.5% identified as Black only, and 23.5% identified as multiracial including Black. Their mean age was 27.2 years [SD, 5.8]. Nearly half (47%) reported being married or living with their partner; all were eligible for Medi-Cal insurance. Interview times ranged from 23 to 96 min. Five themes emerged: (1) Tensions about Heightened Exposure of Black Lives Matter Movement during the pandemic; (2) Fear for Black Son's Safety; (3) Lack of Communication from Health Care Professionals; (4) Disrespect from Health Care Professionals; and (5) Misunderstood or Judged by Health Care Professionals. Participants stressed that the Black Lives Matter Movement is necessary and highlighted that society views their Black sons as a threat. They also reported experiencing unfair treatment and harassment while seeking perinatal care., Conclusions: Black women and birthing people shared that exposure to racism has heightened during the COVID-19 pandemic, increasing their levels of stress and anxiety. Understanding how racism impacts Black birthing people's lives and care experiences is critical to reforming the police force and revising enhanced prenatal care models to better address their needs., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: This study (1) assessed the psychometric properties of a pregnancy-related COVID worry scale, (2) explored variations in pregnancy-related COVID worry over the course of the pandemic, and (3) examined associations between pregnancy-related COVID worry and depressive symptom severity, and evaluated sleep disturbance as a mediator., Methods: Data were drawn from an ongoing randomized trial comparing the effectiveness of two enhanced forms of prenatal care. The current analysis includes baseline pre-randomization data collected from participants who enrolled November 2020-November 2021 (n = 201). Participants were pregnant individuals with low income and primarily Latinx., Results: Our 7-item scale was valid and reliable for assessing pregnancy-related COVID worry. Pregnancy-related COVID worry did not vary significantly by any participant characteristic or pandemic stage. Pregnancy-related COVID worry was significantly associated with depressive symptom severity in multivariate analysis (p = .002). For each unit increase on the 10-point pregnancy-related COVID worry scale, the odds of mild-to-severe depression increased by 16% (odds ratio = 1.16, 95% confidence interval 1.02-1.32, p = .02), holding all other variables constant. Sleep disturbance mediated the pregnancy-related COVID worry-depressive symptom relationship (48% of the total effect mediated)., Conclusions: Worry about how COVID may impact their baby, birth, and postpartum experiences was associated with higher depressive symptom severity, partly through its effect on sleep. These findings suggest that interventions related to improving sleep quality among perinatal populations may reduce depressive symptoms., Trial Registration: ClinicalTrials.gov NCT04154423, "Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) Study"., (Copyright © 2022. Published by Elsevier Ltd.)

Background: The COVID-19 pandemic has been associated with increased social and economic stressors among pregnant individuals. While community and social services have been available to mitigate stressors in pregnancy (e.g. food insecurity and financial hardship) and reduce the risk of adverse maternal outcomes, it is unclear how the pandemic impacted access to these resources, particularly in communities of color with lower incomes., Objective: To examine the experiences accessing community and social service resources during the COVID-19 pandemic among pregnant people of color with low incomes., Design: Participants for this COVID-related qualitative study were recruited from two sources-a prospective comparative effectiveness study of two models of enhanced prenatal care and the California Black Infant Health Program between August and November of 2020., Methods: We conducted 62 interviews with Medicaid-eligible participants in California's Central Valley. During their interviews, study participants were asked to share their pregnancy-related experiences, including how they felt the pandemic had affected those experiences., Results: We identified two broad themes: challenges with accessing community and social service resources during the pandemic and opportunities for improving access to these resources. Sub-themes related to challenges experienced included difficulty with remote access, convoluted enrollment processes for community and social services, and problems specific to accessing COVID-19 resources (e.g. testing). Sub-themes related to opportunities to improve access included leveraging instrumental support from perinatal staff and informational (e.g. practical) support from other community programs and pregnant peers. Participant recommendations included leveraging opportunities to improve client experiences through increased transparency and better patient-provider communication., Conclusion: This study highlights some important trends that emerged with the rollout of remote service delivery for social services among a vulnerable population. Many participants were able to leverage support through other programs and perinatal staff. These individuals identified additional opportunities to improve client experiences that can inform the future implementation of support services for pregnant people.

Recent evidence on perceived stress during the COVID-19 pandemic shows that birthing people experienced stress from pandemic-related stressors. While psychosocial stress is a significant predictor of adverse birth outcomes, social support can reduce stress levels during pregnancy. This study examined social support moderation of relationships between COVID-19-related stressors and perceived stress during pregnancy. The analysis included data from publicly insured pregnant participants who were enrolled in a randomized control trial of two enhanced prenatal care models in Fresno, California, and completed a third-trimester questionnaire between April and August 2020 (n = 77). Multivariate linear regression was used to estimate the associations between perceived stress and COVID-19-related stressors and social support moderation. COVID-19-related stressors related to childcare and tension at home remained significantly associated with perceived stress adjusting for sociodemographic characteristics and other COVID-19-related stressors. Social support moderated the relationship between perceived stress and loss of childcare (β = 2.4, 95 percent CI = 0.5-4.3, p = .014). Overall, social support moderated the association between COVID-19 stressors and perceived stress. While social support is commonly conceptualized as protective, the finding of greater stress around childcare among individuals reporting greater social support suggests complexity for leveraging these support networks during the pandemic.

Background: While annual cytology has not been recommended for many years, it remains many patients' preferred screening strategy for cervical cancer. Patient education and provider recommendations have been found effective in aligning professional society guidelines with patient preferences. We assessed whether an educational video with value elicitation exercises (utility assessments) changed screening strategy preferences among patients who had an initial preference for annual screening., Materials and Methods: We conducted an interventional study of English- or Spanish-speaking women 21-65 years of age, recruited from two women's health clinics in San Francisco, California ( n  = 262). Participants were asked about their preferred method of screening before viewing a 7-minute educational video and using a computerized tool that elicited values for 23 different health states related to cervical cancer screening. Directly afterward, they were again asked about their preferred screening strategy. Multivariable regression analysis was utilized to identify independent predictors of changing preferences., Results: Of 246 enrollees, 62.6% (154/246) had an initial preference for annual cytology; after viewing the video and completing the values elicitation exercises, about half (72/154, 47%) preferred a strategy other than annual screening. Having attended college and being screened every 3 to 5 years in the recent past were independent predictors of changing preferences away from annual screening. In sensitivity analyses, 53.2% of average-risk participants changed preferences away from annual cytology ( p  < 0.01)., Conclusions: Viewing an educational video and conducting a series of value elicitation exercises were associated with a substantially decreased likelihood of preferring annual screening. These findings underscore the importance of patient-centered education to help support informed patient preferences., Competing Interests: No competing financial interests exist., (© Elizabeth Schrier et al., 2022; Published by Mary Ann Liebert, Inc.)

