27 results on '"Creanga, Andreea"'
Search Results
2. Maternal obesity and severe maternal morbidity-It is time to ask new research questions.
- Author
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Creanga AA
- Subjects
- Female, Humans, Pregnancy, Obesity, Pregnancy Complications
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- 2019
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3. Severe maternal morbidity and related hospital quality measures in Maryland.
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Reid LD and Creanga AA
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- Adolescent, Adult, Child, Female, Humans, Logistic Models, Maryland epidemiology, Maternal Death, Middle Aged, Multivariate Analysis, Pregnancy, Pregnancy Complications diagnosis, Prevalence, Risk Factors, Socioeconomic Factors, Young Adult, Hospitals statistics & numerical data, Morbidity, Patient Discharge statistics & numerical data, Pregnancy Complications epidemiology, Quality of Health Care organization & administration
- Abstract
Objective: To determine hospital characteristics and quality metrics associated with severe maternal morbidity (SMM) in Maryland., Study Design: A population-based observational study of 364,113 statewide delivery hospitalizations during 2010-2015 linked with socio-economic community measures and hospital characteristics and quality measures. Multivariable logistic regression models with generalized estimating equations estimated SMM adjusting for individual, community, and hospital-level factors and clustering within hospitals and residence zip codes., Results: The SMM prevalence was 197 per 10,000 deliveries. Adjusted SMM risk ratios were higher for younger (<20 years), older (35+ years), non-White non-Hispanic, unmarried, multiple substance users, women with multiple gestations, and chronic medical and mental health conditions than their counterparts. Communities with greater socio-economic disadvantage and hospitals with poorer patient experience and clinical care quality had higher rates of SMM., Conclusion: Addressing socio-economic disparities and improving quality of care in delivery hospitals are key to reducing the SMM burden in Maryland.
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- 2018
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4. Maternal mortality in the developed world: a review of surveillance methods, levels and causes of maternal deaths during 2006-2010.
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Creanga AA
- Subjects
- Developed Countries, Europe epidemiology, Female, Humans, Population Surveillance, Pregnancy, Pregnancy Complications epidemiology, United States epidemiology, Maternal Death statistics & numerical data, Maternal Mortality, Pregnancy Complications mortality
- Abstract
This article provides an overview of surveillance methods, levels, and causes of maternal mortality in developed countries, in Europe and the United States, during 2006-2010. Accurate identification of maternal deaths is not always possible, and no two countries in the world use the same surveillance methods for maternal mortality. Despite limitations (e.g. underestimation, misclassification), routine vital registration systems are the backbone of maternal mortality surveillance systems in developed countries. Enhanced surveillance methods involve linkages between deaths of women of reproductive age and births within the preceding year, or the use of additional data sources for maternal deaths. Confidential enquiries into maternal deaths, in place in France, the Netherlands, and the UK are the gold standard in maternal mortality surveillance. Levels of maternal mortality in Europe were the lowest in the world during 2006-2010. While Europe has not seen major changes in maternal mortality in recent years, pregnancy-related mortality increased considerably in the USA, where improvements in the identification of deaths appear to play a part. The triad of infection, hemorrhage, and hypertensive disorders of pregnancy, which in the past accounted for >90% of all maternal deaths, now accounts for 60-70% of such deaths in developed countries. Maternal mortality surveillance provides learning opportunities to prevent future maternal deaths. There is need for integration of linked, multiple data sources into current maternal mortality surveillance systems to improve their utility.
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- 2017
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5. Maternal Use of Opioids During Pregnancy and Congenital Malformations: A Systematic Review.
