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Liver injury is an increasingly recognized extra-pulmonary manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Coronavirus disease 2019 (COVID-19) associated liver injury (COVALI) is a clinical syndrome encompassing all patients with biochemical liver injury identified in the setting of SARS-CoV-2 infection. Despite profound clinical implications, its pathophysiology is poorly understood. Unfortunately, most information on COVALI is derived from the general population and may not be applicable to individuals under-represented in research, including pregnant individuals. This manuscript reviews: Clinical features of COVALI, leading theories of COVALI, and existing literature on COVALI during pregnancy, a topic not widely explored in the literature. Ultimately, we synthesized data from the general and perinatal populations that demonstrates COVALI to be a hepatocellular transaminitis that is likely induced by systemic inflammation and that is strongly associated with disease severity and poorer clinical outcome, and offered perspective on approaching transaminitis in the potentially COVID-19 positive patient in the obstetric setting.

Trauma is highly prevalent, and women are twice as likely as men to develop posttraumatic stress disorder following a traumatic exposure. Consequently, many women entering the perinatal period have trauma histories. In the perinatal period, a trauma history can negatively impact treatment engagement and adversely affect the experience of pregnancy, postpartum, and parenting. A trauma-informed care approach can mitigate these effects.This review aims to summarize literature that can aid psychiatrists in (1) identifying signs and symptoms of trauma in perinatal women, (2) integrating elements of trauma-informed care into perinatal mental health care, and (3) offering interventions that can minimize adverse outcomes for perinatal women and their children.A PubMed search was conducted with keywords including trauma, pregnancy, perinatal, posttraumatic stress disorder, postpartum posttraumatic stress disorder, and trauma informed care.Perinatal care, given its somewhat invasive nature, has the potential to traumatize or cause retraumatization. Trauma-related disorders are common and can present or worsen in the perinatal period. Trauma can manifest in multiple forms in this population, including exacerbation of preexisting posttraumatic stress disorder, new onset acute stress disorder in the perinatal period, or postpartum posttraumatic stress disorder secondary to traumatic childbirth. Unaddressed trauma can adversely affect the experience of pregnancy, postpartum, and parenting. Psychiatrists caring for women in the perinatal period are in an ideal position to screen for trauma and offer appropriate intervention. A trauma-informed approach to obstetric care can help clinical teams respond to the unique trauma-related challenges that can arise during obstetric care. Trauma-informed care, with its emphasis on establishing a culture of safety, transparency, trustworthiness, collaboration, and mutuality, can empower health care providers and systems with powerful tools to respond to trauma and its myriad effects in a strengths-based manner. By applying a trauma-informed lens, psychiatrists can help their obstetric colleagues provide patient-centered compassionate care and treatment.Applying a trauma-informed approach to evaluation and treatment of perinatal populations could decrease the toll trauma has on affected women and their children.

BACKGROUND Hypertension (HTN) is a leading cause of maternal mortality, and HTN guidelines recommend home blood pressure monitoring (HBPM) to help achieve blood pressure (BP) control. Evidence suggests that HBPM be coupled with a care team to maximize its effectiveness. HBPM use and the prevalence of provider counseling in child-bearing age women with HTN are unknown. METHODS We used data from 3,614 women in the cross-sectional National Health and Nutrition Examination Surveys 2009–2014 to determine HBPM use and provider counseling for women of child-bearing age (20–50 years) with and without HTN. HBPM use and provider counseling were self-reported. We examined rates of HBPM use by race/ethnicity, poverty–income ratio (PIR), education, and insurance. RESULTS Among women of child-bearing age with HTN, the mean (SE) age was 37.0 (0.3) years, the mean (SE) BMI was 35.5 (0.6) kg/m2, and 73% were on BP medication. Of these women with HTN, 49.6% reported HBPM use in the past year and 40.4% received provider counseling. There was no significant difference in HBPM use by race/ethnicity, PIR, or insurance, though higher education was associated with HBPM use. Women with HTN who received provider counseling were more likely to use HBPM (odds ratio = 15.7, 95% confidence interval 9.1–26.9). CONCLUSIONS Nearly half of child-bearing age women with HTN have adopted HBPM, and provider counseling was strongly associated with HBPM use. This highlights a need and opportunity for providers to improve BP management by supporting a popular and valuable monitoring approach among women of child-bearing age with HTN.

Perinatal Psychiatry Access Programs ("Access Programs") are system-level interventions that aim to build the capacity of perinatal healthcare professionals to address mental health, and thereby improve access to perinatal mental healthcare. Access Programs are widely implemented and positioned to promote health equity in perinatal mental healthcare, but little is known about the adaptations being made to the model in response to calls to promote health equity.One respondent from each of the 14 Access Programs (n = 14) completed an online survey that queried on adaptations made to promote perinatal mental healthcare equity.Twelve of the 14 Access Program team members (86%) indicated implementation of at least one new equity initiative. The average number of initiatives that a single Access Program implemented was 3.5 (range 0-10). Two Access Programs (14%) implemented 8.5 initiatives (range: 7-10), indicating that a small cohort is leading promotion of equity among Access Programs.Efforts to further expand the capacity and services of Access Programs to address perinatal mental healthcare inequities are needed. These adaptations may provide a robust opportunity for implementation initiatives to promote health equity through a system-level intervention.

Rates of perinatal depression and pregnancy hyperglycemia are higher in Hispanic women as compared to non-Hispanic white women. In turn, depressive symptoms may reduce a woman's ability to engage in lifestyle changes that could reduce their subsequent diabetes risk.We conducted a secondary analysis using data from Estudio Parto to evaluate sociodemographic, behavioral, psychosocial, and medical factors associated with perinatal depressive symptoms. Estudio Parto was a randomized controlled trial conducted in Western Massachusetts from 2013 to 17. Eligible participants had pregnancy hyperglycemia. The Edinburgh Postnatal Depression Scale (EPDS) was administered at 24-28 weeks gestation and at 6 weeks, 6 months, and 12 months postpartum. An EPDS cutpoint of 10 or greater defined the presence of depressive symptoms.In this sample of Puerto Rican women with pregnancy hyperglycemia, 32% and 27% showed prenatal and postpartum depressive symptoms, respectively. Among participants, 35.5% were diagnosed with GDM, 44.3% with isolated hyperglycemia, and 20.2% with impaired glucose tolerance. In multivariable models, being unmarried (OR 3.87; 95% CI 1.51-9.94), prenatal substance use (smoking or alcohol consumption; OR 2.96; 95% CI 1.41-6.18), and maternal age (1.11 for each year; 95% CI 1.04-1.18) were associated with higher odds of prenatal depressive symptoms. None of the risk factors were associated with subsequent postpartum depression in adjusted analyses.Identifying factors associated with prenatal and postpartum depression in Puerto Rican women with pregnancy hyperglycemia can inform targeted lifestyle interventions in this at-risk group, increase the likely adoption of healthy lifestyle behaviors, and thereby work to address health disparities.gov NCT01679210; date of registration 08/07/2012.