Background: Maternal psychological stress has been linked to preterm birth. However, the differential contribution of psychological stress versus stress hormones is not clear. Studies focus primarily on perceived stress and cortisol, with few assessing its inter-convertible hormone cortisone. Furthermore, little is known about the potential moderating roles of obstetric risk and fetal sex in the relationship between maternal stress and gestational length. This gap in knowledge is particularly evident for rural women who typically experience chronic multiple stressors during pregnancy. We explored the relationship of hormonal and psychological stress to gestational length and the effects of obstetric risks and fetal sex on this relationship among Kenyan pregnant women., Methods: The sample included 130 women recruited between 22 to 28 weeks gestation. They completed a clinical and sociodemographic questionnaire together with the Perceived Stress Scale and provided a hair sample for cortisol and cortisone assay. Women underwent an ultrasound to assess weeks of gestation. At delivery, their pregnancy-related health problems were identified using information extracted from medical records to compile each woman's number of pregnancy risks on the Obstetric Medical Risk Index (OMRI)., Results: Perceived stress and hair cortisol were not significant predictors of gestational length. However, a greater number of obstetric risks on the OMRI was associated with shorter gestational length. This effect was further explained by the interaction between obstetric risk and hair cortisone ( B = 0.709, p = 0.02). Hair cortisone levels of mothers who had a shorter gestation were significantly higher in mothers with 2 or more risks on the OMRI but not among mothers with only one or no risks ( t = 2.39, p = 0.02). Fetal sex had no relationship to gestational length and also had no moderating effect on the relationship between any stress-related metric and gestational length., Conclusion: Cortisone levels may increase in anticipation of shorter gestation as a compensatory response to increased obstetric risk. Elevated cortisone may be a more sensitive marker of risk for early delivery than cortisol or psychological stress, with salience for both the male and female fetus., (Copyright © 2022 Musana, Cohen, Kuppermann, Gerona, Wanyoro, Aguilar, Santos, Temmerman and Weiss.)

Introduction: Mistreatment by health care providers disproportionately affects Black, Indigenous, and other people of color in the United States. The goal of this study is to adapt the global Person-Centered Maternity Care (PCMC) scale for use in the United States, with particular attention to the experiences of Black women and birthing people., Methods: We used a community-engaged approach including expert reviews and cognitive interviews to assess content validity, relevance, comprehension, and comprehensiveness of the PCMC items. Surveys of 297 postpartum people, 82% of whom identified as Black, were used for psychometric analysis in which we assessed construct and criterion validity and reliability. The University of California, San Francisco California Preterm Birth Initiative's Community Advisory Board, which consists of community members, community-based health workers, and social service providers in Northern California, provided input during all stages of the project., Results: Through an iterative process of factor analysis, discussions with the Community Advisory Board, and a prioritization survey, we eliminated items that performed poorly in psychometric analysis, yielding a 35-item PCMC-U.S. scale with subscales for dignity and respect, communication and autonomy, and responsive and supportive care. The Cronbach's alpha for the full scale is 0.95 and for the subscales is 0.87. Standardized summative scores range from 0 to 100, with higher scores indicating more PCMC. Correlations with related measures indicated high criterion validity., Conclusions: The 35-item PCMC-U.S. scale and its subscales have high validity and reliability in a sample of predominantly Black women. This scale provides a tool to support efforts to reduce the inequities in birth outcomes experienced by Black, Indigenous, and other people of color., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: Current cervical cancer screening guidelines recommend 3-year screening intervals, in contrast to the previous recommendation of annual screening, to prevent over screening and overtreatment. We evaluated the impact of viewing a tablet-based educational tool prior to seeing a clinician on young women's knowledge and understanding of cervical cancer screening, HPV vaccination follow-up of abnormal pap smears, and comfort in communicating with their providers., Methods: This cross-sectional study was part of a cluster-randomized study of fourteen primary care clinics from January 2015 to December 2016. We developed the cervical cancer education tool in English and Spanish using a community-based approach that included formative work and cognitive interviewing. Clinics were randomized to use the intervention (tablet-based patient education tool) or to participate as a control group. We administered surveys to a convenience sample of 229 English- or Spanish-speaking women aged 19 to 35 years in these clinics. We used descriptive analyses and logistic regression models with cluster-robust standard errors to compare differences among the two groups., Results: Compared to women seen in control clinics, women seen in intervention clinics demonstrated greater knowledge regarding human papilloma virus (HPV (p = 0.004) and understanding (p < 0.001) of cervical cancer screening. Comfort in communicating with providers was not statistically different (p = 0.053). Women in the intervention group felt that the tool helped them understand that an abnormal Pap smear does not require immediate treatment (61.5%)., Conclusion: Innovative online patient education that is offered prior to patients' interaction with their clinicians can improve their knowledge about cervical cancer prevention and treatment., (© 2022. The Author(s).)

Objective: The objective of this study was to explore clinician perceptions of how racism affects Black women's pregnancy experiences, perinatal care, and birth outcomes., Materials and Methods: We conducted 25 semi-structured interviews with perinatal care clinicians practicing in the San Francisco Bay Area (January to March 2019) who serve racially diverse women. Participants were primarily recruited through "Dear Perinatal Care Provider" email correspondences sent through department listservs. Culturally concordant, qualitatively trained research assistants conducted all interviews in person. The interviews ranged from 30 to 60 minutes and were audio-recorded and professionally transcribed verbatim. We used the constant comparative method consistent with grounded theory to analyze data., Results: Most participants were obstetrician/gynecologists ( n  = 11, 44%) or certified nurse midwives ( n  = 8, 32%), had worked in their current role for 1 to 5 years ( n  = 10, 40%), and identified as white ( n  = 16, 64%). Three themes emerged from the interviews: provision of inequitable care ( e.g. , I had a woman who had a massive complication during her labor course and felt like she wasn't being treated seriously ); surveillance of Black women and families ( e.g. , A urine tox screen on the Black baby even though it was not indicated, and they didn't do it on the white baby when, in fact, it was indicated ); and structural care issues ( e.g. , the history of medical racial experimentation )., Conclusion: Clinicians' views about how racism is currently operating and negatively impacting Black women's care experiences, health outcomes, and well-being in medical institutions will be used to develop a racial equity training for perinatal care clinicians in collaboration with Black women and clinicians., Competing Interests: No competing financial interests exist., (© Brittany D. Chambers et al., 2022; Published by Mary Ann Liebert, Inc.)

