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Background: Fetal growth nomograms were developed to screen for fetal growth restriction and guide clinical care to improve perinatal outcomes; however, existing literature remains inconclusive regarding which nomogram is the gold standard., Objective: This study aimed to compare the ability of 4 commonly used nomograms (Hadlock, International Fetal and Newborn Growth Consortium for the 21st Century, Eunice Kennedy Shriver National Institute of Child Health and Human Development-unified standard, and World Health Organization fetal growth charts) and 1 institution-specific reference to predict small for gestational age and poor neonatal outcomes., Study Design: This was a retrospective cohort study of all nonanomalous singleton pregnancies undergoing ultrasound at ≥20 weeks of gestation between 2013 and 2020 and delivering at a single academic center. Using random selection methods, the study sample was restricted to 1 pregnancy per patient and 1 ultrasound per pregnancy completed at ≥22 weeks of gestation. Fetal biometry data were used to calculate estimated fetal weight and percentiles according to the aforementioned 5 nomograms. Maternal and neonatal data were extracted from electronic medical records. Logistic regression was used to estimate the association between estimated fetal weight of <10th and <3rd percentiles compared with estimated fetal weight of 10th to 90th percentile as the reference group for small for gestational age and the neonatal composite outcomes (perinatal mortality, hypoxic-ischemic encephalopathy or seizures, respiratory morbidity, intraventricular hemorrhage, necrotizing enterocolitis, hyperbilirubinemia or hypoglycemia requiring neonatal intensive care unit admission, and retinopathy of prematurity). Receiver operating characteristic curve contrast estimation (primary analysis) and test characteristics were calculated for all nomograms and the prediction of small for gestational age and the neonatal composite outcomes. We restricted the sample to ultrasounds performed within 28 days of delivery; moreover, similar analyses were completed to assess the prediction of small for gestational age and neonatal composite outcomes., Results: Among 10,045 participants, the proportion of fetuses classified as <10th percentile varied across nomograms from 4.9% to 9.7%. Fetuses with an estimated fetal weight of <10th percentile had an increased risk of small for gestational age (odds ratio, 9.9 [95% confidence interval, 8.5-11.5] to 12.8 [95% confidence interval, 10.9-15.0]). In addition, the estimated fetal weight of <10th and <3rd percentile was associated with increased risk of the neonatal composite outcome (odds ratio, 2.4 [95% confidence interval, 2.0-2.8] to 3.5 [95% confidence interval, 2.9-4.3] and 5.7 [95% confidence interval, 4.5-7.2] to 8.8 [95% confidence interval, 6.6-11.8], respectively). The prediction of small for gestational age with an estimated fetal weight of <10th percentile had a positive likelihood ratio of 6.3 to 8.5 and an area under the curve of 0.62 to 0.67. Similarly, the prediction of the neonatal composite outcome with an estimated fetal weight of <10th percentile had a positive likelihood ratio of 2.1 to 3.1 and an area under the curve of 0.55 to 0.57. When analyses were restricted to ultrasound within 4 weeks of delivery, among fetuses with an estimated fetal weight of <10th percentile, the risk of small for gestational age increased across all nomograms (odds ratio, 16.7 [95% confidence interval, 12.6-22.3] to 25.1 [95% confidence interval, 17.0-37.0]), and prediction improved (positive likelihood ratio, 8.3-15.0; area under the curve, 0.69-0.75). Similarly, the risk of neonatal composite outcome increased (odds ratio, 3.2 [95% confidence interval, 2.4-4.2] to 5.2 [95% confidence interval, 3.8-7.2]), and prediction marginally improved (positive likelihood ratio, 2.4-4.1; area under the curve, 0.60-0.62). Importantly, the risk of both being small for gestational age and having the neonatal composite outcome further increased (odds ratio, 21.4 [95% confidence interval, 13.6-33.6] to 28.7 (95% confidence interval, 18.6-44.3]), and the prediction of concurrent small for gestational age and neonatal composite outcome greatly improved (positive likelihood ratio, 6.0-10.0; area under the curve, 0.80-0.83)., Conclusion: In this large cohort, Hadlock, recent fetal growth nomograms, and a local population-derived fetal growth reference performed comparably in the prediction of small for gestational age and neonatal composite outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The American College of Obstetricians and Gynecologists recommends that pregnant patients receive expeditious treatment with first-line antihypertensive agents within 1 hour of confirmed severe hypertension to reduce the risk for maternal stroke. However, it is unknown how often this guideline is followed and what factors influence a patient's likelihood of receiving guideline-concordant care., Objective: We aimed to identify factors associated with receiving guideline-concordant treatment for an obstetrical hypertensive emergency., Study Design: We present a case-control study of all pregnant and postpartum patients who had persistent severe hypertension (≥2 systolic blood pressures ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, or both within 1 hour of each other) during their delivery hospitalization at a tertiary hospital from October 1, 2013, to August 31, 2020. Data were extracted from the hospital electronic medical records using standard definitions and billing and diagnosis codes. We defined receipt of the recommended treatment as administration of a first-line antihypertensive agent (intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine) within 60 minutes of the first or second severe-range blood pressure measurement during their delivery hospitalization. Delayed treatment was defined as the administration of a first-line agent >60 minutes after the second elevated blood pressure measurement. Patients were considered untreated if a first-line agent was never administered. Maternal sociodemographic, clinical and pregnancy factors, and time and day of the week of the hypertensive emergency were compared among patients who received the recommended treatment, those who received delayed treatment, and those who were untreated. Bivariate analyses were performed, and multinomial and multivariable logistic regression models were used to adjust for potential confounders., Results: Of the 39,918 deliveries in the cohort, 1987 (5.0%) were