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Lind JN, Interrante JD, Ailes EC, Gilboa SM, Khan S, Frey MT, Dawson AL, Honein MA, Dowling NF, Razzaghi H, Creanga AA, and Broussard CS
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- Female, Humans, Methadone adverse effects, Pregnancy, Research Design, Abnormalities, Drug-Induced, Analgesics, Opioid adverse effects, Morphine Derivatives adverse effects, Opioid-Related Disorders drug therapy, Pregnancy Complications drug therapy
- Abstract
Context: Opioid use and abuse have increased dramatically in recent years, particularly among women., Objectives: We conducted a systematic review to evaluate the association between prenatal opioid use and congenital malformations., Data Sources: We searched Medline and Embase for studies published from 1946 to 2016 and reviewed reference lists to identify additional relevant studies., Study Selection: We included studies that were full-text journal articles and reported the results of original epidemiologic research on prenatal opioid exposure and congenital malformations. We assessed study eligibility in multiple phases using a standardized, duplicate review process., Data Extraction: Data on study characteristics, opioid exposure, timing of exposure during pregnancy, congenital malformations (collectively or as individual subtypes), length of follow-up, and main findings were extracted from eligible studies., Results: Of the 68 studies that met our inclusion criteria, 46 had an unexposed comparison group; of those, 30 performed statistical tests to measure associations between maternal opioid use during pregnancy and congenital malformations. Seventeen of these (10 of 12 case-control and 7 of 18 cohort studies) documented statistically significant positive associations. Among the case-control studies, associations with oral clefts and ventricular septal defects/atrial septal defects were the most frequently reported specific malformations. Among the cohort studies, clubfoot was the most frequently reported specific malformation., Limitations: Variabilities in study design, poor study quality, and weaknesses with outcome and exposure measurement., Conclusions: Uncertainty remains regarding the teratogenicity of opioids; a careful assessment of risks and benefits is warranted when considering opioid treatment for women of reproductive age., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)
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- 2017
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6. Patterns and Determinants of Care-Seeking for Antepartum and Intrapartum Complications in Rural Bangladesh: Results from a Cohort Study.
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Khanam R, Creanga AA, Koffi AK, Mitra DK, Mahmud A, Begum N, Moin SM, Ram M, Quaiyum MA, Ahmed S, Saha SK, and Baqui AH
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- Adolescent, Adult, Bangladesh epidemiology, Female, Humans, Pregnancy, Socioeconomic Factors, Delivery of Health Care, Patient Acceptance of Health Care, Pregnancy Complications epidemiology, Rural Population
- Abstract
Background: The burden of maternal complications during antepartum and intrapartum periods is high and care seeking from a trained provider is low, particularly in low middle income countries of sub-Saharan Africa and South Asia. Identification of barriers to access to trained care and development of strategies to address them will contribute to improvements in maternal health. Using data from a community-based cohort of pregnant women, this study identified the prevalence of antepartum and intrapartum complications and determinants of care-seeking for these complications in rural Bangladesh., Methods: The study was conducted in 24,274 pregnant women between June 2011 and December 2013 in rural Sylhet district of Bangladesh. Women were interviewed during pregnancy to collect data on demographic and socioeconomic characteristics; prior miscarriages, stillbirths, live births, and neonatal deaths; as well as data on their ability to make decision to go to health center alone. They were interviewed within the first 7 days of child birth to collect data on self-reported antepartum and intrapartum complications and care seeking for those complications. Bivariate analysis was conducted to explore association between predisposing (socio-demographic), enabling (economic), perceived need, and service related factors with care-seeking for self-reported antepartum and intrapartum complications. Multivariable multinomial logistic regression was performed to examine the association of selected factors with care-seeking for self-reported antepartum and intrapartum complications adjusting for co-variates., Results: Self-reported antepartum and intrapartum complications among women were 14.8% and 20.9% respectively. Among women with any antepartum complication, 58.9% sought care and of these 46.5% received care from a trained provider. Of the women with intrapartum complications, 61.4% sought care and of them 46.5% did so from a trained provider. Care-seeking for both antepartum and intrapartum complications from a trained provider was significantly higher for women with higher household wealth status, higher literacy level of both women and their husbands, and for those living close to a health facility (<10 km). Women's decision making ability to go to health centre alone was associated with untrained care only for antepartum complications, but was associated with both trained and untrained care for intrapartum complications., Conclusions: Nearly 40.0% of the women who experienced either an antepartum or intrapartum complications did not seek care from any provider and 11.5% -14.9% received care from untrained providers, primarily because of economic and geographic barriers to access. Development and evaluation of context specific, cost-effective, and sustainable strategies that will address these barriers to access to care for the maternal complications will enhance care seeking from trained health care providers and improve maternal health., Competing Interests: The authors have declared that no competing interests exist.