Objective: To describe and compare how obstetric patients and care providers view preterm birth risk assessment and communication., Methods: We conducted eight focus groups with obstetric patients (n = 35) and 16 qualitative interviews with obstetric providers. Grounded theory was used to identify and analyze themes., Results: Patients' knowledge about preterm birth varied greatly. Similar benefits and risks of preterm birth risk counseling were discussed by patients and providers with notable exceptions: patients cited preparedness as a benefit and providers cited maternal blame, patient alienation, and estimate uncertainty as potential risks. Most patients expressed a desire to know their personalized preterm birth risk during pregnancy. Providers differed in whether they offer universal versus selective, and quantitative versus qualitative, preterm birth risk counseling. Many providers expressed concern about discussing social and structural risk factors for preterm birth., Conclusion: While many patients desired knowing their personalized preterm birth risk, prenatal care providers' disclosure practices vary because of uncertainty of estimates, concerns about negative consequences and challenges of addressing systemic inequities and social determinants of health., Practice Implications: Given the existing asymmetry of information about preterm birth risk, providers should consider patient preferences regarding and potential benefits and risks of such disclosure in their practice., Competing Interests: Declarations of interest None., (Copyright © 2021. Published by Elsevier B.V.)

Objective: To elicit advice from women who have experienced periviable birth to optimize periviable counseling, care, and decision support., Methods: We conducted a qualitative study among 21 women who experienced periviable deliveries within three years. Using semi-structured interviews, we asked participants what advice they would offer providers and women/families based on their own experiences. Interviews were independently coded by three trained coders., Results: For providers: Participants said to be 'patient' and appreciate the novelty of each family's experience. They suggested being 'realistic' and 'factual'; favored joint OB/Neonatology counseling; and encouraged providers to attend to maternal guilt and self-blame. For women/families: They encouraged asking questions, avoiding the internet, and finding joy in whatever time they had with their child. For hospitals: They advocated for changes to facilitate more mother/baby contact., Conclusion: Providers can support parents by presenting facts, showing empathy and patience, and reassuring women that they are not to blame. This study highlights patient perspectives to improve interactions with providers, optimize women/families' experiences, and advance efforts toward developing patient-centered systems of periviable care., Practice Implications: Women who experience periviable birth desire counseling that is empathetic and 'realistic', encouragement to ask questions, and reassurance that outcomes are not their fault., (Copyright © 2021. Published by Elsevier B.V.)

Background: Given the stark disparities in maternal mortality and adverse birth outcomes among Black, indigenous, and other people of color, there is a need to better understand and measure how individuals from these communities experience their care during pregnancy., Objective: This study aimed to develop and validate a tool that can be used to measure person-centered prenatal care that reflects the experiences of people of color., Study Design: We followed standard procedures for scale development-integrated with community-based participatory approaches-to adapt a person-centered maternity care scale that was initially developed and validated for intrapartum care in low-resource countries to reflect the needs and prenatal care experiences of people of color in the United States. The adaptation process included expert reviews with a Community Advisory Board, consisting of community members, community-based health workers, and social service providers from San Francisco, Oakland, and Fresno, to assess content validity. We conducted cognitive interviews with potential respondents to assess the clarity, appropriateness, and relevance of the questions, which were then refined and administered in an online survey to people in California who had given birth in the past year. Data from 293 respondents (84% of whom identified as Black) who received prenatal care were used in psychometric analysis to assess construct and criterion validity and reliability., Results: Exploratory factor analysis yielded 3 factors with eigenvalues of >1, but with 1 dominant factor. A 34-item version of the person-centered prenatal care scale was developed based on factor analyses and recommendations from the Community Advisory Board. We also developed a 26-item version using stricter criteria for relevance, factor loadings, and uniqueness. Items were grouped into 3 conceptual domains representing subscales for "dignity and respect," "communication and autonomy," and "responsive and supportive care." The Cronbach alphas for the 34-item and the 26-item versions and for the subscales were >0.8. Scores based on the sum of responses for the 2 person-centered prenatal care scale versions and all subscales were standardized to range from 0 to 100, where higher scores indicate more person-centered prenatal care. These scores were correlated with global measures of prenatal care satisfaction suggesting good criterion validity., Conclusion: We present 2 versions of the person-centered prenatal care scale: a 34-item and a 26-item version. Both versions have high validity and reliability in a sample made up predominantly of Black women. This scale will facilitate measurement to improve person-centered prenatal care for people of color and could contribute to reducing disparities in birth outcomes. The similarity with the original scale also suggests that the person-centered prenatal care may be applicable across different contexts. However, validation with more diverse samples in additional settings is needed., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

This project examines risk and protective factors for preterm birth (PTB) among Black women in Oakland, California. Women with singleton births in 2011-2017 (n = 6199) were included. Risk and protective factors for PTB and independent risk groups were identified using logistic regression and recursive partitioning. Having less than 3 prenatal care visits was associated with highest PTB risk. Hypertension (preexisting, gestational), previous PTB, and unknown Women, Infant, Children (WIC) program participation were associated with a two-fold increased risk for PTB. Maternal birth outside of the USA and participation in WIC were protective. Broad differences in rates, risks, and protective factors for PTB were observed., (© 2020. W. Montague Cobb-NMA Health Institute.)

Introduction: Our understanding of the association between coronavirus disease 19 (COVID-19) and preterm or early term birth among racially and ethnically diverse populations and people with chronic medical conditions is limited., Methods: We determined the association between COVID-19 and preterm (PTB) birth among live births documented by California Vital Statistics birth certificates between July 2020 and January 2021 (n=240,147). We used best obstetric estimate of gestational age to classify births as very preterm (VPTB, <32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks), as each confer independent risks to infant health and development. Separately, we calculated the joint effects of COVID-19 diagnosis, hypertension, diabetes, and obesity on PTB and VPTB., Findings: COVID-19 diagnoses on birth certificates increased for all racial/ethnic groups between July 2020 and January 2021 and were highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). There was no effect modification of the overall association by race/ethnicity or insurance status. COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity., Interpretation: In a large population-based study, COVID-19 diagnosis increased the risk of VPTB, PTB, and early term birth, particularly among people with medical comorbidities. Considering increased circulation of COVID-19 variants, preventative measures, including vaccination, should be prioritized for birthing persons., Funding: UCSF-Kaiser Department of Research Building Interdisciplinary Research Careers in Women's Health Program (BIRCWH) National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH) [K12 HD052163] and the California Preterm Birth Initiative, funded by Marc and Lynn Benioff., Competing Interests: The authors have no conflicts of interest to disclose., (© 2021 The Authors. Published by Elsevier Ltd.)