complicated by severe, persistent obstetrical hypertension. Of these patients, 532 (26.8%) received the recommended treatment, 356 (17.9%) received delayed treatment, and 1099 (55.3%) did not receive any first-line antihypertensive therapy. The multinomial regression models that were used to compare these 3 groups indicated that patients who received the recommended treatment were more likely to be Black (adjusted odds ratio, 1.85; 95% confidence interval, 1.36-2.51), Hispanic (adjusted odds ratio, 1.77; 95% confidence interval, 1.28-2.52), or pregnant and at <37 weeks of gestation (adjusted odds ratio, 6.65; 95% confidence interval, 5.08-8.72). Treatment was less likely if the severe obstetrical hypertension emergency occurred overnight (7:00 PM to 6:59 AM) (adjusted odds ratio, 0.79; 95% confidence interval, 0.64-0.97) or during the postpartum period (adjusted odds ratio, 0.66; 95% confidence interval, 0.51-0.86)., Conclusion: Approximately half of obstetrical patients with at least 2 documented severely elevated blood pressure measurements did not receive the recommended antihypertensive treatment. Of those who did receive treatment, about 40% had delayed treatment. Black and Hispanic race and preterm gestation were associated with an increased likelihood of receiving the recommended treatment when compared with White race and term pregnancies. Patients whose severe obstetrical hypertension emergency occurred overnight and those who were postpartum were less likely to receive any first-line antihypertensive treatment. Overall, patients without sociodemographic and clinical risk factors for severe obstetrical hypertension or other pregnancy complications were less likely to be treated. However, treatment improved significantly over time with the implementation of targeted quality measures and specific institutional policies based on the American College of Obstetricians and Gynecologists' latest severe obstetrical hypertension management guidelines., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Hypertension was redefined in 2017 with lower diagnostic thresholds; elevated blood pressure is defined as systolic blood pressure of 120 to 129 mm Hg with diastolic blood pressure of <80 mm Hg and stage 1 hypertension as systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg. These guidelines did not include pregnant women. There is limited information on stage 1 hypertension and pregnancy outcomes., Objective: This study aimed to determine whether elevated blood pressure and stage 1 hypertension as newly defined by the 2017 American College of Cardiology and the American Heart Association guidelines are associated with an increased risk of hypertensive disorders of pregnancy and other adverse maternal and neonatal outcomes., Study Design: In this retrospective cohort study, 18,801 women with singletons from 2013 to 2019 were categorized as normotensive, prehypertensive (elevated blood pressure), stage 1 hypertensive, or chronic hypertensive. Women with ≥2 systolic blood pressures of 120 to 129 mm Hg before 20 weeks' gestation were classified into the elevated blood pressure group. Women with ≥2 systolic blood pressures of 130 to 139 mm Hg or ≥2 diastolic blood pressures of 80 to 89 mm Hg before 20 weeks' gestation were assigned to the stage 1 hypertension group. Women were classified as chronic hypertensives if they had any of the following: ≥2 systolic blood pressure of ≥140 mm Hg or ≥2 diastolic blood pressure of ≥90 mm Hg before 20 weeks' gestation, a history of chronic hypertension, or antihypertensive medication use before 20 weeks' gestation. Women with pregestational diabetes, lupus, or <2 blood pressures before 20 weeks' gestation were excluded. The association of stage 1 hypertension with the risk of developing hypertensive disorders of pregnancy was estimated using multivariate logistic regression controlling for maternal sociodemographic characteristics, gestational weight gain by prepregnancy body mass index, parity, and aspirin use. Secondary outcomes included subgroups of hypertensive disorders (gestational hypertension, preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome), gestational diabetes, placental abruption, intrauterine growth restriction, preterm birth, neonatal intensive care unit admission, stillbirth and neonatal death, and maternal intensive care unit admission. All outcomes were adjusted for potential confounders., Results: Of the 18,801 women, 13,478 (71.7%) were normotensive, 2659 (14.1%) had elevated blood pressure, 1384 (7.4%) were stage 1 hypertensive, and 1280 (6.8%) were chronic hypertensive. A dose-response relationship was observed: the risk of hypertensive disorders of pregnancy increased from 4.2% in normotensive women to 6.7% (adjusted odds ratio, 1.50; 95% confidence interval, 1.26-1.79) in women with elevated blood pressure, to 10.9% (adjusted odds ratio, 2.54; 95% confidence interval, 2.09-3.08) in women with stage 1 hypertension, and 28.4% (adjusted odds ratio, 7.14; 95% confidence interval, 6.06-8.40) in women with chronic hypertension. Compared with normotensive women, women with stage 1 hypertension had an increased risk of neonatal intensive care unit admissions (15.8% vs 13.0%; adjusted odds ratio, 1.21; 95% confidence interval, 1.03-1.42), preterm birth at <37 weeks' gestation (7.2% vs 5.2%; adjusted odds ratio, 1.45; 95% confidence interval, 1.16-1.81), and gestational diabetes (14.8% vs 6.8%; adjusted odds ratio, 2.68; 95% confidence interval, 2.27-3.17)., Conclusion: Our study demonstrates that elevated blood pressure and stage 1 hypertension, using the 2017 American College of Cardiology and the American Heart Association guideline definition, are associated with increased maternal and neonatal risk. This group of women warrants further investigation to determine whether pregnancy management can be altered to reduce maternal and neonatal morbidity., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To assess the validity of Spanish versions of the Survey of Well-being of Young Children (SWYC) Milestones and the Ages & Stages Questionnaire, Third Edition (ASQ-3), and to document the rates of developmental delays in an urban cohort of children with Hispanic parents., Methods: Spanish-speaking families with a child 9 to 60 months of age (N = 991) were initially screened using Spanish translations of the SWYC Milestones and the ASQ-3. A stratified random sample of 494 of these children subsequently received standardized clinical assessment to confirm the presence of developmental delays. Reverse weighting corrected for the selection bias inherent in the