Introduction Despite increased attention on severe maternal morbidity and maternal mortality, scant research exists on adverse maternal outcomes in women with disabilities. This study compares the rates of severe maternal morbidity and maternal mortality in women with and without intellectual and developmental disabilities. Methods This study used 2004–2017 Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Analyses were conducted in 2019‒2020. The risk of severe maternal morbidity with and without blood transfusion and maternal mortality during delivery among women with and without intellectual and developmental disabilities were compared using modified Poisson regression analysis. Results This study identified 32,324 deliveries to women with intellectual and developmental disabilities. Per 10,000 deliveries, 566 deliveries with severe maternal morbidity occurred in women with intellectual and developmental disabilities compared with 239 in women without intellectual and developmental disabilities. Women with intellectual and developmental disabilities had greater risk of both severe maternal morbidity (risk ratio=2.36, 95% CI=2.06, 2.69) and nontransfusion severe maternal morbidity (risk ratio=2.95, 95% CI=2.42, 3.61) in unadjusted analyses, which was mitigated in adjusted analyses for sociodemographic characteristics (risk ratio=1.74, 95% CI=1.47, 2.06; risk ratio=1.85, 95% CI=1.42, 2.41) and the expanded obstetric comorbidity index (risk ratio=1.23, 95% CI=1.04, 1.44; risk ratio=1.31, 95% CI=1.02, 1.68). The unadjusted incidence of maternal mortality in women with intellectual and developmental disabilities was 284 per 100,000 deliveries, nearly 4-fold higher than in women without intellectual and developmental disabilities (69 per 100,000 deliveries; risk ratio=4.07, 95% CI=2.04, 8.12), and the risk remained almost 3-fold higher after adjustment for sociodemographic characteristics (risk ratio=2.86, 95% CI=1.30, 6.29) and the expanded obstetric comorbidity index (risk ratio=2.30, 95% CI=1.05, 5.29). Conclusions Women with intellectual and developmental disabilities are at increased risk of severe maternal morbidity and maternal mortality. These findings underscore the need for enhanced monitoring of the needs and maternal outcomes of women with intellectual and developmental disabilities in efforts to improve maternal health.

BACKGROUND Upwards of one in seven individuals experience perinatal depression and many individuals cannot access treatment. In response, perinatal depression is increasingly being managed in the obstetric setting. This study aimed to characterize the experiences of clinicians and clinician assistants to inform the extent to which clinician assistants can help address depression in obstetric settings. METHODS This cross-sectional analysis used data from an ongoing cluster randomized control trial: The PRogram In Support of Moms (PRISM). Participants included clinicians (physicians, certified nurse midwives, nurse practitioners) and clinician assistants (medical assistants, nursing assistants). Baseline data regarding practices and attitudes of clinicians and clinician assistants toward addressing depression in the obstetric setting were described. Logistic regressions were used to examine the association of clinician time to complete work and depression management. RESULTS Clinician assistants experienced significantly fewer time constraints than did clinicians. However, having adequate time to complete work was not significantly associated with increased depression management in clinicians. Clinician assistants reported feeling that addressing depression is an important part of their job, despite variation in doing so. CONCLUSION Clinician assistants are interacting with perinatal women extensively and are a vital part of obstetric care workflows. Clinician assistants report that they want to address depression and have time to do so. Thus, clinician assistants may be poised to help address the mental health needs of perinatal individuals.

Background The COVID-19 pandemic has affected mental health and created barriers to healthcare. In this study, we sought to elucidate the pandemic's effects on mental health and access to care for perinatal individuals. Methods This cross-sectional study of individuals in Massachusetts who were pregnant or up to three months postpartum with a history of depressive symptoms examined associations between demographics and psychiatric symptoms (via validated mental health screening instruments) and the COVID-19 pandemic's effects on mental health and access to care. Chi-square associations and multivariate regression models were used. Results Of 163 participants, 80.8% perceived increased symptoms of depression and 88.8% of anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD at time of interview, higher education, and income were associated with increased symptoms of depression and anxiety due to the pandemic. Positive screens for depression, anxiety, and/or PTSD were also associated with perceived changes in access to mental healthcare. Compared to non-Hispanic White participants, participants of color (Black, Asian, Multiracial, and/or Hispanic/Latinx) were more likely to report that the pandemic changed their mental healthcare access (aOR:3.25, 95%CI:1.23, 8.59). Limitations Limitations included study generalizability, given that participants have a history of depressive symptoms, and cross-sectional design. Conclusions The pandemic has increased symptoms of perinatal depression and anxiety and impacted perceived access to care. Self-reported increases in depression and anxiety and changes to healthcare access varied by education, race/ethnicity, income, and positive screens. Understanding these differences is important to address perinatal mental health and provide equitable care.

Purpose: Perinatal depression affects upwards of one in seven women and is associated with significant negative maternal and child consequences. Despite this, it remains under-detected and under-treated. We sought to identify clinician practices, self-efficacy, and remaining barriers to comprehensively addressing perinatal depression care. Materials and Methods: Surveys were administered to obstetric clinicians in Massachusetts that queried frequency of depression screening and Likert questions about subsequent depression management. Results: Approximately 79.0% of clinicians approached completed the survey. Whereas most clinicians (93.5%) screened for perinatal depression at 6 weeks postpartum, fewer clinicians (66.1%) screened during pregnancy. Most reported they were comfortable providing support to their patients (98.4%), but fewer endorsed being able to treat them on their own (43.0%). Most noted an ability to treat with antidepressants (77.9%); however, fewer endorsed adequate access to nonmedication treatment (45.5%). Conclusions: The majority of surveyed clinicians screen for depression consistent with guidelines. However, efforts are focused on the postpartum period, despite literature citing two-thirds of patients experiencing onset before or during pregnancy. Respondents indicated an ability to treat with medication management, while noting greater challenge with referral. These findings describe the challenges of interdisciplinary coordination as a barrier to comprehensive perinatal mental health care. Clinical Trial Registration Number: NCT02760004.

Lifestyle interventions can facilitate healthy gestational weight gain but attending in-person meetings can be challenging. High rates of use and the popularity of pregnancy content suggests Instagram as a possible platform for delivering gestational weight gain interventions. We assessed the logistics and acceptability of creating a private Instagram group and to obtain feedback on intervention posts. We conducted a 2-week study with pregnant women with pre-pregnancy overweight or obesity who use Instagram daily. Participants created a private Instagram account and followed other participants and a moderator who shared twice-daily posts about physical activity and healthy eating during pregnancy. Participants provided feedback through a follow-up survey and focus group/interviews. Engagement data was abstracted from Instagram. Participants (N = 11) were on average 26.3 (SD: 7.4) weeks gestation and 54% had obesity pre-pregnancy. All participants followed the moderator's account, 73% followed all other participants, participants engaged with 100% of study posts, 82% felt comfortable sharing in the group, and 73% would participate in a similar group if pregnant in the future. While participants felt the posts were visually attractive and included helpful information, they wanted more personalized content and felt reluctant to post photos they felt were not "Instagram worthy." Moderators should foster an environment in which participants feel comfortable posting unedited, authentic photos of their lives, perhaps by sharing personal photos that are relatable and represent their own imperfect lives. Results will inform further development and testing of an Instagram-delivered gestational weight gain intervention.Lifestyle interventions can facilitate healthy gestational weight gain but attending in-person meetings can be challenging. The majority of young women use Instagram and pregnancy is a popular topic, suggesting that Instagram might be a means to deliver a pregnancy weight gain intervention. In this study, we asked pregnant women with pre-pregnancy overweight or obesity to join a private group on Instagram and provide feedback on intervention posts about healthy eating and physical activity during pregnancy. All participants followed the moderator’s account, 73% followed all other participants, participants engaged with 100% of study posts, 82% felt comfortable sharing in the group, and 73% would participate in a similar group if pregnant in the future. Participants shared their opinions of the posts in a focus group. While participants felt that the posts were visually attractive and included helpful information, they wanted more personalized content and felt reluctant to post photos they felt were not “Instagram worthy”. Moderators should foster an environment in which participants feel comfortable posting unedited, authentic photos of their lives, perhaps by sharing personal photos that are relatable and represent their own imperfect lives. These findings will inform further development and testing of an Instagram-delivered gestational weight gain intervention.