Background: To report user-centered design methods and stakeholder acceptability ratings of the Periviable GOALS (Getting Optimal Alignment around Life Support) decision aid (DA)., Methods: 'Experienced' and 'expectant' mothers engaged in content and design refining sessions. Five videos (10 families) were embedded in the DA to highlight life after delivery. User-testing sessions were conducted with mothers and providers to assess acceptability. End-user testing was conducted with hospitalized women facing potential periviable delivery to assess acceptability and feasibility in the clinical setting., Results: 108 participants engaged in sessions from July 2017-January 2020. Twenty-seven refining sessions resulted in a DA providing survival estimates, neonatal outcomes descriptions, and values clarification exercises. Five white and five black women participated in the videos; six having surviving children (ages 16 months-4 years). Twelve mothers, 16 providers, and six hospitalized women evaluated acceptability. 95.1 % found the content "just right," 94.9 % rated the videos "good" or "excellent," and 97.2 % believed GOALS would support families in periviable decision-making., Conclusion: Our results highlight the importance of developing a DA that is acceptable for patient use with direct involvement of stakeholders., Practice Implications: The GOALS DA may prepare families to engage in shared decision-making to facilitate more patient-centered models of periviable care., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Introduction: This study sought to determine whether a provider mobile phone application, used with or without a patient educational tool accessed on a computer tablet, would promote adherence to guidelines for cervical cancer screening and management of abnormal cytology in young women., Methods: The study was conducted as a prospective cohort study in which 14 Family Planning, Access, Care, and Treatment provider clinics were randomized to 1 of 2 arms: (1) provider mobile phone application only or (2) provider mobile phone application plus patient educational tool. The provider mobile phone application gave information to providers regarding cervical cancer screening and management of abnormal cytology. The patient educational tool accessed on a computer tablet was a patient-centered educational tool. Each arm was compared with clinic control groups (no intervention) in a 2:1 ratio (control:intervention). Claims data were used to calculate and compare 18-month cytology (Pap) and colposcopy rates before the intervention and during the 18 months using the Poisson mixed-effect regression model. A sensitivity analysis examined the differences in the rate of change between each arm and controls. The study took place between July 2015 and December 2016, and analysis was performed in 2019., Results: The clinics randomized to the provider mobile phone application plus patient educational tool arm and their control group achieved similar 18-month Pap rates (0.52, 95% CI=0.37, 0.74 and 0.68, 95% CI=0.53, 0.86, respectively) as well as the provider mobile phone application arm and their control group (0.44, 95% CI=0.33, 0.58 and 0.41, 95% CI=0.34, 0.51; p-values >0.1). In the sensitivity analysis, the difference in the rate of change in Pap rates for the provider mobile phone application plus patient educational tool arm and their control group before and during the intervention was -0.22 and -0.09, respectively (p=0.02), but no differences were seen between the provider mobile phone application arm and their control group. No significant changes were observed for colposcopy rates., Conclusions: Providing clinicians and patients with information on guidelines had no demonstrable effect on 18-month Pap and colposcopy rates in the regression model; however, results from the sensitivity analysis for the patient educational tool were encouraging., Trial Registration: This study is registered at www.clinicaltrials.gov NCT02270021., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Multifetal gestation is more frequent among gestational carrier pregnancies than non-surrogacy IVF pregnancies. We aimed to evaluate the association between multifetal gestation and obstetric and neonatal morbidity among gestational carrier pregnancies., Methods: Pooled cross-sectional study of birth certificate data from gestational carrier pregnancies in Utah from 2009 to 2018. Our primary outcome was a composite of severe obstetric morbidity; secondary outcomes included cesarean delivery (CD), hypertensive disorders of pregnancy, preterm birth (PTB), and a neonatal morbidity composite. Logistic regression was utilized to compare odds of these outcomes between gestational carrier pregnancies with and without multifetal gestation., Results: A total of 361 gestational carrier pregnancies resulted in the delivery of 435 neonates during the study period. Of these, 284 were singleton pregnancies, and 77 were multifetal, a multifetal gestation rate of 21.3%. Baseline demographic characteristics did not differ between singleton and multifetal gestations. Multifetal gestation was not associated with higher rates of severe obstetric morbidity (odds ratio [OR] 1.87, 95% confidence interval [CI] 0.34-10.39). Multifetal gestation was associated with increased odds of neonatal morbidity (OR 9.49, 95% CI 5.35-15.83); PTB < 37, 34, and 32 weeks (OR 21.88, 95% CI 11.64-41.12; OR 11.67, 95% CI 5.25-25.91; OR 8.79, 95% CI 3.41-22.68); and CD (OR 4.82, 95% CI 2.81-8.27)., Conclusion: Severe obstetric morbidity did not differ between singleton and multifetal gestations among gestational carrier pregnancies. However, multifetal gestation was associated with increased odds of neonatal morbidity, CD, and PTB. This information may be useful when counseling prospective gestational carriers and intended parents.

Over the past decade, increasing attention has been paid to intervening in individuals' health in the "preconception" period as an approach to optimizing pregnancy outcomes. Increasing attention to the structural and social determinants of health and to the need to prioritize reproductive autonomy has underscored the need to evolve the preconception health framework to center race equity and to engage with the historical and social context in which reproduction and reproductive health care occur. In this commentary, we describe the results of a meeting with a multidisciplinary group of maternal and child health experts, reproductive health researchers and practitioners, and Reproductive Justice leaders to define a new approach for clinical and public health systems to engage with the health of nonpregnant people. We describe a novel "Reproductive and Sexual Health Equity" framework, defined as an approach to comprehensively meet people's reproductive and sexual health needs, with explicit attention to structural influences on health and health care and grounded in a desire to achieve the highest level of health for all people and address inequities in health outcomes. Principles of the framework include centering the needs of and redistributing power to communities, having clinical and public health systems acknowledge historical and ongoing harms related to reproductive and sexual health, and addressing root causes of inequities. We conclude with a call to action for a multisectoral effort centered in equity to advance reproductive and sexual health across the reproductive life course., Competing Interests: Financial Disclosure UCSF hosted the expert panel that this work summarizes. All non-UCSF authors had travel, hotel and per diem expenses covered by UCSF, and were provided with an honorarium of $1,500. Aletha Y. Akers received funds from Merck, Inc. for serving on the HPV Advisory Panel, from the Association of Reproductive Health Professionals for serving on the HPV advisory group, and from Bayer Healthcare for an investigator-initiated grant. Barbara Levy disclosed receiving payments from AbbVie, Elidah Health, Dorsata, Acessa Health, Alydia Health, FLO Health, and Zebra Medical. Laura Jimenez disclosed that on occasion, her organization acts in an advisory capacity to various research entities that are under the UCSF umbrella. The other authors did not report any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.)