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- 2016
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7. The role of screening, brief intervention, and referral to treatment in the perinatal period.
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Wright TE, Terplan M, Ondersma SJ, Boyce C, Yonkers K, Chang G, and Creanga AA
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- Alcoholism diagnosis, Alcoholism therapy, Counseling methods, Female, Humans, Mass Screening, Postnatal Care, Pregnancy, Pregnancy Complications therapy, Substance-Related Disorders therapy, Tobacco Use Disorder diagnosis, Tobacco Use Disorder therapy, Motivational Interviewing methods, Pregnancy Complications diagnosis, Prenatal Care methods, Referral and Consultation, Substance-Related Disorders diagnosis
- Abstract
Substance use during pregnancy is at least as common as many of the medical conditions screened for and managed during pregnancy. While harmful and costly, it is often ignored or managed poorly. Screening, brief intervention, and referral to treatment is an evidence-based approach to manage substance use. In September 2012, the US Centers for Disease Control and Prevention convened an Expert Meeting on Perinatal Illicit Drug Abuse to help address key issues around drug use in pregnancy in the United States. This article reflects the formal conclusions of the expert panel that discussed the use of screening, brief intervention, and referral to treatment during pregnancy. Screening for substance use during pregnancy should be universal. It allows stratification of women into zones of risk given their pattern of use. Low-risk women should receive brief advice, those classified as moderate risk should receive a brief intervention, whereas those who are high risk need referral to specialty care. A brief intervention is a patient-centered form of counseling using the principles of motivational interviewing. Screening, brief intervention, and referral to treatment has the potential to reduce the burden of substance use in pregnancy and should be integrated into prenatal care., (Copyright © 2016 Elsevier Inc. All rights reserved.)
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- 2016
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8. Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age.
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Ko JY, Farr SL, Tong VT, Creanga AA, and Callaghan WM
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- Adolescent, Adult, Alcohol Drinking epidemiology, Case-Control Studies, Cross-Sectional Studies, Female, Humans, Pregnancy, Prevalence, Risk Factors, Smoking epidemiology, Substance-Related Disorders epidemiology, United States epidemiology, Young Adult, Attitude to Health, Marijuana Abuse epidemiology, Marijuana Smoking epidemiology, Pregnancy Complications epidemiology
- Abstract
Objective: The objective of the study was to provide national prevalence, patterns, and correlates of marijuana use in the past month and past 2-12 months among women of reproductive age by pregnancy status., Study Design: Data from 2007-2012 National Surveys on Drug Use and Health, a cross-sectional nationally representative survey, identified pregnant (n = 4971) and nonpregnant (n = 88,402) women 18-44 years of age. Women self-reported marijuana use in the past month and past 2-12 months (use in the past year but not in the past month). χ(2) statistics and adjusted prevalence ratios were estimated using a weighting variable to account for the complex survey design and probability of sampling., Results: Among pregnant women and nonpregnant women, respectively, 3.9% (95% confidence interval [CI], 3.2-4.7) and 7.6% (95% CI, 7.3-7.9) used marijuana in the past month and 7.0% (95% CI, 6.0-8.2) and 6.4% (95% CI, 6.2-6.6) used in the past 2-12 months. Among past-year marijuana users (n = 17,934), use almost daily was reported by 16.2% of pregnant and 12.8% of nonpregnant women; and 18.1% of pregnant and 11.4% of nonpregnant women met criteria for abuse and/or dependence. Approximately 70% of both pregnant and nonpregnant women believe there is slight or no risk of harm from using marijuana once or twice a week. Smokers of tobacco, alcohol users, and other illicit drug users were 2-3 times more likely to use marijuana in the past year than respective nonusers, adjusting for sociodemographic characteristics., Conclusion: More than 1 in 10 pregnant and nonpregnant women reported using marijuana in the past 12 months. A considerable percentage of women who used marijuana in the past year were daily users, met abuse and/or dependence criteria, and were polysubstance users. Comprehensive screening, treatment for use of multiple substances, and additional research and patient education on the possible harms of marijuana use are needed for all women of reproductive age., (Published by Elsevier Inc.)