stratification scheme., Results: Fifty-five percent of toddlers (9 to 41 months of age) and 34.8% of preschoolers (42 to 60 months of age) scored in the moderately to severely delayed range, most frequently in language. Sensitivity and specificity for toddlers with severe delays associated with the SWYC were 0.69 and 0.64, respectively, and 0.55 and 0.75 for the ASQ-3. Sensitivity and specificity for preschoolers with severe delays associated with the SWYC were 0.87 and 0.58, respectively, and 0.71 and 0.86 for the ASQ-3., Conclusions: Although psychometric properties of the Spanish translated versions are not as strong as the English versions, the findings suggest that both the SWYC Milestones and ASQ-3 represent promising tools for identifying Hispanic children with developmental delays. The rate of delays were consistent with other studies showing a high percentage of Hispanic children with developmental delays, most frequently in language skills., (Copyright © 2018 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Research suggests the health consequences of economic hardship can be transmitted across generations. Some of these disparities are thought to be passed to offspring during gestation. But this hypothesis has not been tested in contemporary American samples, and the mechanisms of transmission have not been characterized. Accordingly, this study had two goals: first, to determine if women exposed to economic hardship during childhood showed higher rates of adverse birth outcomes; and second, to evaluate the contribution of inflammation, psychosocial, lifestyle, and obstetric characteristics to this phenomenon. This prospective study enrolled 744 women with singleton pregnancies (59.1% White; 16.3% Black; 18.7% Latina; 5.9% Other). Childhood economic hardship was measured by self-report. Birth outcomes included length of gestation and incidence of preterm birth; birth weight percentile and small for gestational age; length of hospital stay and admission to Special Care Nursery. Analyses revealed that mothers' childhood economic hardship was independently associated with multiple adverse birth outcomes, even following adjustment for demographics, maternal education, and obstetrical confounders. Women raised in economically disadvantaged conditions had shorter gestation length and higher preterm delivery rates. Their babies had lower birth weights, were more likely to be small for gestational age, stayed in the hospital longer, and had more Special Care Nursery admissions. Mediation analyses suggested these associations arose through multiple pathways, and highlighted roles for inflammation, education, adiposity, and obstetric complications. Collectively, these findings suggest that childhood economic hardship predisposes women to adverse birth outcomes, and highlights likely behavioral and biological mechanisms., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Patient-centered health care recognizes that adolescents and parents are stakeholders in adolescent health. We investigate adolescent and parent interest in receiving information about health topics and parent-teen communication from clinicians., Methods: Ninety-one parent-adolescent dyads in one practice completed individual interviews. Items assessed levels of interest in receiving health and health communication information from the adolescent's doctor about 18 topics, including routine, mental health, sexual health, substance use, and injury prevention issues. Analyses tested differences between parents and adolescents, within-dyad correlations, and associations with adolescent gender and age., Results: Most parents were female (84%). Adolescents were evenly divided by gender; 36 were aged 12-13 years, 35 were aged 14-15 years, and 20 were aged 16-17 years. Adolescent race reflected the practice population (60% black; 35% white). The vast majority of parents and adolescents reported moderate or high levels of interest in receiving information about all 18 health issues and information to increase parent-teen communication about these topics. Parents' interest in receiving information varied by adolescent age when the expected salience of topics varied by age (e.g., acne, driving safety), whereas adolescents reported similar interest regardless of age. Adolescent gender influenced parent and adolescent interest. Level of interest in receiving information from doctors within adolescent-parent pairs was not significantly correlated for one-half of topics., Conclusions: Parents and adolescents want health care professionals to help them learn and talk about a wide range of adolescent health topics. Feasible primary care interventions that effectively improve parent-teen health communication, and specific adolescent health outcomes are needed., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe pregnancy intention and contraceptive use among women with a recent delivery that occurred at 35 weeks gestation or fewer and who were enrolled in a large-scale randomized control trial., Design: In this descriptive study we used data from assessments conducted at 6 months postpartum as part of a randomized controlled clinical trial, the Philadelphia Collaborative Preterm Prevention Project (PCPPP)., Participants and Setting: Participants were recruited following a preterm birth (PTB) in one of the 12 urban birth hospitals. All women enrolled in PCPPP, who completed their 6-month postpartum assessment, and who were sexually active at the time of that assessment (n = 566), were included in the analysis., Methods: Data were collected during face-to-face interviews. Study questionnaires included questions about participants' plans for the timing of subsequent pregnancies, contraceptive behaviors, and other health variables., Results: Nearly all of the participants (90.1%, n = 509) reported they did not want to get pregnant within one year of the index PTB. However, more than one half of these women (54.6%) reported contraceptive practices of low or moderate effectiveness. Most predictive of intending another pregnancy within the year was the death of the index PTB infant (odds ratio [OR]= 18.2,95% confidence interval [CI] [8.9, 37.0])., Conclusions: Discordant pregnancy intention and contraceptive use were reported among this group of mothers of PTB infants who are at particularly high risk for a poor outcome of any subsequent pregnancy. The findings highlight the need for further investigation of the causes, correlates, and consequences of discordant pregnancy intentions and contraceptive practices., (© 2012 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.)