Purpose: We sought to characterize severe obstetric morbidity among women who are gestational carriers compared to other patients., Methods: This was a population-based study comparing gestational carrier pregnancies to non-surrogate pregnancies (non-surrogate IVF pregnancies, all non-gestational carrier pregnancies, and a cohort of matched controls) delivering in Utah between 2009 and 2018, using birth certificate data. Our primary outcome was a composite of severe morbidity, including death, ICU admission, eclampsia, HELLP syndrome, transfusion, and unplanned hysterectomy. Our secondary outcomes were cesarean delivery (CD) and hypertensive disorders of pregnancy., Results: During the study period, 361 gestational carrier pregnancies and 509,015 other pregnancies resulted in live births. Severe morbidity was less common among gestational carrier pregnancies than IVF pregnancies (1.7% versus 5.5%, odds ratio [OR] 0.29, 95% confidence interval [CI] 0.12-0.70), but was not different when compared to all other pregnancies (1.0%, OR 1.61, 95% CI 0.72-3.60), or a cohort of matched controls (1.0%, OR 1.37, 95% CI 0.55-3.40). CD was less common among gestational carrier pregnancies than IVF pregnancies, but not different than all other pregnancies or matched controls. While frequency of hypertensive disorders of pregnancy was lower among gestational carrier pregnancies than IVF pregnancies, it was higher than all other women who delivered and comparable to matched controls., Conclusion: Severe obstetric morbidity is uncommon among gestational carrier pregnancies. Women who are gestational carriers are at lower risk of morbidity and CD than others who conceive through IVF and do not appear to be at increased risk compared to matched controls.

Objectives: The purpose of this study was to characterize the stress experienced by pregnant women in Kenya and assess the relationship between perceived stress and stress-related biomarkers of cortisol and cortisone. Background: Kenyan women are exposed to multiple stressors that may result in chronic stress. However, antenatal stress has not been examined and characterized in Kenya; nor has the relationship between pregnant women's self-reported stress and stress biomarkers been established. Methods: One hundred and fifty women were recruited between 22 and 28 weeks gestation. Participants completed the Perceived Stress Scale (PSS) and a sociodemographic questionnaire. Hair samples were obtained for analysis of cortisol and cortisone. Factor analysis was used to extract unique clusters of stress symptoms from items in the PSS. Regression models were computed to examine relationships of stress to cortisone and cortisol, controlling for obstetric risk. Results: Mean age of the women was 25 years (SD = 5, ±16-41). Their degree of perceived stress and cortisol/cortisone concentrations both indicated moderate levels of stress. There was no association between general perceived stress and either hair cortisol or cortisone. However, factor analysis of the PSS identified three clusters of stress symptoms and one cluster - a woman's negative frame of mind regarding life and inefficacy in handling its problems - was associated with higher levels of cortisone (β= -.231, p  = 0.011). Conclusions: Specific stress symptoms may have unique relationships to specific biomarkers and be more useful in assessment than general perceived stress. Assays of both hair cortisol and cortisone might enable a more comprehensive assessment of glucocorticoid activity and better prediction of health risks from stress.Lay summaryUnderstanding stress among rural pregnant Kenyan women may help in addressing risks during pregnancy that lead to adverse birth outcomes. Findings suggest that a woman's tendency to think negatively about life and to doubt her ability to handle life's problems are symptoms of stress that may contribute to higher levels of stress hormones. Assessing women's specific symptoms of stress and different stress hormones during pregnancy may more effectively identify women who need intervention to reduce their health risk.

Objective: To explore the role of reproductive travel (travel to another state or country for reproductive services) for intended parents at the time of delivery of gestational carrier pregnancies and to analyze the sociodemographic characteristics of those who build families through gestational surrogacy., Methods: We conducted a cross-sectional study of births involving gestational surrogacy in Utah from 2009 to 2018. Data were obtained from birth certificates. State and country of residence were collected for intended parents, and the legal climates of these locations were assessed by reviewing laws at the time. Sociodemographic characteristics were compared among intended parents, parents with pregnancies resulting from assisted reproductive technology (ART) without gestational surrogacy, and parents with spontaneous pregnancies., Results: A total of 361 gestational carrier pregnancies resulted in the birth of at least one liveborn neonate during the study period, involving 715 intended parents. Additionally, 50,434 parents delivered children after nonsurrogacy ART, and 950,460 parents delivered children after spontaneous fertilization. Many intended parents (17.2%) lived in countries outside of the United States, the majority of which (69.9%) had laws against surrogacy. Of those who lived within the United States, 57.4% lived outside of Utah, but only 15.9% lived in states that banned compensated surrogacy. Statutes in Utah support compensated and uncompensated gestational surrogacy. Intended parents were significantly older than parents with both nonsurrogacy ART pregnancies and spontaneous pregnancies (median age 38, 31, and 29 years, respectively) and had higher levels of education; 70.2% of intended parents had a bachelor's degree or above, compared with 48.2% of parents with nonsurrogacy ART pregnancies and 33.1% of parents with spontaneous pregnancies., Discussion: A majority of intended parents live outside of Utah, which may be an important consideration for health care professionals caring for women with gestational carrier pregnancies. However, most intended parents live in places that do not have laws banning surrogacy, suggesting that there may be other reasons that intended parents travel for delivery.

Purpose. In 2018, the US Preventive Services Task Force (USPSTF) endorsed three strategies for cervical cancer screening in women ages 30 to 65: cytology every 3 years, testing for high-risk types of human papillomavirus (hrHPV) every 5 years, and cytology plus hrHPV testing (co-testing) every 5 years. It further recommended that women discuss with health care providers which testing strategy is best for them. To inform such discussions, we used decision analysis to estimate outcomes of screening strategies recommended for women at age 30. Methods. We constructed a Markov decision model using estimates of the natural history of HPV and cervical neoplasia. We evaluated the three USPSTF-endorsed strategies, hrHPV testing every 3 years and no screening. Outcomes included colposcopies with biopsy, false-positive testing (a colposcopy in which no cervical intraepithelial neoplasia grade 2 or worse was found), treatments, cancers, and cancer mortality expressed per 10,000 women over a shorter-than-lifetime horizon (15-year). Results. All strategies resulted in substantially lower cancer and cancer death rates compared with no screening. Strategies with the lowest likelihood of cancer and cancer death generally had higher likelihood of colposcopy and false-positive testing. Conclusions. The screening strategies we evaluated involved tradeoffs in terms of benefits and harms. Because individual women may place different weights on these projected outcomes, the optimal choice for each woman may best be discerned through shared decision making., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2020.)