BACKGROUND: Dysregulation of inflammatory processes is linked to perinatal complications yet a comprehensive description of cytokine levels throughout the perinatal period is lacking. We report prospective, serial levels of 29 unique cytokines measured in maternal blood during pregnancy, in the cord blood at birth, and in the neonatal blood. METHODS: Pregnant women (n = 140) for recruited from a Midwest tertiary medical center. Blood was obtained at five timepoints: 12–20 weeks, 24–28 weeks, and at labor in the women, umbilical cord at birth, 24–72 h in the newborn. Cytokine levels were analyzed using an electrochemiluminescence-based immunoassay. RESULTS: Levels for 29 cytokines were measured. The data were separated into two groups: pregnancies with (n = 82) and without major complications (n = 53) (preterm birth, preeclampsia, diabetes mellitus). Eighteen cytokines showed significant changes over time (p < .002). The majority of the cytokines were highest in the newborn. No differences in cytokine levels between complication groups were noted at any timepoint. CONCLUSIONS: This is the first known study to report prospective, serial cytokine levels throughout the perinatal period for pregnancies with/without complications. No differences in maternal cytokine levels between those with/without complications were detected; studies with a larger sample size would be needed to validate our current findings. Results also suggest cytokine dysregulation may be more localized to the placenta making it difficult to measure and predict during pregnancy using maternal systemic blood specimens.

Aims To test a model of psychosocial/cultural/biological risk factors for poor birth outcomes in Latina pregnant women. Design An observational study measuring acculturation, progesterone, cortisol, cotinine, age, marital status, income, stress, depressive symptoms and coping. We tested a structural equation model to predict risk. Methods We obtained a convenience sample (N = 515) of low medical risk pregnant Mexican American Hispanic women at 22–24 weeks of gestation. Bilingual research nurses collected data from blood, urine and questionnaires. Self‐report measures were the Beck Depression Inventory‐II, the Perceived Stress Scale, the Acculturation Rating Scale for Mexican Americans‐II and the Brief Cope. We measured progesterone and cortisol in plasma and cotinine levels in urine by enzyme‐linked immunoassays. Results A PLS‐SEM model revealed that Mexican American Hispanic pregnant women who were younger, single, lower income, more acculturated and who had greater negative coping, stress and depression were most at risk for having earlier and smaller babies.

Perinatal Psychiatry Access Programs have emerged to help obstetric professionals meet the needs of perinatal individuals with mental health conditions, including bipolar disorder (BD). We elucidate obstetric professionals' perspectives on barriers and facilitators to managing BD in perinatal patients, and how Access Programs may affect these processes.We conducted three focus groups with obstetric professionals, two with- and one without-exposure to an Access Program, the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms. Focus groups discussed experiences, barriers, facilitators, and solutions to caring for perinatal individuals with BD. Qualitative data were coded and analyzed by two independent coders; emergent themes were examined across exposure groups.Thirty-one obstetric professionals (7 without-exposure, 24 with-exposure) participated. Identified themes included: (1) gaps in perinatal BD education; (2) challenges in patient assessment; (3) MCPAP for Moms as a facilitator for addressing BD; and (4) importance of continued outreach and destigmaization to increase care collaboration.Barriers to obstetric professionals accessing adequate mental healthcare for their patients with BD abound. With psychiatric supports in place, it is possible to build obstetric professionals' capacity to address BD. Perinatal Psychiatry Access Programs can facilitate obstetric professionals bridging these gaps in mental health care.

Understanding the pregnancy experiences of racial and ethnic minority women with intellectual and developmental disabilities (IDD) is critical to ensuring that policies can effectively support these women. This research analyzed data from the 1998–2013 Massachusetts Pregnancy to Early Life Longitudinal (PELL) data system to examine the racial and ethnic disparities in birth outcomes and labor and delivery charges of U.S. women with IDD. There was significant preterm birth disparity among non-Hispanic Black women with IDD compared to their non-Hispanic White peers. There were also significant racial and ethnic differences in associated labor and delivery-related charges. Further research, examining potential mechanisms behind the observed racial and ethnic differences in labor and delivery-related charges in Massachusetts' women with IDD is needed.

Depression screening is recommended for all pregnant veterans; however, little is known on how often symptomatic women receive care, how depression treatment presents in practice, and whether women veterans are utilizing treatment during the appreciable perinatal period. Our sample included 142 pregnant veterans from 15 Veterans Health Administration (VA) medical facilities with Edinburgh Postnatal Depression Scale (EPDS) scores ≥10. Sociodemographic characteristics, military service, health utilization, and pregnancy related factors were collected as part of a telephone survey. A majority of our sample (70%) had 1 or more mental health visits or antidepressant prescriptions during pregnancy. Women with a history of depression had more mental health visits and a higher percentage of antidepressant use before and during pregnancy than women without a history of depression. Pregnant women veterans without a history of depression may be less likely to receive care for depression during pregnancy. However, the majority of our veterans showing depression symptoms prenatally had at least one mental health visit or an antidepressant medication fill during their pregnancy window, suggesting that mental health care is readily available for women veterans.

Background: Excessive weight gain during pregnancy is common and has been shown to be associated with increased long-term maternal weight. However, less is known on whether there is a cumulative effect of excessive gestational weight gain (GWG) over multiple pregnancies. Methods: Data from the Study of Women's Health Across the Nation were used, restricted to parous women with no history of stillbirth or premature birth. The effect of the number of excessive GWG pregnancies on body mass index (BMI) in midlife (age 42–53) was analyzed using multivariable linear regression. Fully adjusted models included parity, inadequate GWG, demographic, and behavioral characteristics. Results: The 1181 women included in this analysis reported a total of 2693 births. Overall, 466 (39.5%) were categorized as having at least one pregnancy with excessive GWG. The median BMI at midlife was 26.0 kg/m(2) (interquartile range 22.5–31.1). In fully adjusted models, each additional pregnancy with excessive GWG was associated with 0.021 higher estimated log BMI (p = 0.031). Among women with 1–3 births, adjusted mean (95% confidence interval) BMI for those with 0, 1, 2, and 3 excessive GWG pregnancies was 25.4 (24.9–25.9), 26.8 (26.1–27.5), 27.5 (26.6–28.4), and 28.8 (27.3–30.5), respectively. Conclusions: In this multiethnic study of women with a history of term live births, the number of pregnancies with excessive GWG was associated with increased maternal BMI in midlife. Our findings suggest that prevention of excessive GWG at any point in a woman's reproductive history can have an impact on long-term maternal health.