In 2009, the Global Alliance to Prevent Prematurity and Stillbirth Conference charged the authors to propose a new comprehensive, consistent, and uniform classification system for preterm birth. This first article reviews issues related to measurement of gestational age, clinical vs etiologic phenotypes, inclusion vs exclusion of multifetal and stillborn infants, and separation vs combination of pathways to preterm birth. The second article proposes answers to the questions raised here, and the third demonstrates how the proposed system might work in practice., (Copyright © 2012 Mosby, Inc. All rights reserved.)

A comprehensive classification system for preterm birth requires expanded gestational boundaries that recognize the early origins of preterm parturition and emphasize fetal maturity over fetal age. Exclusion of stillbirths, pregnancy terminations, and multifetal gestations prevents comprehensive consideration of the potential causes and presentations of preterm birth. Any step in parturition (cervical softening and ripening, decidual-membrane activation, and/or myometrial contractions) may initiate preterm parturition, and should be recorded for every preterm birth, as should the condition of the mother, fetus, newborn, and placenta, before a phenotype is assigned., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Preterm birth is a syndrome with many causes and phenotypes. We propose a classification that is based on clinical phenotypes that are defined by ≥ 1 characteristics of the mother, the fetus, the placenta, the signs of parturition, and the pathway to delivery. Risk factors and mode of delivery are not included. There are 5 components in a preterm birth phenotype: (1) maternal conditions that are present before presentation for delivery, (2) fetal conditions that are present before presentation for delivery, (3) placental pathologic conditions, (4) signs of the initiation of parturition, and (5) the pathway to delivery. This system does not force any preterm birth into a predefined phenotype and allows all relevant conditions to become part of the phenotype. Needed data can be collected from the medical records to classify every preterm birth. The classification system will improve understanding of the cause and improve surveillance across populations., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: The purpose of this study was to assess whether vaginal sialidases level in early pregnancy is associated with preterm birth among women who are bacterial vaginosis-positive., Study Design: Of the 1806 women who were enrolled at < 20 weeks of gestation, 800 of the women were bacterial vaginosis-positive (Nugent score, 7-10); 707 of the women had birth outcome data; 109 of the women who were bacterial vaginosis-positive had an adverse preterm outcome, which included 53 spontaneous preterm births (19 births were early at 20-34 weeks, and 34 births were late at 34-37 weeks), and 14 of the women had late miscarriages (12-20 weeks). Sialidase levels were compared with 352 control subjects (term normal birthweight infants)., Results: Sialidase levels at ≥ 5, ≥ 10, and ≥ 14 nmol (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.01-2.41; OR, 2.14; 95% CI, 1.25-3.64; OR, 3.17; 95% CI, 1.64-6.10, respectively) was associated significantly with all adverse preterm outcomes. The ≥ 10 nmol and ≥ 14 nmol cut-points were associated strongly with early spontaneous preterm births (OR, 3.79; 95% CI, 1.42-10.10 and OR, 5.36; 95% CI, 1.77-16.23, respectively) and late miscarriages (OR, 4.87; 95% CI, 1.61-14.65; OR, 8.33; 95% CI, 2.57-26.9, respectively)., Conclusion: Elevated sialidase level that is measured at 12 weeks of gestation is associated strongly with early spontaneous preterm births and late miscarriage., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Objectives: Adverse childhood experiences (ACEs) are risk factors for health problems later in life. This study aims to assess the influence of ACEs on risky health behaviors among mothers-to-be and determine whether a dose response occurs between ACEs and risky behaviors., Methods: A prospective survey of women attending health centers was conducted at the first prenatal care visit, and at 3 and 11 months postpartum. Surveys obtained information on maternal sociodemographic and health characteristics, and 7 ACEs prior to age 16. Risky behaviors included smoking, alcohol use, marijuana use, and other illicit drug use during pregnancy., Results: Our sample (N = 1476) consisted of low-income (mean annual personal income, $8272), young (mean age, 24 years), African American (71%), single (75%) women. Twenty-three percent of women reported smoking even after finding out they were pregnant, 7% reported alcohol use, and 7% reported illicit drug use during pregnancy. Nearly three fourths (72%) had one or more ACEs. There was a higher prevalence of each risky behavior among those exposed to each ACE than among those unexposed. The exception was alcohol use during pregnancy, where there was not an increased risk among those exposed when compared with those unexposed to witnessing a shooting or having a guardian in trouble with the law or in jail. The adjusted odds ratio for each risky behavior was >2.5 for those with >3 ACEs when compared with those without., Conclusions: ACEs were associated with risky health behaviors reported by mothers-to-be. Greater efforts should target the prevention of ACEs to lower the risk for adverse health behaviors that have serious consequences for adults and their children., (2010 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Bacterial vaginosis (BV) infections are common in women of reproductive age and are easily diagnosed and treatable. Aside from being an annoyance when symptoms of discharge, odor, and pruritus occur in the gravid female, BV infections increase risk of late miscarriage, preterm labor, preterm premature rupture of membranes, and, consequently, preterm delivery. Antepartum and puerperal issues such as chorioamnionitis and endometritis are increased in the context of maternal BV. Moreover, the morbidities and mortality of preterm delivery are consequently increased as a result of BV during pregnancy. Although the pathology associated with BV appears to result from inflammation, more investigation is needed in terms of designing guidelines for appropriate screening and treatment for the prevention of adverse outcomes.