Objective: To evaluate whether deviation from American Society for Reproductive Medicine (ASRM) safety guidelines for women who are gestational carriers is associated with increased risk of severe obstetric and perinatal morbidity and mortality., Methods: This is a cross-sectional study of births from gestational carrier pregnancies in Utah from 2009 to 2018 with data collected from birth certificates. Deviations from ASRM guidelines include women aged younger than 21 years or older than 45 years, nulliparity, prior stillbirth, tobacco or percutaneous drug use, more than five prior deliveries, more than three prior cesarean deliveries, major comorbidities, and mental health conditions. The primary outcome was a composite of severe obstetric morbidity and mortality (death within 1 year of delivery; intensive care unit admission; eclampsia; hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome; transfusion; unplanned hysterectomy). Secondary outcomes were cesarean delivery, gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm delivery (analyzed per pregnancy), and a composite neonatal outcome. Associations were analyzed using descriptive statistics and multivariable logistic regression., Results: A total of 361 gestational carrier deliveries of 435 neonates were included in this analysis. Sixteen percent (58/361) of pregnancies did not meet guidelines. Rates of severe obstetric morbidity or mortality did not differ between gestational carrier pregnancies that deviated from guidelines and those that did not (1.7% for both, odds ratio [OR] 1.04, 95% CI 0.12-9.12). Rate of cesarean delivery was higher among pregnancies that deviated from guidelines (36.2% vs 23.4%, OR 1.85, 95% CI 1.02-3.37). Rates of gestational diabetes mellitus and hypertensive disorders of pregnancy did not differ. Preterm delivery was also more common among pregnancies that deviated from guidelines, particularly after controlling for multifetal gestation (36.2% vs 23.4%, adjusted OR 2.16, 95% CI 1.04-4.48). Neonatal complications were significantly more common in pregnancies that did not meet guidelines, even after adjusting for gestational age and multifetal gestation (adjusted OR 3.66, 95% CI 1.44-9.29)., Conclusion: Nearly one in five gestational carrier pregnancies in this cohort did not meet ASRM guidelines. Deviation from guidelines is associated with increased rate of cesarean delivery, neonatal morbidity, and preterm birth. Future research should focus on the safety of women who are gestational carriers and on why deviation occurs.

Objectives. Health utility estimates from the current era of HIV treatment, critical for cost-effectiveness analyses (CEA) informing HIV health policy, are limited. We examined peer-reviewed literature to assess the appropriateness of commonly referenced utilities, present previously unreported quality-of-life data from two studies, and discuss future implications for HIV-related CEA. Methods. We searched a database of cost-effectiveness analyses specific to HIV prevention efforts from 1999 to 2016 to identify the most commonly referenced sources for health utilities and to examine practices around using and reporting health utility data. Additionally, we present new utility estimates from the Centers of Disease Control and Prevention's Medical Monitoring Project (MMP) and the INSIGHT Strategies for Management of Anti-Retroviral Therapy (SMART) trial. We compare data collection time frames, sample characteristics, assessment methods, and key estimates. Results. Data collection for the most frequently cited utility estimates ranged from 1985 to 1997, predating modern HIV treatment. Reporting practices around utility weights are poor and lack details on participant characteristics, which may be important stratifying factors for CEA. More recent utility estimates derived from MMP and SMART were similar across CD4+ count strata and had a narrower range than pre-antiretroviral therapy (ART) utilities. Conclusions. Despite the widespread use of ART, cost-effectiveness analysis of HIV prevention interventions frequently apply pre-ART health utility weights. Use of utility weights reflecting the current state of the US epidemic are needed to best inform HIV research and public policy decisions. Improved practices around the selection, application, and reporting of health utility data used in HIV prevention CEA are needed to improve transparency., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

It is unknown whether the HPV vaccine is effective in immunocompromised women during catch-up ages. We performed a case-control study of 4,357 women with incident CIN2+ (cases) and 5:1 age-matched, incidence-density selected controls (N = 21,773) enrolled in an integrated health care system from 2006 to 2014. Vaccine effectiveness was estimated from multivariable conditional logistic regression models, with results stratified by immunosuppression history, defined as prior HIV infection, solid organ transplant history, or recently prescribed immunosuppressive medications. HPV vaccination resulted in a 19% reduction in CIN2+ rates for women without an immunosuppression history but a nonsignificant 4% reduction for women with an immunosuppression history. Further research is needed to evaluate whether catch-up HPV vaccine effectiveness varies by immunosuppression status, especially given the recent approval of the HPV vaccine for adults up to 45 years of age., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Importance: Reducing cesarean delivery rates in the US is an important public health goal; despite evidence of the safety of vaginal birth after cesarean delivery, most women have scheduled repeat cesarean deliveries. A decision support tool could help increase trial-of-labor rates., Objective: To analyze the effect of a patient-centered decision support tool on rates of trial of labor and vaginal birth after cesarean delivery and decision quality., Design, Setting, and Participants: Multicenter, randomized, parallel-group clinical trial conducted in Boston, Chicago, and the San Francisco Bay area. A total of 1485 English- or Spanish-speaking women with 1 prior cesarean delivery and no contraindication to trial of labor were enrolled between January 2016 and January 2019; follow-up was completed in June 2019., Interventions: Participants were randomized to use a tablet-based decision support tool prior to 25 weeks' gestation (n=742) or to receive usual care (without the tool) (n=743)., Main Outcomes and Measures: The primary outcome was trial of labor; vaginal birth was the main secondary outcome. Other secondary outcomes focused on maternal and neonatal outcomes and decision quality., Results: Among 1485 patients (mean age, 34.0 [SD, 4.5] years), 1470 (99.0%) completed the trial (n = 735 in both randomization groups) and were included in the analysis. Trial-of-labor rates did not differ significantly between intervention and control groups (43.3% vs 46.2%, respectively; adjusted absolute risk difference, -2.78% [95% CI, -7.80% to 2.25%]; adjusted relative risk, 0.94 [95% CI, 0.84-1.05]). There were no statistically significant differences in vaginal birth rates (31.8% in both groups; adjusted absolute risk difference, -0.04% [95% CI, -4.80% to 4.71%]; adjusted relative risk, 1.00 [95% CI, 0.86-1.16]) or in any of the other 6 clinical maternal and neonatal secondary outcomes. There also were no significant differences between the intervention and control groups in the 5 decision quality measures (eg, mean decisional conflict scores were 17.2 and 17.5, respectively; adjusted mean difference, -0.38 [95% CI, -1.81 to 1.05]; scores >25 are considered clinically important)., Conclusions and Relevance: Among women with 1 previous cesarean delivery, use of a decision support tool compared with usual care did not significantly change the rate of trial of labor. Further research may be needed to assess the efficacy of this tool in other clinical settings or when implemented at other times in pregnancy.