BACKGROUND: A known relationship exists between oxidative stress and preterm birth (PTB). However, few studies have measured oxidative stress prospectively in early or midpregnancy, and no studies have used electron paramagnetic resonance (EPR) spectroscopy prospectively to predict PTB. OBJECTIVE: The purpose of this study was to identify predictive relationships between antioxidants and reactive oxygen species (ROS), specifically, superoxide ([Formula: see text]), peroxynitrite (OONO(−)), and hydroxyl radical ((●)OH), using EPR spectroscopy, measured between 12 and 20 weeks of gestation and compare with the incidence of PTB. METHODS: Blood was obtained from pregnant women (n = 140) recruited from a tertiary perinatal center. Whole blood was analyzed directly for ROS, [Formula: see text] , OONO(−), and (●)OH using EPR spectroscopy. Red blood cell lysate was used to measure antioxidants. PTB was defined as parturition at

Objective: To assess healthcare resource utilization (HRU) and costs in children of mothers with and without postpartum depression (PPD).Methods: Administrative claims data from the IBM Watson Health MarketScan Databases (2010-2016) were used. Women with live births (index date = delivery date) were identified and linked to their newborns. The mother-child pairs were divided into PPD and non-PPD exposure cohorts based on claims for depression, mood or adjustment disorders, or anxiety identified in the mother between 15 and 365 days after delivery. Mother-child pairs with PPD exposure were propensity score matched 1:3 to mother-child pairs without PPD exposure. Children were required to have 24 months of continuous health plan enrolment following delivery. Additional comparisons were performed between mother-child pairs with and without preterm delivery.Results: Overall, 33,314 mother-child pairs with PPD exposure were propensity score matched to 102,364 mother-child pairs without PPD exposure. During the 24-month follow-up period, HRU across most service categories was significantly higher among children in the PPD exposure cohort than non-PPD exposure cohort. Among outpatient services, the percentages of children with a physician specialist service (68% versus 64%), early-intervention screening (40% versus 37%), and an emergency room visit (48% versus 42%) were greater in children of mothers with PPD (all p < .001). Furthermore, children of mothers with PPD incurred 12% higher total healthcare costs in the first 24 months of life compared to children of mothers without PPD ($24,572 versus $21,946; p < .001). After excluding mothers with preterm delivery, the proportion of children with ER visits, physician specialist services, and outpatient pharmacy claims was significantly higher in the PPD exposure cohort than non-PPD exposure cohort (all p < .001).Conclusion: The results of this analysis suggest that HRU and costs over the first 24 months of life in children of mothers with PPD exceeded that of children of mothers without evidence of PPD.

Background The neonatal intensive care unit (NICU) can cause significant psychological distress in a mother. There is no common definition of maternal distress in the NICU currently in use. Purpose To develop a clear conceptual understanding of maternal distress in the NICU using conceptual definitions and empirical findings. Methods/search strategy A literature search was conducted using EBSCOhost, MEDLINE, CINAHL, PsychINFO, and Google Scholar. The concept analysis was guided by Walker and Avant's (2011) guide. Findings/results Maternal distress in the NICU consists of a combination of depressive, anxiety, trauma, and posttraumatic stress symptoms. The symptoms occur together on a spectrum and present differently in each mother. The antecedents to maternal distress are a NICU hospitalization and a perceived interruption to the transition to motherhood. Consequences of maternal distress in the NICU are issues with developing a healthy maternal-infant bond, adverse infant development, and decreased maternal quality of life. Implications for practice A complete understanding of maternal distress in the NICU will lead to increased awareness of adverse mental health states in this population. Implications for research Identification of mothers at risk for maternal distress in the NICU, as well as the identification of antecedents and consequences related to the mother and the infant from maternal distress in the NICU. Using a single, clear definition of maternal distress in the NICU population will lead to a more cohesive body of literature.

Each year approximately 700 people die in the United States from pregnancy-related complications. We describe the characteristics of pregnancy-related deaths due to mental health conditions, including substance use disorders, and identify opportunities for prevention based on recommendations from fourteen state Maternal Mortality Review Committees (MMRCs) from the period 2008-17. Among 421 pregnancy-related deaths with an MMRC-determined underlying cause of death, 11 percent were due to mental health conditions. Pregnancy-related mental health deaths were more likely than deaths from other causes to be determined by an MMRC to be preventable (100 percent versus 64 percent), to occur among non-Hispanic White people (86 percent versus 45 percent), and to occur 43-365 days postpartum (63 percent versus 18 percent). Sixty-three percent of pregnancy-related mental health deaths were by suicide. Nearly three-quarters of people with a pregnancy-related mental health cause of death had a history of depression, and more than two-thirds had past or current substance use. MMRC recommendations can be used to prioritize interventions and can inform strategies to enable screening, care coordination, and continuation of care throughout pregnancy and the year postpartum.

Background There is a lack of nationally representative estimates for the consequences of early childhood undernutrition on preadolescent outcomes in India. Understanding this relationship is helpful to develop interventions that not only prevent child undernutrition but also mitigate its consequences. Methods and findings In this cohort study, we analyzed prospectively gathered data from 2 waves of the India Human Development Survey (IHDS) to investigate the association of undernutrition during early childhood (0 to 5 years) in 2004 to 2005 with physical and cognitive outcomes during preadolescent (8 to 11 years) years in 2011 to 2012. These surveys interviewed 41,554 households across all 33 states and union territories in India in 2004 to 2005 and reinterviewed 83% of the households in 2011 to 2012. Primary exposure was assessed using the Composite Index of Anthropometric Failure (CIAF) based on 2004 to 2005 survey. Primary outcomes were short stature (height-for-age z-score [HAZ], Apurv Soni and co-workers study child nutrition and developmental outcomes in India., Author summary Why was this study done? India has the largest number of undernourished children under the age of 5. Previous studies report an absence of gender disparities among child undernutrition in India despite well-documented disparities in adulthood. Current national programs for addressing child undernutrition focus on the first 5 years of life and do not include gender-focused interventions. What did the researchers do and find? We carried out a population-based cohort study based on data gathered prospectively from nationally representative survey of 41,554 households in India in 2004 to 2005 and a follow-up in 2011 to 2012 among 83% of the same households. This study leverages India’s only nationally representative panel dataset to report that undernutrition in the first 5 years of life is associated with increased odds of adverse physical outcomes, i.e., having short stature and being very thin and cognitive outcomes, i.e., unable to read and do arithmetic during preadolescent years. Female children who were undernourished were the most vulnerable for experiencing these adverse outcomes, and the gender disparities widened with age during the preadolescent period. As an example, the adjusted probability of short stature for undernourished female children increased from 31% among 8 year olds to 45% among 11 year olds. There was no such increase observed among male children. Presence of a woman in the household with more than secondary level of education mitigated the disadvantage associated with both being undernourished and being a female child. What do these findings mean? Sex differences in physical and cognitive outcomes emerge during the preadolescent period and are associated with early childhood nutrition. Higher level of female education within the household is an important protective factor for these disparities. Elevation of women’s status through improved female education should be central to the national level programs in India focused on maternal and child health.

Relationship conflict and lack of partner support are risk factors for perinatal mood and anxiety disorders. An intervention to strengthen couples' relationships before birth may reduce relationship risk factors for perinatal mood and anxiety disorders, though no research has explored this to date. The aims of this Stage 1 open-series non-experimental proof of concept study were to adapt the 'Marriage Checkup', an evidence-based intervention for relationship distress, as a preventative intervention for perinatal mood and anxiety disorders and to assess its feasibility and acceptability. Pregnant women receiving care at a university-based obstetric practice, and their partners, were recruited. Ten couples participated in the Before Baby Relationship Checkup, a personalized relationship health service offered in the obstetric clinic. Quantitative and qualitative data gathered suggests the intervention is feasible to implement in an obstetric setting, and acceptable to perinatal couples. Specific adaptations to the Marriage Checkup for perinatal couples are warranted and further testing is needed to evaluate efficacy.