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- 2015
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9. In reply.
- Author
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Creanga AA, Syverson C, Seed K, Bruce FC, and Callaghan WM
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- Female, Humans, Pregnancy, Black or African American statistics & numerical data, Hispanic or Latino statistics & numerical data, Maternal Mortality trends, Pregnancy Complications mortality, White People statistics & numerical data
- Published
- 2015
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10. Infant and maternal characteristics in neonatal abstinence syndrome--selected hospitals in Florida, 2010-2011.
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Lind JN, Petersen EE, Lederer PA, Phillips-Bell GS, Perrine CG, Li R, Hudak M, Correia JA, Creanga AA, Sappenfield WM, Curran J, Blackmore C, Watkins SM, and Anjohrin S
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- Adult, Analgesics, Opioid, Benzodiazepines, Breast Feeding statistics & numerical data, Cannabis, Causality, Chronic Pain drug therapy, Chronic Pain epidemiology, Cocaine, Comorbidity, Female, Florida, Humans, Infant, Low Birth Weight, Infant, Newborn, Infant, Premature, Intensive Care Units, Neonatal statistics & numerical data, Length of Stay statistics & numerical data, Maternal Age, Pregnancy, Survival Rate, Nicotiana, Hospitalization statistics & numerical data, Neonatal Abstinence Syndrome epidemiology, Pregnancy Complications epidemiology, Prenatal Exposure Delayed Effects epidemiology, Substance-Related Disorders epidemiology
- Abstract
Neonatal abstinence syndrome (NAS) is a constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs taken by a mother during pregnancy. The number of hospital discharges of newborns diagnosed with NAS has increased more than 10-fold (from 0.4 to 4.4 discharges per 1,000 live births) in Florida since 1995, far exceeding the three-fold increase observed nationally. In February 2014, the Florida Department of Health requested the assistance of CDC to 1) assess the accuracy and validity of using Florida's hospital inpatient discharge data, linked to birth and infant death certificates, as a means of NAS surveillance and 2) describe the characteristics of infants with NAS and their mothers. This report focuses only on objective two, describing maternal and infant characteristics in the 242 confirmed NAS cases identified in three Florida hospitals during a 2-year period (2010-2011). Infants with NAS experienced serious medical complications, with 97.1% being admitted to an intensive care unit, and had prolonged hospital stays, with a mean duration of 26.1 days. The findings of this investigation underscore the important public health problem of NAS and add to current knowledge on the characteristics of these mothers and infants. Effective June 2014, NAS is now a mandatory reportable condition in Florida. Interventions are also needed to 1) increase the number and use of community resources available to drug-abusing and drug-dependent women of reproductive age, 2) improve drug addiction counseling and rehabilitation referral and documentation policies, and 3) link women to these resources before or earlier in pregnancy.
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- 2015
11. Pregnancy-related mortality in the United States, 2006-2010.
- Author
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Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, and Callaghan WM
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- Adult, Cause of Death, Female, Humans, Live Birth, Maternal Age, Maternal Mortality ethnology, Pregnancy, United States epidemiology, Young Adult, Black or African American statistics & numerical data, Hispanic or Latino statistics & numerical data, Maternal Mortality trends, Pregnancy Complications mortality, White People statistics & numerical data
- Abstract
Objective: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2006-2010., Methods: We used data from the Pregnancy Mortality Surveillance System and calculated pregnancy-related mortality ratios by year and age group for four race-ethnicity groups: non-Hispanic white, non-Hispanic black, Hispanic, and other. We examined causes of pregnancy-related deaths by pregnancy outcome during 2006-2010 and compared causes of pregnancy-related deaths since 1987., Results: The 2006-2010 pregnancy-related mortality ratio was 16.0 deaths per 100,000 live births (20,959,533 total live births). Specific race-ethnicity pregnancy-related mortality ratios were 12.0, 38.9, 11.7, and 14.2 deaths per 100,000 live births for non-Hispanic white, non-Hispanic black, Hispanic, and other race women, respectively. Pregnancy-related mortality ratios increased with maternal age for all women and within all age groups, non-Hispanic black women had the highest risk of dying from pregnancy complications. Over time, the contribution to pregnancy-related deaths of hemorrhage, hypertensive disorders of pregnancy, embolism, and anesthesia complications continued to decline, whereas the contribution of cardiovascular conditions and infection increased. Seven of 10 categories of causes of death each contributed from 9.4% to 14.6% of all 2006-2010 pregnancy-related deaths; cardiovascular conditions ranked first., Conclusion: Relative to previous years, during 2006-2010, the U.S. pregnancy-related mortality ratio increased as did the contribution of cardiovascular conditions and infection to pregnancy-related mortality. Although the identification of pregnancy-related deaths may be improving in the United States, the increasing contribution of chronic diseases to pregnancy-related mortality suggests a change in risk profile of the birthing population., Level of Evidence: II.