Objective: This study was undertaken to characterize the course of bacterial vaginosis in pregnancy and to discern the bacterial morphotypes responsible for infection., Study Design: Vaginal secretions were obtained in each trimester of pregnancy and were evaluated for bacterial vaginosis by Gram stain, categorized as normal or any of the following: Lactobacillus deficient, Gardnerella, Bacteroides, or Mobiluncus positive and by Nugent score. Results were evaluated for trends of bacterial vaginosis and Gram stain over pregnancy., Results: One hundred forty-eight women were evaluated. Seventy-one women (48%) were bacterial vaginosis negative in all trimesters, compared with 14 (9.4%) who were positive throughout pregnancy. Among the 14 women who remained bacterial vaginosis positive, Gram stain findings were Gardnerella+Bacteroides+Lactobacillus, with approximately 50% harboring Mobiluncus. Few women become bacterial vaginosis positive as pregnancy progressed (6.1%). With each increasing week of pregnancy, the risk of becoming bacterial vaginosis positive decreased (0.93: 0.91-0.95; P < .001)., Conclusion: In this population, the majority of pregnant women trend toward bacterial vaginosis negative status. Few women are bacterial vaginosis positive across their pregnancy.

Objective: To determine the association between adverse childhood experiences (ACEs), positive influences in childhood (PICs), and depressive symptoms among low-income pregnant women., Methods: Face-to-face survey of women receiving prenatal care at Philadelphia community health centers. We conducted surveys at the first prenatal care visit and at a mean age +/- standard deviation of 11 +/- 1 months postpartum, and obtained information on sociodemographic characteristics and childhood experiences before age 16. Group differences were tested with respect to a cutpoint of 23 on the Center for Epidemiologic Studies-Depression scale (CES-D), with the chi(2) test used for categorical variables and the Student's t test used for continuous variables. Logistic regression analyses were conducted to adjust for potential confounding variables., Results: The sample consisted of 1476 mostly young, African American, low-income women. The majority (70% and 90%, respectively) of women reported at least one ACE and one PIC. For each ACE, affected women were more likely to have depressive symptoms than their counterparts. There was a dose-response effect in that a higher number of ACEs was associated with a higher likelihood of having depressive symptoms. PICs, on the other hand, were associated with a lower likelihood of having depressive symptoms., Conclusions: Among low-income women, ACEs were associated with a higher likelihood of having depressive symptoms in a dose-response fashion, and PICs were associated with a lower risk. Efforts to prevent ACEs and to promote PICs might help reduce the risk of depressive symptoms and their associated problems in adulthood.

Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.