PROSPERO, CRD42019124057.

Objectives: The COVID-19 pandemic has caused considerable stress throughout the world. Little is known about how postpartum women who gave birth during the early months of the pandemic were impacted. The purpose of this study was to explore and describe the associations between potential risk, protective factors, and psychological distress among postpartum women who gave birth during the early months of the COVID-19 pandemic. Methods: Postpartum women over the age of 18 years who gave birth in the US hospitals between March and July of 2020 and spoke English completed a survey about their experiences. Demographic and health variables were measured via self-report. Stress was measured using the Perceived Stress Scale-10. Mastery was measured with the Pearlin Mastery Scale. Resilience was measured with the Connor–Davidson Resilience Scale-2. Results: This study included 885 women. Participants had higher stress and lower resilience relative to pre-pandemic norms. Participants had high levels of depression, anxiety, and stress. Women who had an infant admitted to the neonatal intensive care unit had more stress. Income, full-time employment, and partnered relationships were associated with lower stress. Resilience and mastery were related to lower stress, depression, and anxiety. Black, Indigenous, or People of Color women showed higher stress and lower resiliency. Single women were likely to report lower levels of mastery than partnered women. Conclusion: Stress, depression, and anxiety were high in postpartum women in this study. Income, partnered relationships, and employment security, along with protective traits such as mastery and resilience, may reduce the impact of stress on postpartum women in a pandemic. Care models should be modified to support women during a pandemic. Health disparities exist in postpartum stress. Future interventions should focus on building resiliency and mastery and ensuring appropriate resources are available to postpartum women in a pandemic.

Limited data are available regarding family and financial well-being among parents whose infants were hospitalized during the 2019 coronavirus (COVID-19) pandemic. The study objective was to evaluate the family and financial well-being of parents whose infants were hospitalized in the neonatal intensive care unit (NICU) during COVID-19.Parents were recruited for this online, cross-sectional survey via support groups on social media. Data collection was completed between May 18, 2020 and July 31, 2020. The final sample consisted of 178 parents, who had an infant hospitalized in an NICU between February 1, 2020 and July 31, 2020. The primary outcomes were impact on family life and financial stability, as measured by the Impact on Family scale, an instrument that evaluates changes to family life as a result of infant or childhood illness.Of the 178 parent respondents, 173 (97%) were mothers, 107 (59.4%) were non-Hispanic White, and 127 (69.5%) of the infants were born prematurely. Parents reported significant family impact and greater financial difficulty. Extremely premature infants, lower household income, parent mental health, and lower parental confidence were predictive of greater impacts on family life.Parents reported significant family and financial impacts during their infant's hospitalization amid COVID-19. Further studies are needed to guide clinical practice and inform family-supportive resources that can mitigate consequences to family well-being.· Impact of infant hospitalization in the context of COVID-19 is largely unknown.. · In a cohort of NICU parents during COVID-19, they reported changes to family life and finances.. · Greater impacts were reported by parents with lower income, confidence, and very premature infants..

Background Pregnant persons have received mixed messages regarding whether or not to receive COVID-19 vaccines as limited data are available regarding vaccine safety for pregnant and lactating persons and breastfeeding infants. Objective The aims of this study were to examine pregnant Veteran’s acceptance of COVID-19 vaccines, along with perceptions and beliefs regarding vaccine safety and vaccine conspiracy beliefs. Design and Participants We conducted a cross-sectional survey of pregnant Veterans enrolled in VA care who were taking part in an ongoing cohort study at 15 VA medical centers between January and May 2021. Main Measures Pregnant Veterans were asked whether they had been offered the COVID-19 vaccine during pregnancy, and whether they chose to accept or refuse it. Additional questions focused on perceptions of COVID-19 vaccine safety and endorsements of vaccine knowledge and conspiracy beliefs. Logistic regression was utilized to examine predictors of acceptance of a vaccine during pregnancy. Key Results Overall, 72 pregnant Veterans were offered a COVID-19 vaccine during pregnancy; over two-thirds (69%) opted not to receive a vaccine. Reasons for not receiving a vaccine included potential effects on the baby (64%), side effects for oneself (30%), and immunity from a past COVID-19 infection (12%). Those who received a vaccine had significantly greater vaccine knowledge and less belief in vaccine conspiracy theories. Greater knowledge of vaccines in general (aOR: 1.78; 95% CI: 1.2–2.6) and lower beliefs in vaccine conspiracies (aOR: 0.76; 95% CI: 0.6–0.9) were the strongest predictors of acceptance of a COVID-19 vaccine during pregnancy. Conclusions Our study provides important insights regarding pregnant Veterans’ decisions to accept the COVID-19 vaccine, and reasons why they may choose not to accept the vaccine. Given the high endorsement of vaccine conspiracy beliefs, trusted healthcare providers should have ongoing, open discussions about vaccine conspiracy beliefs and provide additional information to dispel these beliefs.

Objective Perinatal depression is a common pregnancy complication and universal screening is recommended. The Practice Readiness to Evaluate and address Perinatal Depression (PREPD) was developed to measure obstetric practice readiness to integrate depression care into workflows. Objectives were to describe: (1) the PREPD; (2) associated characteristics by readiness level; and (3) use of the assessment to measure change. Method The PREPD has four components, each scored to a 16-point maximum: (1) Environmental Scan (10% of PREPD); (2) Depression Detection, Assessment, and Treatment Questionnaire (30%); (3) Depression-related Policies Questionnaire (10%); and (4) Chart Abstraction (50%). Components were weighted and summed for an overall score. Summary and component scores were calculated by patient, practice, and provider. Results Average overall PREPD score was 7.3/16 (range: 4.8–9.9); scores varied between practices. The Environmental Scan averaged 2.0/16 (range: 0–5.2); Detection, Assessment, and Treatment averaged 8.3/16 (range: 3.0–11.5); Chart Abstraction averaged 7.2/16 (range: 5.1–9.6); and Depression-related Policies averaged 10.4/16 (range: 7.5–15). Conclusion We found wide variation in obstetric practices’ readiness to implement interventions for depression; most were minimally prepared. These data may be used to tailor practice intervention goals and as benchmarks with which to measure changes in integration of depression care over time.

Purpose To develop and validate an International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)-based algorithm to identify cases of stillbirth using electronic healthcare data. Methods We conducted a retrospective study using claims data from three Data Partners (healthcare systems and insurers) in the Sentinel Distributed Database. Algorithms were developed using ICD-10-CM diagnosis codes to identify potential stillbirths among females aged 12-55 years between July 2016 and June 2018. A random sample of medical charts (N = 169) was identified for chart abstraction and adjudication. Two physician adjudicators reviewed potential cases to determine whether a stillbirth event was definite/probable, the date of the event, and the gestational age at delivery. Positive predictive values (PPVs) were calculated for the algorithms. Among confirmed cases, agreement between the claims data and medical charts was determined for the outcome date and gestational age at stillbirth. Results Of the 110 potential cases identified, adjudicators determined that 54 were stillbirth events. Criteria for the algorithm with the highest PPV (82.5%; 95% CI, 70.9%-91.0%) included the presence of a diagnosis code indicating gestational age ≥ 20 weeks and occurrence of either >1 stillbirth-related code or no other pregnancy outcome code (i.e., livebirth, spontaneous abortion, induced abortion) recorded on the index date. We found ≥90% agreement within 7 days between the claims data and medical charts for both the outcome date and gestational age at stillbirth. Conclusions Our results suggest that electronic healthcare data may be useful for signal detection of medical product exposures potentially associated with stillbirth. This article is protected by copyright. All rights reserved.