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- 2015
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12. Opioid abuse and dependence during pregnancy: temporal trends and obstetrical outcomes.
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Maeda A, Bateman BT, Clancy CR, Creanga AA, and Leffert LR
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- Adolescent, Adult, Female, Humans, Insurance, Health, Maternal Mortality, Obstetric Labor Complications epidemiology, Obstetric Labor Complications etiology, Pregnancy, Prevalence, Socioeconomic Factors, United States epidemiology, Young Adult, Opioid-Related Disorders complications, Opioid-Related Disorders epidemiology, Pregnancy Complications epidemiology, Pregnancy Outcome
- Abstract
Background: The authors investigated nationwide trends in opioid abuse or dependence during pregnancy and assessed the impact on maternal and obstetrical outcomes in the United States., Methods: Hospitalizations for delivery were extracted from the Nationwide Inpatient Sample from 1998 to 2011. Temporal trends were assessed and logistic regression was used to examine the associations between maternal opioid abuse or dependence and obstetrical outcomes adjusting for relevant confounders., Results: The prevalence of opioid abuse or dependence during pregnancy increased from 0.17% (1998) to 0.39% (2011) for an increase of 127%. Deliveries associated with maternal opioid abuse or dependence compared with those without opioid abuse or dependence were associated with an increased odds of maternal death during hospitalization (adjusted odds ratio [aOR], 4.6; 95% CI, 1.8 to 12.1, crude incidence 0.03 vs. 0.006%), cardiac arrest (aOR, 3.6; 95% CI, 1.4 to 9.1; 0.04 vs. 0.01%), intrauterine growth restriction (aOR, 2.7; 95% CI, 2.4 to 2.9; 6.8 vs. 2.1%), placental abruption (aOR, 2.4; 95% CI, 2.1 to 2.6; 3.8 vs. 1.1%), length of stay more than 7 days (aOR, 2.2; 95% CI, 2.0 to 2.5; 3.0 vs. 1.2%), preterm labor (aOR, 2.1; 95% CI, 2.0 to 2.3; 17.3 vs. 7.4%), oligohydramnios (aOR, 1.7; 95% CI, 1.6 to 1.9; 4.5 vs. 2.8%), transfusion (aOR, 1.7; 95% CI, 1.5 to 1.9; 2.0 vs. 1.0%), stillbirth (aOR, 1.5; 95% CI, 1.3 to 1.8; 1.2 vs. 0.6%), premature rupture of membranes (aOR, 1.4; 95% CI, 1.3 to 1.6; 5.7 vs. 3.8%), and cesarean delivery (aOR, 1.2; 95% CI, 1.1 to 1.3; 36.3 vs. 33.1%)., Conclusions: Opioid abuse or dependence during pregnancy is associated with considerable obstetrical morbidity and mortality, and its prevalence is dramatically increasing in the United States. Identifying preventive strategies and therapeutic interventions in pregnant women who abuse drugs are important priorities for clinicians and scientists.
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- 2014
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13. Brief interventions for illicit drug use among peripartum women.