This paper is the first in a three-part series on preterm birth, which is the leading cause of perinatal morbidity and mortality in developed countries. Infants are born preterm at less than 37 weeks' gestational age after: (1) spontaneous labour with intact membranes, (2) preterm premature rupture of the membranes (PPROM), and (3) labour induction or caesarean delivery for maternal or fetal indications. The frequency of preterm births is about 12-13% in the USA and 5-9% in many other developed countries; however, the rate of preterm birth has increased in many locations, predominantly because of increasing indicated preterm births and preterm delivery of artificially conceived multiple pregnancies. Common reasons for indicated preterm births include pre-eclampsia or eclampsia, and intrauterine growth restriction. Births that follow spontaneous preterm labour and PPROM-together called spontaneous preterm births-are regarded as a syndrome resulting from multiple causes, including infection or inflammation, vascular disease, and uterine overdistension. Risk factors for spontaneous preterm births include a previous preterm birth, black race, periodontal disease, and low maternal body-mass index. A short cervical length and a raised cervical-vaginal fetal fibronectin concentration are the strongest predictors of spontaneous preterm birth.

Objectives: The aim of this study was to 1) assess sociodemographic and health characteristics associated with having a continuous source of care (CSOC) among young children and 2) determine the relationship between having a CSOC and use of parenting practices., Methods: We conducted a prospective, community-based survey of women receiving prenatal care at Philadelphia community health centers. We conducted surveys at the first prenatal visit and at a mean age +/- standard deviation of 3 +/-1, 11 +/- 1, and 24 +/- 2 months postpartum, obtaining information on sociodemographic and health characteristics, child's health care provider, and 6 parenting practices. Group differences were tested between those with and without a CSOC by using the chi-square test for categorical variables and the Student's t test for continuous variables. Logistic regression analysis was conducted to adjust for potential confounding variables., Results: Our sample consisted of 894 mostly young, African American, single women and their children. In the adjusted analysis, mothers of children with a CSOC, when compared with those without a CSOC, were more likely to have a high school education or less, be born in the United States, have a postpartum checkup, have stable child health insurance, and initiate care for their child at a site other than a community-based health center. Use of parenting practices was similar for children with and without a CSOC., Conclusions: Maternal nativity, postpartum care, child health insurance, and initial site of infant care were associated with CSOC, but infant health characteristics were not. Use of parenting practices did not differ for those with and without a CSOC.

Objective: The objective of the study was to explore the mechanisms of local innate immunity induction and modulation in pregnant women with bacterial vaginosis (BV)., Study Design: A total of 200 singleton pregnant women in early gestation (12 +/- 4 weeks) with BV (Nugent 7-10) without concurrent vaginal infections with Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoeae, syphilis, and yeast. Concentrations of vaginal interleukin (IL)-1beta and IL-8, the number of neutrophils, and the levels of sialidase and prolidase hydrolytic enzymes were determined in vaginal fluid., Results: Concentrations of vaginal IL-1beta had a strong positive correlation with levels of sialidase (P < .001) and prolidase (P < .001). Conversely, such enzymes were negatively correlated with the ratio of IL-8/IL-1beta (both P < .001) and were not significantly associated with concentrations of IL-8. Notably, the number of vaginal neutrophils had a negative correlation with sialidase (P = .007)., Conclusion: The strong induction of IL-1beta in BV-positive women appears to be associated with the production of the hydrolytic enzymes sialidase and prolidase by BV-associated bacteria. However, these 2 enzymes may inhibit the expected amplification of the proinflammatory IL-1beta cascade as evaluated by the down-regulation of the IL-8/IL-1beta ratio. A blunted response to IL-1beta signals may cause the poor rise of neutrophils, which is peculiar to BV. This impairment of local defense may contribute to increased susceptibility to adverse outcomes in BV-positive pregnant women.

Pregnancy outcomes in the United States and other developed countries are considerably better than those in many developing countries. However, adverse pregnancy outcomes are generally more common in the United States than in other developed countries. Low-birth-weight infants, born after a preterm birth or secondary to intrauterine growth restriction, account for much of the increased morbidity, mortality, and cost. Wide disparities exist in both preterm birth and growth restriction among different population groups. Poor and black women, for example, have twice the preterm birth rate and higher rates of growth restriction than do most other women. Low birth weight in general is thought to place the infant at greater risk of later adult chronic medical conditions, such as diabetes, hypertension, and heart disease. Of interest, maternal thinness is a strong predictor of both preterm birth and fetal growth restriction. However, in the United States, several nutritional interventions, including high-protein diets, caloric supplementation, calcium and iron supplementation, and various other vitamin and mineral supplementations, have not generally reduced preterm birth or growth restriction. Bacterial intrauterine infections play an important role in the etiology of the earliest preterm births, but, at least to date, antibiotic treatment either before labor for risk factors such as bacterial vaginosis or during preterm labor have not consistently reduced the preterm birth rate. Most interventions have failed to reduce preterm birth or growth restriction. The substantial improvement in newborn survival in the United States over the past several decades is mostly due to better access to improved neonatal care for low-birth-weight infants.