Objective: To compare differences in patient-provider communication among patients who, prior to contraceptive counseling, used or did not use a decision support tool ("My Birth Control") which has educational and interactive modules and produces a provider printout with the patient's preferences., Methods: As part of a cluster-randomized trial of the tool in four San Francisco safety net clinics, we collected and thematically analyzed 70 audio recordings of counseling visits (31 pre- and 39 post-tool implementation) from 15 providers randomized to the intervention., Results: Without the tool, most providers began by asking participants what method they were considering and focused counseling on that method or on directing patients towards long-acting reversible contraception; with the tool, most focused on reviewing and discussing multiple methods of interest to the participant as indicated on the printout. Discussion of patients' preferences for specific method features was not observed in pre-implementation recordings but was part of several post-implementation recordings. Several participants explicitly noted they had gained knowledge from the tool., Conclusion: Observed counseling differences suggest the tool may have a positive impact on patient-centeredness of contraceptive counseling, consistent with findings from the main study., Practice Implications: My Birth Control shows potential for improving patient-centeredness in counseling without extensive provider training., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Hospital policies restricting access to trial of labor after cesarean (TOLAC) are prevalent. Many women with a previous cesarean birth are affected by these bans, but there are limited data on the effect of these bans and whether women would consider changing delivery hospitals in the setting of a real or hypothetical TOLAC ban., Methods: This was a survey of TOLAC-eligible women receiving prenatal care at four hospitals where TOLAC is available, and 1 non-TOLAC site. Participants were asked about their likelihood of switching hospitals to pursue TOLAC if it were unavailable. Women at the non-TOLAC site had their medical records reviewed to ascertain final location and approach to delivery., Results: A total of 297 women were interviewed, 48 from the non-TOLAC site. 162 (54%) participants indicated they would transfer care if TOLAC were unavailable. Among women at the non-TOLAC site, 57% who indicated an intention to switch hospitals did so. In a multivariable logistic regression model, variables associated with transferring care included race/ethnicity other than Latina (aOR 25.20 [95% CI 2.23-284.26]), being unaware of the TOLAC ban (19.81 [1.99-196.64]), and perceiving that a close friend/relative thought they should undergo TOLAC (17.31 [1.70-176.06])., Conclusions: More than half of women with prior cesarean would consider transferring care if TOLAC became unavailable, and more than 1 of 3 of women at a non-TOLAC site transferred care. More research is needed on the impact of TOLAC bans and how to facilitate transfer for those who desire TOLAC., (© 2019 Wiley Periodicals, Inc.)

Objectives: Barriers to the provision of patient-centered contraceptive counseling include time limitations, frequent misconceptions and misinformation about methods among patients, and the availability of numerous contraceptive options, which increases the complexity of contraceptive decision making. Decision support tools are interventions designed to facilitate quality decision making in preference-sensitive decisions. We evaluated the impact of a contraceptive decision support tool, My Birth Control, on providers' experience with contraceptive counseling., Study Design: We interviewed 15 providers who participated in the intervention arm of a cluster randomized controlled trial of My Birth Control to obtain their impressions of their patients' interactions with the tool. We analyzed the interviews using thematic analysis, compared appointment lengths of patients in each arm (n=749) and assessed provider burnout in each arm (n=28)., Results: Providers reported that incorporating My Birth Control into their practice helped them allocate time more efficiently, enabling them to hone in on patients' areas of interest. They also reported that patients who interacted with the tool appeared more informed about contraception options and features, and took a more active role in method selection. All providers described using the tool as acceptable and feasible, and indicated they would like to incorporate it into their practice. There was no difference in provider burnout scores comparing before and after the trial of My Birth Control., Conclusion: Providers had a positive impression of the impact of My Birth Control on contraceptive counseling, including the quality of counseling, and perceived the tool to be a feasible intervention to use in the clinical setting., Implications: Family planning clinics should consider incorporating My Birth Control into their clinical services as a means of improving contraceptive care and provider experience of counseling., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To evaluate the association of patient preferences and attitudes with TOLAC., Study Design: Prospective observational study of TOLAC-eligible women at 26-34 weeks gestation. Preferences (utilities) were elicited using the time trade-off and standard gamble metrics. Logistic regression was used to identify preference- and attitude-based factors associated with TOLAC., Results: Of the 231 participants, most (n = 197, 85%) preferred vaginal delivery, but only 40% (n = 93) underwent TOLAC. Utilities for uterine rupture outcomes did not differ based on delivery approach. In multivariable analysis, strength of preference for vaginal delivery, value for the experience of labor, and the opinion of the person whom the participant thought of as most important to this decision were associated with TOLAC., Conclusions: Future decision support interventions incorporating individualized information regarding the likelihood of vaginal birth and empowering patients to express their preferences and engage their families in the decision-making process may improve decision quality and increase TOLAC rates.

Background: The decrease in trial of labor after cesarean (TOLAC) at institutions that offer this option suggests that patient preference could be a factor in the declining TOLAC rate. However, data regarding how women value the potential processes and outcomes of TOLAC and elective repeat cesarean delivery (ERCD) are limited. We sought to determine how women view the processes and outcomes of TOLAC and ERCD and identify sociodemographic and clinical factors associated with these preferences. Materials and Methods: This is a multicenter cross-sectional study of mode of delivery preferences among TOLAC-eligible women at 26-34 weeks gestation. The time tradeoff metric was used to obtain utilities for the processes and outcomes of TOLAC and ERCD. Multivariable regression analysis was utilized to identify independent predictors of utilities. Results: The 299 study participants constituted a geographically and racially/ethnically diverse group. Although uncomplicated TOLAC resulting in vaginal birth after cesarean and uncomplicated ERCD resulted in high utility values, any alteration in either the process or outcome resulted in substantial utility decrements. In multivariable regression analysis, race/ethnicity, insurance status, and order of scenario presentation emerged as statistically significant predictors. Conclusions: Information regarding both maternal and infant implications is important to women in discussions about approach to delivery. Both the way in which information regarding labor interventions and potential complications is presented and the characteristics of the women contemplating this information affect its impact. These findings underscore the need for evidence-based decision support to help create realistic expectations and incorporate informed patient preferences into decision-making to optimize both clinical outcomes and individual patient experience for women with a prior cesarean delivery.