Background: Perinatal depression is common, underdiagnosed, and undertreated. Obstetric providers often do not receive training in perinatal depression, despite being the frontline providers for pe...

Background Depression is the most commonly diagnosed medical condition among women veterans ages 18 to 44; however, depression symptoms occurring during pregnancy have not been well-studied in this population. Methods Pregnant veterans were recruited from 15 Veterans Health Administration sites across the United States; our sample included 501 participants. Sociodemographic characteristics, military service, health status, and pregnancy related factors, as well as the Edinburgh Postnatal Depression Scale (EPDS), were collected as part of a telephone survey. Additional data were obtained from electronic health record data. We used multivariable logistic regression models to examine factors associated with an EPDS score suggestive of clinically significant depressive symptoms (≥10). Findings Prenatal EPDS scores of 10 or greater were calculated for 28% of our sample. Our final model indicated that factors associated with decreased odds of an EPDS score of 10 or greater included spousal or partner support during pregnancy (adjusted odds ratio [aOR], 0.35; 95% confidence interval [CI], 0.16–0.77) and employment (aOR, 0.40; 95% CI, 0.24–0.67). A past diagnosis of anxiety (aOR, 2.54; 95% CI, 1.43–4.50), past antidepressant use (aOR, 3.27; 95% CI, 1.71–6.24), and active duty service (aOR, 1.91; 95% CI, 1.08–3.37) were associated with increased odds of having an EPDS score of 10 or greater. Conclusions This is the first quantitative estimate of depression symptoms in pregnant veterans across multiple Veterans Affairs facilities. The prevalence of depression symptomology was greater than the high end of prevalence estimates in the general pregnant population. Given that the risk of depression increases during the postpartum period, women who can be identified with depressive symptomatology during pregnancy can be offered critical resources and support before giving birth.

To describe national, state-specific, and sociodemographic trends in diagnoses of depressive disorders recorded during delivery hospitalizations.Data were analyzed from the National Inpatient Sample (2000-2015) and 31 publicly available State Inpatient Databases (2000-2015) of the Healthcare Cost and Utilization Project. Delivery hospitalizations were identified by using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes for obstetric delivery. Depressive disorders were identified from ICD-9-CM diagnoses codes classified as depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (291.89, 292.84, 293.83, 296.2-296.26, 296.3-296.36, 300.4, and 311). Prevalence rates and average annual rate change were calculated nationally and across 28 states with at least 3 years of data and age, payer source, and race or ethnicity.The U.S. rate of depressive disorders recorded during delivery hospitalizations increased from 4.1 diagnoses per 1,000 hospitalizations in 2000 to 28.7 in 2015. Rates significantly increased in 27 of the 28 states. Recent (2014-2015) rates were lowest in Hawaii and Nevada (less than 14/1,000) and highest in Vermont, Minnesota, Oregon, and Wisconsin (greater than 49/1,000). Rates in 2015 were highest among those aged 35 years or older, public insurance recipients, and non-Hispanic white women (greater than 31/1,000). The highest annual rate increases were in Vermont and Maine (3.8/1,000 or greater). Non-Hispanic white women, those 35 years of age or older, and public insurance recipients showed the highest annual rate increases during 2000-2015 (1.7/1,000 or greater).During 2000-2015, rates of depressive disorders recorded during delivery hospitalizations increased nationally, in 27 states with available data, and across all sociodemographic categories.

BackgroundAn emerging body of evidence underscores the often-intensive perinatal healthcare needs of women with intellectual and developmental disabilities (IDD). However, population-based research examining postpartum experiences of US women with IDD is sparse. We examined emergency department (ED) use in the postpartum period among Massachusetts mothers with IDD.MethodsWe analysed 2002–2010 Massachusetts Pregnancy to Early Life Longitudinal data to compare any and ≥2 ED visits between mothers with and without IDD: within 1–42 days post partum, 1–90 days post partum and 1–365 days post partum. We also determined whether or not such ED use was non-urgent or primary-care sensitive.ResultsWe identified 776 births in women with IDD and 595 688 births in women without IDD. Across all three postpartum periods, women with IDD were vastly more likely to have any postpartum ED use, to have ≥2 ED visits and to have ED visits for mental health reasons. These findings persisted after controlling for numerous sociodemographic and clinical characteristics. Women with IDD were less likely to have non-urgent ED visits during the three postpartum periods and they were less likely to have primary-care sensitive ED visits during the postpartum period.ConclusionThese findings contribute to the emerging research on perinatal health and healthcare use among women with IDD. Further research examining potential mechanisms behind the observed ED visit use is warranted. High ED use for mental health reasons among women with IDD suggests that their mental health needs are not being adequately met.

Perinatal depression is common and can have deleterious effects on mothers, infants, children, partners, and families. Despite this, few women who screen positive for depression receive psychiatric treatment. A comprehensive perinatal depression care pathway includes: (1) screening, (2) assessment, (3) triage and referral, (4) treatment access, (5) treatment initiation, (6) symptom monitoring, and (7) adaptation of treatment based on measurement until symptoms remit. This depression care pathway provides a scaffold on which to frame the challenges encountered when, and the opportunities that exist for, addressing depression in obstetric settings. Comprehensive interventions that address each step on the care pathway are needed to support obstetric practices in providing high-quality, evidence-based, effective treatment including pro-active follow-up for depression management. Despite recent attention being brought to, and significant progress in the field of maternal mental health, gaps in care persist. Ultimately, depression care needs to be fully integrated into obstetric care. Additionally, more targeted maternal mental health support and structure are needed for integration to occur and ultimately be optimized. Specific areas requiring more attention include consistency of screening, evaluation of patients with a positive depression screen for bipolar disorder, anxiety or substance use disorders, and monitoring of symptom improvement.

BACKGROUND: Women with intellectual and developmental disabilities (IDD) experience disparities in obstetric care access and quality, in addition to communication gaps with healthcare providers. Many obstetric providers are untrained and uneducated about critical aspects of providing care to persons with IDD. OBJECTIVE: The study was conducted to describe obstetric clinicians’ training experiences related to providing obstetric care to women with IDD, to assess the perceived need for formalized training, and to identify recommendations for training content. METHODS: This study involved qualitative individual interviews (n=9) and one focus group (n=8) with obstetric clinicians who self-reported experience caring for women with IDD during pregnancy. Descriptive coding and content analysis techniques were used to develop an iterative codebook related to education and training; codes were applied to the data. Coded data were analyzed for larger themes and relationships. RESULTS: Analysis revealed three main themes: 1. Need for obstetric training and education: No participant reported receiving any training in caring for pregnant women with IDD. Participants expressed a need for formal education. 2. Recommendations for formal training: Participants noted the need for training during residency and beyond, and all healthcare staff should be included in training. 3. Training outcomes should increase knowledge, enhance attitudes, and develop practical skills related to care for pregnant women with IDD. CONCLUSION: Results indicate a need for systematic training efforts regarding obstetric care for women with IDD. Improved training and education may decrease health inequities and improve the quality of care, and thus pregnancy outcomes, for women with IDD. LEVEL OF EVIDENCE: VI