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Farr SL, Hutchings YL, Ondersma SJ, and Creanga AA
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- Female, Humans, Pregnancy, Time Factors, Treatment Outcome, Peripartum Period, Pregnancy Complications therapy, Pregnancy Outcome, Substance-Related Disorders therapy
- Abstract
We review the evidence and identify limitations of the current literature on the effectiveness of brief interventions (≤5 intervention sessions) on illicit drug use, treatment enrollment/retention, and pregnancy outcomes among pregnant and postpartum women; and consider this evidence in the context of the broader brief intervention literature. Among 4 published studies identified via systematic review and meeting a priori quality criteria, we found limited, yet promising evidence of the benefit of brief interventions to reduce illicit drug use among postpartum women. Two of the 4 randomized controlled trials tested similar computer-delivered single-session interventions; both demonstrate effects on postpartum drug use. Neither of the 2 randomized controlled trials that assessed treatment use found differences between intervention and control groups. Studies examining brief interventions for smoking and alcohol use among pregnant women, and for illicit drug use in the general adult population, have shown small but statistically significant results of the effectiveness of such interventions. Larger studies, those that examine the effect of assessment alone on illicit drug use, and those that use technology-delivered brief interventions are needed to assess the effectiveness of brief interventions for drug use in the peripartum period., (Published by Elsevier Inc.)
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- 2014
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14. Racial and ethnic disparities in severe maternal morbidity: a multistate analysis, 2008-2010.
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Creanga AA, Bateman BT, Kuklina EV, and Callaghan WM
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- Adolescent, Adult, Chronic Disease, Female, Hospitalization statistics & numerical data, Humans, Hypertension epidemiology, Kidney Diseases epidemiology, Liver Diseases epidemiology, Middle Aged, Pregnancy, Pregnancy Complications, Cardiovascular epidemiology, Pregnancy in Diabetics epidemiology, Respiratory Tract Diseases epidemiology, Social Class, United States epidemiology, Young Adult, Pregnancy Complications ethnology
- Abstract
Objective: The purpose of this study was to examine racial and ethnic disparities in severe maternal morbidity during delivery hospitalizations in the United States., Study Design: We identified delivery hospitalizations from 2008-2010 in State Inpatient Databases from 7 states. We used International Classification of Diseases, 9th Revision, codes to create severe maternal morbidity indicators during delivery hospitalizations. We calculated the rates of severe maternal morbidity that were measured with and without blood transfusion for 5 racial/ethnic groups: non-Hispanic white, non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women. Poisson regression models were fitted to explore the associations between race/ethnicity and severe maternal morbidity after we controlled for potential confounders., Results: Overall, severe maternal morbidity rates that were measured with and without blood transfusion were 150.7 and 64.3 per 10,000 delivery hospitalizations, respectively. Non-Hispanic black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native women had 2.1, 1.3, 1.2, and 1.7 times (all P < .05), respectively, higher rates of severe morbidity that were measured with blood transfusion compared with non-Hispanic white women; similar increased rates were observed when severe morbidity was measured without blood transfusion. Other significant positive predictors of severe morbidity were age <20 and ≥30 years, self-pay or Medicaid coverage for delivery, low socioeconomic status, and presence of chronic medical conditions., Conclusion: Severe maternal morbidity disproportionally affects racial/ethnic minority women, especially non-Hispanic black women. There is a need for a systematic review of severe maternal morbidities at the facility, state, and national levels to guide the development of quality improvement interventions to reduce the racial/ethnic disparities in severe maternal morbidity., (Published by Mosby, Inc.)
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- 2014
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15. Clinical care for opioid-using pregnant and postpartum women: the role of obstetric providers.