Objective: This study was undertaken to examine the influence of coinfections on vaginal innate and adaptive immunity, and microbial enzyme activities of pregnant women with bacterial vaginosis (BV)., Study Design: The population consisted of 265 singleton pregnant women in early gestation (<20 weeks) with BV (Nugent 7-10) who had vaginal fluid collected for measurement of interleukin-1beta (IL-1beta) and IL-8 concentrations, number of neutrophils, immunoglobulin A against Gardnerella vaginalis (anti-Gvh IgA), and activities of microbial sialidase and prolidase., Results: Among women with BV, median levels of vaginal IL-1beta (4-fold, P = .005), IL-8 (4-fold, P < .001), and neutrophils (6-fold, P = .013) were greatly increased in women with T vaginalis with respect to women without any coinfection. Yeast increased the level of IL-8 (5-fold, P < .001), but not IL-1beta (P = .239) and neutrophils (P = .060). Chlamydia trachomatis and Neisseria gonorrhoeae had no effect on vaginal cytokines. None of the coinfections influenced vaginal anti-Gvh IgA, sialidase and prolidase activities., Conclusion: The strong proinflammatory cytokine induction by T. vaginalis may contribute to the observed increase in preterm birth among BV positive women coinfected with T. vaginalis treated with metronidazole.

Objective: This study was undertaken to assess if levels of interleukin-1beta (IL-1beta), IL-8, sialidase, prolidase and immunoglobulin A against Gardenerella vaginalis hemolysin (anti-Gvh IgA) in vaginal secretions differ between BV+ women with (M+) and without (M-) Mobiluncus spp., Study Design: Vaginal secretions were obtained from 265 women at their first prenatal care visit and assessed for all study parameters. Gram stain evaluation using Nugent criteria was performed and coinfection with sexually transmitted infections determined. Differences between BV+/M+ and BV+/M- women were evaluated using the chi2 statistic or Mann-Whitney test., Results: Of the 265 BV+ women, 43% (n = 113) were M+ of which 97% (n = 110) had Nugent scores of 9 or 10 . BV+/M+ women had elevated levels of sialidase (median value: 4.11 nmol vs 1.91 nmol of converted substrate; P = .003) but no difference in prolidase, anti-Gvh IgA, IL-1beta, IL-8, levels were found between the two groups. BV+/M- women had significantly higher rates of coinfection with Trichomonas vaginalis., Conclusion: BV+/M+ women have higher vaginal concentrations of sialidase and lower rates of T. vaginalis compared with BV+/M- women. Further research is needed to assess the association of this, and other, microbiologic profiles to risk of adverse pregnancy outcome.

Objective: The purpose of this study was to assess the contribution of depressive symptoms and poor contraceptive use early in the first postpartum year to the risk of unintended repeat pregnancy at the end of that year among adults with low educational status (< 12th grade or equivalence)., Study Design: This was a prospective observational cohort study of 643 sexually active, low-income, inner-city adult women (age > or = 19) who enrolled prenatally (14.7 +/- 6.9 weeks gestational age) and were followed twice after delivery (3.3 +/- 1.3 months and 11.0 +/- 1.3 months). Associations were assessed by multivariate logistic regression., Results: Low educational status (odds ratio, 2.32; 95% CI, 1.25-4.33) and less effective contraceptive use (odds ratio, 2.31; 95% CI, 1.05-4.51) were associated with unintended pregnancy. Neither depressive symptoms nor contraceptive use reduced the risk of pregnancy that was associated with low educational status., Conclusion: Low educational status was associated with more than twice the risk of unintended pregnancy 1 year after delivery. We found no evidence that depression or poor contraceptive use mediate this relationship.

Objectives: To describe where women receiving prenatal care (PNC) at community-based health centers (CBHCs) go for infant primary care, and to assess reasons for and factors associated with leaving CBHCs and using other practices for infant care., Methods: A prospective survey of women receiving PNC at CBHCs from February 2000 to February 2002 was conducted. In-person, prepartum, and postpartum surveys included questions about sociodemographic and health characteristics, and health services use., Results: Among 1,107 primarily low-income, African American mothers, 60% of women left CBHCs and used other practices for their infants due to dissatisfaction, inconvenience, referral to and perceived expertise at other sites, and insurance changes. Leaving CBHCs was associated with being white, Latina, US born, educated beyond high school, single, owning a car, using non-CBHC practices for prepregnancy care, and having child health insurance. Among those who left, 48% used hospital-based clinics (HBCs) and 52% used private practices (PPs). Mothers using HBCs, when compared to those using PPs, were more likely to be African American (AOR = 6.83; 95% CI: 3.82, 12.22) or Latina (AOR = 5.60; 95% CI: 2.79, 11.24), dissatisfied with their PNC (AOR = 2.02; 95% CI: 1.05, 3.89) and to leave CBHCs because of insurance changes (AOR = 2.27; 95% CI: 1.18, 4.39) and perceived pediatric expertise at other sites (AOR = 4.81; 95% CI: 2.53, 9.11)., Conclusions: The majority of women in our study left CBHCs and used other sites for pediatric care. Higher education, having child health insurance, and car ownership were associated with leaving CBHCs. Among women who left, race/ethnicity and perceived pediatric expertise were major factors associated with using HBCs rather than PPs.