Objective To elicit the perspectives of individuals with a traumatic birth experience on barriers and facilitators to receiving mental health support in the postpartum period. Methods Individuals who experienced a traumatic birth within the last three years (n = 32) completed semi-structured phone interviews about their birth and postpartum experience. The Post-traumatic Stress Disorder Checklist for DSM-V (PCL-5), Patient Health Questionnaire (PHQ-8), and Generalized Anxiety Disorder scale (GAD-7) were administered. Qualitative data was analyzed using a modified grounded theory by three independent coders. Results Among participants, 34.4% screened positive for PTSD, 18.8% for depression, and 34.4% for anxiety. Participants described multi-level barriers that prevented clinicians from recognizing and supporting patients' postpartum mental health needs; those involved lack of communication, education, and resources. Recommendations from participants included that 1) obstetric professionals should acknowledge birth-related trauma experienced by any individual, 2) providers of multiple disciplines need to be integrated into postpartum care, and 3) mental health support may be needed before the ambulatory postpartum visit. Conclusions There are multi-level barriers towards detecting and responding to individuals' mental health needs after a traumatic birth. Obstetric professionals need to use a trauma-informed approach and proactively assess mental health throughout the postpartum period.

Pregnancy is a physiological state of continuous adaptation to changing maternal and fetal nutritional needs, including a reduction of maternal insulin sensitivity allowing for appropriately enhanced glucose availability to the fetus. However, excessive insulin resistance in conjunction with insufficient insulin secretion results in gestational diabetes mellitus (GDM), greatly increasing the risk for pregnancy complications and predisposing both mothers and offspring to future metabolic disease. Here, we report a signaling pathway connecting pregnancy-associated plasma protein A (PAPPA) with adipose tissue expansion in pregnancy. Adipose tissue plays a central role in the regulation of insulin sensitivity, and we show that, in both mice and humans, pregnancy caused remodeling of adipose tissue evidenced by altered adipocyte size, vascularization, and in vitro expansion capacity. PAPPA is known to be a metalloprotease secreted by human placenta that modulates insulin-like growth factor (IGF) bioavailability through prolteolysis of IGF binding proteins (IGFBPs) 2, 4, and 5. We demonstrate that recombinant PAPPA can stimulate ex vivo human adipose tissue expansion in an IGFBP-5– and IGF-1–dependent manner. Moreover, mice lacking PAPPA displayed impaired adipose tissue remodeling, pregnancy-induced insulin resistance, and hepatic steatosis, recapitulating multiple aspects of human GDM. In a cohort of 6361 pregnant women, concentrations of circulating PAPPA are inversely correlated with glycemia and odds of developing GDM. These data identify PAPPA and the IGF signaling pathway as necessary for the regulation of maternal adipose tissue physiology and systemic glucose homeostasis, with consequences for long-term metabolic risk and potential for therapeutic use.

Background Hypertension (HTN) in pregnancy is a leading cause of maternal morbidity and mortality in the United States. Although the Dietary Approaches to Stop Hypertension (DASH) diet is recommended for all adults with HTN, rates of DASH adherence and antihypertensive medication use in women of child-bearing age are unknown. Our objectives were to determine DASH adherence and antihypertensive medication use in women of child-bearing age. Methods In the National Health and Nutrition Examination Surveys from 2001 to 2016, we estimated DASH adherence among women of child-bearing age (20–50 years). We derived a DASH score (0–9) based on 9 nutrients, with DASH adherence defined as DASH score ≥4.5. HTN was defined by blood pressure (BP) ≥130/80 mm Hg or antihypertensive medication use. DASH scores were compared across BP categories and antihypertensive medication use was categorized. Results Of the 7,782 women, the mean age (SE) was 32.8 (0.2) years, 21.4% were non-Hispanic Black, and 20.3% had HTN. The mean DASH score was 2.11 (0.06) for women with self-reported HTN and 2.40 (0.03) for women with normal BP (P < 0.001). DASH adherence was prevalent in 6.5% of women with self-reported HTN compared with 10.1% of women with normal BP (P < 0.05). Self-reported HTN is predominantly managed with medications (84.8%), while DASH adherence has not improved in these women from 2001 to 2016. Moreover, 39.5% of US women of child-bearing age are taking medications contraindicated in pregnancy. Conclusions Given the benefits of optimized BP during pregnancy, this study highlights the critical need to improve DASH adherence and guide prescribing among women of child-bearing age.

Objective To examine sugar-sweetened beverage (SSB) consumption, sleep duration, and quality during pregnancy. Methods Pregnant women completed 3 24-hour dietary recalls and the Pittsburgh Sleep Quality Index. Logistic regression models estimated odds of short sleep duration ( 5) by SSB consumption (servings/d averaged across 3 days). Results Participants (n = 108) were a median age of 30 years old (interquartile range [IQR], 26–33) and at 23.9 weeks gestation (IQR, 18.9–30.6). Participants consumed a median of 0.4 servings of SSBs per day on average (IQR, 0–1.1; range, 0–4.6). Fifty-two percent reported poor quality sleep and 38% short sleep. Each additional serving of SSB was associated with higher odds of short sleep (adjusted odds ratio, 1.6; 95% confidence interval, 1.1–2.5) and poor sleep quality (adjusted odds ratio, 2.1; 95% confidence interval, 1.2–3.6). Conclusions and Implications SSB consumption may be a modifiable risk factor for short/poor sleep during pregnancy. Longitudinal research is needed to explore the interplay between SSB consumption and sleep.

The objective of this review is to describe the extent to which (1) obstetric settings are currently screening for mental health and substance use disorders and social determinants of health (SDoH), and (2) screening is followed by systematic approaches for ensuring an adequate response to positive screens. Additionally, clinical and policy implications of current screening practices and recommendations are discussed. Screening for perinatal depression in obstetric settings has increased. Despite their prevalence and negative impact, screening for other mental health and substance use disorders and SDoH is much less common and professional society recommendations are either nonexistent, less consistent, or less prescriptive. To truly address maternal mental health, we need to move beyond focusing solely on depression and address other mental health and substance use disorders and the contextual social determinants in which they occur.

To synthesize literature addressing maternal distress and associated variables in response to infant hospitalization in the NICU. CINAHL, Medline, PubMed, PsychINFO, and Scopus were searched for studies addressing maternal distress during NICU hospitalization published between January 2009 and August 2019. The initial literature search yielded 862 articles. Articles were included for analysis if (a) they were peer-reviewed, (b) maternal distress was defined or measured, and (c) maternal distress occurred in the NICU. Ultimately, 33 articles were included for analysis. Distress symptoms were not consistently measured across the literature by one specific instrument. However, despite the variety of instruments, distress was prevalent in this population. Individual elements of maternal distress in the NICU include depression, anxiety, trauma, and post-traumatic stress symptoms. These elements often occur together and tend to follow a specific trajectory during hospitalization. This body of literature was inconsistent regarding the timing of distress measurement as well as the relationship between relevant associated variables (e.g., marital status or infant illness severity) and maternal distress. Additionally, researchers often excluded mothers of non-preterm infants and infants with congenital anomalies from investigation. Researchers and clinicians should carefully consider timing and instrumentation in their interpretations of maternal distress measurement during a NICU hospitalization. Future work should focus on developing a comprehensive, valid, and reliable screening tool for clinicians and researchers to use to identify maternal distress in the NICU. Additionally, future research should address gaps in the populations included in studies.