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Jones HE, Deppen K, Hudak ML, Leffert L, McClelland C, Sahin L, Starer J, Terplan M, Thorp JM Jr, Walsh J, and Creanga AA
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- Analgesics, Opioid administration & dosage, Buprenorphine therapeutic use, Confidentiality, Dose-Response Relationship, Drug, Emergency Service, Hospital, Female, Humans, Labor Pain drug therapy, Labor, Obstetric, Mental Disorders diagnosis, Methadone therapeutic use, Narcotic Antagonists therapeutic use, Opiate Substitution Treatment, Opioid-Related Disorders diagnosis, Pain, Postoperative drug therapy, Postnatal Care, Pregnancy, Pregnancy Complications diagnosis, Prenatal Care, Referral and Consultation, Triage, Opioid-Related Disorders complications, Opioid-Related Disorders therapy, Physician-Patient Relations, Pregnancy Complications therapy
- Abstract
We review clinical care issues that are related to illicit and therapeutic opioid use among pregnant women and women in the postpartum period and outline the major responsibilities of obstetrics providers who care for these patients during the antepartum, intrapartum, and postpartum periods. Selected patient treatment issues are highlighted, and case examples are provided. Securing a strong rapport and trust with these patients is crucial for success in delivering high-quality obstetric care and in coordinating services with other specialists as needed. Obstetrics providers have an ethical obligation to screen, assess, and provide brief interventions and referral to specialized treatment for patients with drug use disorders. Opioid-dependent pregnant women often can be treated effectively with methadone or buprenorphine. These medications are classified as pregnancy category C medications by the Food and Drug Administration, and their use in the treatment of opioid-dependent pregnant patients should not be considered "off-label." Except in rare special circumstances, medication-assisted withdrawal during pregnancy should be discouraged because of a high relapse rate. Acute pain management in this population deserves special consideration because patients who use opioids can be hypersensitive to pain and because the use of mixed opioid-agonist/antagonists can precipitate opioid withdrawal. In the absence of other indications, pregnant women who use opioids do not require more intense medical care than other pregnant patients to ensure adequate treatment and the best possible outcomes. Together with specialists in pain and addiction medicine, obstetricians can coordinate comprehensive care for pregnant women who use opioids and women who use opioids in the postpartum period., (Copyright © 2014 Mosby, Inc. All rights reserved.)
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- 2014
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16. Maternal mortality and morbidity in the United States: where are we now?
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Creanga AA, Berg CJ, Ko JY, Farr SL, Tong VT, Bruce FC, and Callaghan WM
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- Adolescent, Adult, Female, Health Surveys, Humans, Maternal Health Services organization & administration, Mental Disorders epidemiology, Pregnancy, Prenatal Care, Socioeconomic Factors, Substance-Related Disorders epidemiology, United States epidemiology, Young Adult, Maternal Mortality trends, Maternal Welfare, Morbidity trends, Pregnancy Complications mortality
- Abstract
This article provides a brief overview of the work conducted by the Division of Reproductive Health at the Centers for Disease Control and Prevention on severe maternal morbidity and mortality in the United States. The article presents the latest data and trends in maternal mortality and severe maternal morbidity, as well as on maternal substance abuse and mental health disorders during pregnancy, two relatively recent topics of interest in the Division, and includes future directions of work in all these areas.
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- 2014
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17. Development of a comorbidity index for use in obstetric patients.
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Bateman BT, Mhyre JM, Hernandez-Diaz S, Huybrechts KF, Fischer MA, Creanga AA, Callaghan WM, and Gagne JJ
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- Acute Disease mortality, Adolescent, Adult, Cohort Studies, Comorbidity, Disseminated Intravascular Coagulation mortality, Female, Heart Failure mortality, Humans, Logistic Models, Medicaid statistics & numerical data, Middle Aged, Postpartum Period, Pregnancy, Reproducibility of Results, Risk Assessment, Sepsis mortality, United States, Young Adult, Delivery, Obstetric mortality, Pregnancy Complications mortality, Severity of Illness Index
- Abstract
Objective: To develop and validate a maternal comorbidity index to predict severe maternal morbidity, defined as the occurrence of acute maternal end-organ injury, or mortality., Methods: Data were derived from the Medicaid Analytic eXtract for the years 2000-2007. The primary outcome was defined as the occurrence of maternal end-organ injury or death during the delivery hospitalization through 30 days postpartum. The data set was randomly divided into a two-thirds development cohort and a one-third validation cohort. Using the development cohort, a logistic regression model predicting the primary outcome was created using a stepwise selection algorithm that included 24-candidate comorbid conditions and maternal age. Each of the conditions included in the final model was assigned a weight based on its beta coefficient, and these were used to calculate a maternal comorbidity index., Results: The cohort included 854,823 completed pregnancies, of which 9,901 (1.2%) were complicated by the primary study outcome. The derived score included 20 maternal conditions and maternal age. For each point increase in the score, the odds ratio for the primary outcome was 1.37 (95% confidence interval [CI] 1.35-1.39). The c-statistic for this model was 0.657 (95% CI 0.647-0.666). The derived score performed significantly better than available comorbidity indices in predicting maternal morbidity and mortality., Conclusion: This new maternal comorbidity index provides a simple measure for summarizing the burden of maternal illness for use in the conduct of epidemiologic, health services, and comparative effectiveness research., Level of Evidence: II.