Objective: The purpose of this study was to determine if clinical findings and sociodemographic variables among bacterial vaginosis (BV)-positive pregnant women are associated with different microbiologic profiles., Study Design: Pregnant women were assessed for BV by Nugent criteria. BV+ women were separated into 6 mutually exclusive microbiologic groups. In unadjusted analyses, we compared (1) sociodemographic and behavioral characteristics, and (2) 3 clinical characteristics among BV+ women with and without Mobiluncus (M+ vs M-). Unadjusted data were analyzed using the chi-square test. Multiple logistic regression was used to assess the likelihood of having clinical signs of BV in women with and without Mobiluncus spp while controlling for confounders., Results: A total of 1756 BV+ pregnant women were followed. The M+ group (n=702) was significantly more likely than the M- group (n=1054) to be non-Hispanic black (80.9% vs 66.2%; P < .0001), older than 21 years (61.7% vs 48.7%; P < .0001), and to have had more than 3 lifetime sexual partners (66.4% vs 54.9%; P < .0001). The M+ group was also more likely to have clue cells on wet mount (63.9% vs 47.2%; P < .0001) and a positive amine odor after addition of KOH (57.2% vs 45.0%; P=.001). There was no difference in other demographic variables or physician diagnosis of abnormal vaginal discharge. In the adjusted analyses for each clinical outcome, all findings were consistent with the unadjusted analyses., Conclusion: BV+ pregnant women with Mobiluncus spp are more likely to have clue cells present on wet mount, a positive amine odor after KOH preparation, and to be older, non-Hispanic black, and have had more lifetime sexual partners compared to BV+ women without any Mobiluncus species.

Racial and social class differences in rates of preterm birth and other adverse outcomes are among the most widely recognized and least well-understood phenomena in the study of reproductive health. Individual-level characteristics have failed to account for such gradients. Recently, researchers have begun to argue that health in general and reproductive outcomes specifically are rooted in social inequalities. One area of such inequality may be residential segregation and the associated race/ethnic differences in exposure to adverse neighborhood conditions. We review the empiric data that examine the association between neighborhood conditions and reproductive health. We also review the major challenges that researchers face when trying to incorporate neighborhood-level variables into studies of health outcomes. Our goal is to stimulate further research that simultaneously considers social, economic, and biologic determinants of reproductive health.

Epidemiological evidence suggests that maternal psychosocial stress, strenuous physical activity and fasting are independent risk factors for preterm birth and low birth weight. Data from clinical studies consistently demonstrate that women in preterm labor have significantly elevated levels of corticotropin-releasing hormone compared with age-matched control subjects. Because production of corticotropin-releasing hormone appears to be stress sensitive, this neuropeptide may play a critical role in the physiological mediation among stressful experiences, work stress and fasting and risk of preterm birth. In addition to the direct effect of elevated corticotropin-releasing hormone on the initiation of labor, it may have an immunomodulatory effect such that women with high levels of corticotropin-releasing hormone may be more susceptible to infection or the pathological consequences of infection. We review the epidemiological data linking maternal stress, physical stain and fasting to preterm birth and low birth weight and review the plausible biological pathways through which these exposures may increase risk of preterm birth. The timing of these exposures is considered important. Future research and clinical programs addressing these exposures must consider assessments and interventions before pregnancy.

Objective: The purpose of this study was to assess the contribution of chronic social stressors to race/ethnic differences in the rate of bacterial vaginosis among pregnant women in the inner-city area., Study Design: We conducted a cross-sectional clinical prevalence study in a sample of 2304 women at the first prenatal visit (14.8 +/- 0.2 weeks of gestation). Bacterial vaginosis was diagnosed by Nugent's method. Stress was measured at the individual and community levels with the use of interviews and administrative records. Logistic regression was used to assess the effects of stress on the odds of bacterial vaginosis occurrence, after adjustment for demographic and behavioral risk., Results: Black women had significantly higher rates of bacterial vaginosis (64%) compared with white women (35%). Exposure to chronic stressors at the individual level differed by race (eg, 32% of the black women reported threats to personal safety compared with 13% of white women). There were significant racial differences in exposure to stress at the community level (eg, 63% of the black women lived in neighborhoods with aggravated assault rates that were above the citywide mean compared with 25% of the white women). After the adjustment for sociodemographic, behavioral risk, and perceived stress, the odds of the occurrence of bacterial vaginosis that was associated with the community level stressor of "homelessness" was significant (odds ratio, 6.7; 95% CI, 1.6-27.8). Inclusion of both individual and community level stressors reduced the black/white bacterial vaginosis odds ratio by 27%., Conclusion: Stressful exposures are associated positively with bacterial vaginosis in pregnancy in a sample of women of low income in the inner city. The measurement of stressors at multiple levels explained a significant proportion of the racial disparity in the rates of occurrence of bacterial vaginosis.