This systematic review searched 4 databases (PubMed/MEDLINE, Scopus, CINAHL, and PsychINFO) and identified 21 articles eligible to evaluate the extent to which interventions that integrate depression care into outpatient obstetric practice are feasible, effective, acceptable, and sustainable. Despite limitations among the available studies including marked heterogeneity, there is evidence supporting feasibility, effectiveness, and acceptability. In general, this is an emerging field with promise that requires additional research. Critical to its real-world success will be consideration for practice workflow and logistics, and sustainability through novel reimbursement mechanisms.

OBJECTIVES: This study examined the risk of postpartum hospital admissions and emergency department (ED) visits among U.S. women with intellectual and developmental disabilities (IDD). METHODS: We used the 2002–2012 Pregnancy to Early Life Longitudinal Data System and identified deliveries to women with and without IDD. Women with IDD (n=1,104) or case subjects were identified from the International Classification of Diseases and Related Health Problems 9th Revision (ICD-9 CM) codes. The study primary outcome measures were any postpartum hospital admission and any ED visit during three critical postpartum periods (1–42 days, 43–90 days, and 1–365 days). We conducted unadjusted and adjusted survival analysis using Cox proportional hazard models to compare the occurrence of first hospital admission or ED visits between women with and without IDD. RESULTS: We found that women with IDD had markedly higher rates of postpartum hospital admissions and ED visits during the critical postpartum periods (within 1–42 days, 43–90 days and 91–365 days) after a childbirth. CONCLUSION FOR PRACTICE: Given the heightened risk of pregnancy complications and adverse birth outcomes and the findings of this study, there is an urgent need for clinical guidelines related to the frequency and timing of postpartum care among new mothers with IDD. Further, this study provides evidence of the need for evidence-based interventions for new mothers with IDD to provide preventive care and routine assessments that would identify and manage complications for both the mother and the infant outside of the traditional postpartum health care framework.

Bipolar disorder among pregnant women has deleterious effects on birth and child outcomes and is currently under-detected, not addressed effectively, or exacerbated through inappropriate treatment. The goal of this study was to identify perspectives of pregnant and postpartum women with bipolar disorder on barriers and facilitators to psychiatric treatment during pregnancy. In-depth interviews were conducted with pregnant and postpartum women who scored ≥ 10 on the Edinburgh Postnatal Depression Scale and met DSM-IV criteria for bipolar disorder I, II or not otherwise specified using the Mini International Neuropsychiatric Interview version 5.0. Interviews were transcribed, and resulting data were analyzed using a grounded theory approach to identify barriers and facilitators to bipolar disorder treatment access in pregnancy. Participant identified barriers included perception that psychiatric providers lack training and experience in the treatment of psychiatric illness during pregnancy, are reluctant to treat bipolar disorder among pregnant women, and believe that pharmacotherapy is not needed for psychiatric illness during pregnancy. Facilitators included participants' perception that providers' acknowledge risks associated with untreated or undertreated psychiatric illness during pregnancy and provide psycho-education about the risks, benefits and alternatives to pharmacotherapy. Psychiatric providers are critically important to the treatment of bipolar disorder and need knowledge and skills necessary to provide care during the perinatal period. Advancing psychiatric providers' knowledge/skills may improve access to pharmacotherapy for pregnant women with bipolar disorder.

Perinatal mood and anxiety disorders are among the most common mental health conditions encountered by women of reproductive age. When left untreated, perinatal mood and anxiety disorders can have profound adverse effects on women and their children, ranging from increased risk of poor adherence to medical care, exacerbation of medical conditions, loss of interpersonal and financial resources, smoking and substance use, suicide, and infanticide. Perinatal mood and anxiety disorders are associated with increased risks of maternal and infant mortality and morbidity and are recognized as a significant patient safety issue. In 2015, the Council on Patient Safety in Women's Health Care convened an interdisciplinary work group to develop an evidence-based patient safety bundle to address maternal mental health. The focus of this bundle is perinatal mood and anxiety disorders. The bundle is modeled after other bundles released by the Council on Patient Safety in Women's Health Care and provides broad direction for incorporating perinatal mood and anxiety disorder screening, intervention, referral, and follow-up into maternity care practice across health care settings. This commentary provides information to assist with bundle implementation.

Study Objective To determine whether complications during pregnancy or at delivery influence postpartum contraception choices and rapid repeat pregnancy rates in adolescent women. Design, Setting, Participants, Interventions, and Main Outcome Measures This retrospective cohort study included 321 adolescents delivering at UMASS Memorial Healthcare. Complications during pregnancy and delivery along with subsequent contraception use were investigated. Postpartum contraception choice (long-acting reversible contraception [LARC] vs non-LARC) at either delivery, hospitalization discharge, or at postpartum outpatient appointment, and rapid repeat pregnancy rate (pregnancy confirmed within 12 months of index delivery), were analyzed according to pregnancy complications. Comparisons were made with χ 2 and Fisher exact tests for categorical variables, and with Wilcoxon rank sum test for continuous variables. Results Of the study population, 27.7% (n = 89/321) used LARC in the postpartum period. The LARC and non-LARC patient populations differed significantly regarding history of abortion ( P = .029), with no differences in obstetric complications between the groups. Of the population, 16.6% (n = 53/320) became pregnant again within 1 year of their index delivery. Those with a rapid repeat pregnancy had significantly increased gravidity ( P = .002), parity ( P = .003), number of previous spontaneous or therapeutic abortions ( P = .026); they were also more like to have nonlive birth as a complication ( P = .028), compared with those without repeat pregnancy. No other obstetrical complications were statistically significantly different between the compared groups. Conclusion Obstetrical complications seem to have little effect on postpartum contraception choice or repeat pregnancy rate with the notable exception of nonlive birth being associated with rapid repeat pregnancy.

Background: Oxidative stress is associated with poor perinatal outcomes. Little is known regarding the longitudinal levels of oxidative stress in the perinatal period or the correlation between maternal and neonatal oxidative stress levels. Objective: Describe and compare oxidative stress, specifically superoxide, superoxide dismutase, catalase, and glutathione levels, over the perinatal period. Study Design: Longitudinal descriptive design using a convenience sample of medically high- and low-risk pregnant women ( n = 140) from a maternal–fetal medicine and general obstetrics practice, respectively. Blood was obtained from women at 12–20 and 24–28 weeks’ gestation and during labor, from the umbilical cord at birth, and from neonates at 24–72 hr after birth. Levels of superoxide were measured using electron paramagnetic resonance (EPR) spectroscopy; antioxidants (superoxide dismutase, catalase, and glutathione) were measured using commercial assay kits. Relationships between oxidative stress levels at different time points were examined using nonparametric methods. Pregnancy outcome was collected. Results: Demographic variables, outcome variables, and oxidative stress levels in maternal blood, cord blood, and infants differed between medically high- and low-risk women. Descriptive patterns for oxidative stress measures varied over time and between risk groups. Significant correlations between time points were noted, suggesting intraindividual consistency may exist throughout the perinatal period. However, these correlations were not consistent across each medical risk group. Conclusion: EPR spectroscopy is a feasible method for the perinatal population. Results provide new information on perinatal circulating superoxide levels and warrant further investigation into potential relationships between prenatal and neonatal physiologic dysregulation of oxidative stress.