Importance: Many cervical cancer screening strategies are now recommended in the United States, but the benefits, harms, and costs of each option are unclear., Objective: To estimate the cost-effectiveness of 12 cervical cancer screening strategies., Design, Setting, and Participants: The cross-sectional portion of this study enrolled a convenience sample of 451 English-speaking or Spanish-speaking women aged 21 to 65 years from September 22, 2014, to June 16, 2016, identified at women's health clinics in San Francisco. In this group, utilities (preferences) were measured for 23 cervical cancer screening-associated health states and were applied to a decision model of type-specific high-risk human papillomavirus (hrHPV)-induced cervical carcinogenesis. Test accuracy estimates were abstracted from systematic reviews. The evaluated strategies were cytologic testing every 3 years for women aged 21 to 65 years with either repeat cytologic testing in 1 year or immediate hrHPV triage for atypical squamous cells of undetermined significance (ASC-US), cytologic testing every 3 years for women age 21 to 29 years followed by cytologic testing plus hrHPV testing (cotesting), or primary hrHPV testing alone for women aged 30 to 65 years. Screening frequency, abnormal test result management, and the age to switch from cytologic testing to hrHPV testing (25 or 30 years) were varied. Analyses were conducted from both the societal and health care sector perspectives., Main Outcomes and Measures: Utilities for 23 cervical cancer screening-associated health states (cross-sectional study) and quality-adjusted life-years (QALYs) and total costs for each strategy., Results: Utilities were measured in a sociodemographically diverse group of 451 women (mean [SD] age, 38.2 [10.7] years; 258 nonwhite [57.2%]). Cytologic testing every 3 years with repeat cytologic testing for ASC-US yielded the most lifetime QALYs and conferred more QALYs at higher costs ($2166 per QALY) than the lowest-cost strategy (cytologic testing every 3 years with hrHPV triage of ASC-US). All cytologic testing plus hrHPV testing (cotesting) and primary hrHPV testing strategies provided fewer QALYs at higher costs. Adding indirect costs did not change the conclusions. In sensitivity analyses, hrHPV testing every 5 years with genotyping triage beginning at age 30 years was the lowest-cost strategy when hrHPV test sensitivity was markedly higher than cytologic test sensitivity or when hrHPV test cost was equated to the lowest reported cytologic test cost ($14)., Conclusions and Relevance: Cytologic testing every 3 years for women aged 21 to 29 years with either continued cytologic testing every 3 years or switching to a low-cost hrHPV test every 5 years confers a reasonable balance of benefits, harms, and costs. Comparative modeling is needed to confirm the association of these novel utilities with cost-effectiveness.

Background: Research suggests the need for improvement in the patient-centeredness and comprehensiveness of contraceptive counseling. My Birth Control is a tablet-based decision support tool designed to improve women's experience of contraceptive counseling and to help them select contraceptive methods that are consistent with their values and preferences., Objective: The objective of this study was to evaluate the effect of My Birth Control on contraceptive continuation, experience of contraceptive care, and decision quality., Study Design: Using a cluster randomized design, randomized at the provider level, patient participants interested in starting or changing contraception interacted with My Birth Control before their family planning visit (intervention) or received usual care (control). A postvisit survey assessed experience of care method satisfaction, decision quality, and contraceptive knowledge. Surveys at 4 and 7 months assessed the primary outcome of contraceptive continuation, along with method use, satisfaction, and unintended pregnancy. Mixed-effects logistic regression models with multiple imputation for missing data were used to examine the effect of treatment assignment., Results: Twenty-eight providers participated and 758 patients enrolled between December 5, 2014, and February 5, 2016. Participants were racially/ethnically diverse; less than a quarter self-identified as white. No effect was found on 7-month continuation (56.6% and 59.6% for intervention and control group respectively, odds ratio, 0.89; 95% confidence interval, 0.65-1.22). However, assignment to the intervention group increased reporting of the greatest Interpersonal Quality of Family Planning score (66.0% vs 57.4%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), the greatest scores on the informed decision and uncertainty subscales of the Decisional Conflict Scale (50.5% vs 43.2%, odds ratio, 1.34; 95% confidence interval, 1.0-1.80 and 41.6% vs 33.3%, odds ratio, 1.45; 95% confidence interval, 1.03-2.05), and greater knowledge., Conclusion: My Birth Control had no effect on contraceptive continuation. The intervention did enhance the experience of contraceptive counseling and informed decision making, as well as contraceptive knowledge., The intervention's effect on patient experience is important, particularly given the personal nature of contraceptive decision making and the social and historical context of family planning care., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Shared decision-making (SDM) is optimal in the context of periviable delivery, where the decision to pursue life-support measures or palliation is both preference sensitive and value laden. We sought to develop a decision support tool (DST) prototype to facilitate SDM by utilizing a user-centered design research approach., Methods: We convened four patient and provider advisory boards with women and their partners who had experienced a surviving or non-surviving periviable delivery, pregnant women who had not experienced a prior preterm birth, and obstetric providers. Each 2-h session involved design research activities to generate ideas and facilitate sharing of values, goals, and attitudes. Participant feedback shaped the design of three prototypes (a tablet application, family story videos, and a virtual reality experience) to be tested in a final session., Results: Ninety-five individuals (48 mothers/partners; 47 providers) from two hospitals participated. Most participants agreed that the prototypes should include factual, unbiased outcomes and probabilities. Mothers and support partners also desired comprehensive explanations of delivery and care options, while providers wanted a tool to ease communication, help elicit values, and share patient experiences. Participants ultimately favored the tablet application and suggested that it include family testimonial videos., Conclusion: Our results suggest that a DST that combines unbiased information and understandable outcomes with family testimonials would be meaningful for periviable SDM. User-centered design was found to be a useful method for creating a DST prototype that may lead to improved effectiveness, usability, uptake, and dissemination in the future, by leveraging the expertise of a wide range of stakeholders.