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- 2013
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18. Severe maternal morbidity among delivery and postpartum hospitalizations in the United States.
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Callaghan WM, Creanga AA, and Kuklina EV
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- Female, Hospital Mortality, Humans, Pregnancy, United States epidemiology, Delivery, Obstetric, Epidemiological Monitoring, Hospitalization statistics & numerical data, Morbidity, Postpartum Period, Pregnancy Complications epidemiology
- Abstract
Objectives: To propose a new standard for monitoring severe maternal morbidity, update previous estimates of severe maternal morbidity during both delivery and postpartum hospitalizations, and estimate trends in these events in the United States between 1998 and 2009., Methods: Delivery and postpartum hospitalizations were identified in the Nationwide Inpatient Sample for the period 1998-2009. International Classification of Diseases, 9 Revision codes indicating severe complications were used to identify hospitalizations with severe maternal morbidity and related in-hospital mortality. Trends were reported using 2-year increments of data., Results: Severe morbidity rates for delivery and postpartum hospitalizations for the 2008-2009 period were 129 and 29, respectively, for every 10,000 delivery hospitalizations. Compared with the 1998-1999 period, severe maternal morbidity increased by 75% and 114% for delivery and postpartum hospitalizations, respectively. We found increasing rates of blood transfusion, acute renal failure, shock, acute myocardial infarction, respiratory distress syndrome, aneurysms, and cardiac surgery during delivery hospitalizations. Moreover, during the study period, rates of postpartum hospitalization with 13 of the 25 severe complications examined more than doubled, and the overall mortality during postpartum hospitalizations increased by 66% (P<.05)., Conclusions: Severe maternal morbidity currently affects approximately 52,000 women during their delivery hospitalizations and, based on current trends, this burden is expected to increase. Clinical review of identified cases of severe maternal morbidity can provide an opportunity to identify points of intervention for quality improvement in maternal care., Level of Evidence: III.
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- 2012
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19. Associations between self-reported obstetric complications and experience of care: a secondary analysis of survey data from Ghana, Kenya, and India.
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Kapula, Ntemena, Sacks, Emma, Wang, Dee T., Odiase, Osamuedeme, Requejo, Jennifer, Afulani, Patience A., the Revisioning EmONC Quality of Care Workgroup, Benova, Lenka, Creanga, Andreea, Day, Louise Tina, Freedman, Lynn, Hill, Kathleen, Morgan, Allison, Sodzi-Tettey, Sodzi, Walker, Dilys, Breen, Catherine, Monet, Jean Pierre, Moran, Allisyn, Muzigaba, Moise, and Maliqi, Blerta
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MATERNAL health services ,MOTHERS ,STATISTICS ,PATIENT autonomy ,SELF-evaluation ,CROSS-sectional method ,MULTIVARIATE analysis ,PATIENT-centered care ,POPULATION geography ,PATIENTS' attitudes ,SURVEYS ,SEVERITY of illness index ,COMPARATIVE studies ,PREGNANCY complications ,DESCRIPTIVE statistics ,RESEARCH funding ,SECONDARY analysis - Abstract
Background: Although several indicators have been proposed to measure women's experience of care in health facilities during the intrapartum period, it is unknown if these indicators perform differently in the context of obstetric emergencies. We examined the relationship between experience of care indicators from the Person-Centered Maternity Care (PCMC) scale and obstetric complications. Methods: We used data from four cross-sectional surveys conducted in Kenya (rural: N = 873; urban: N = 531), Ghana (N = 531), and India (N = 2018) between August 2016 and October 2017. The pooled sample included 3953 women aged 15–49 years who gave birth within 9 weeks prior to the survey. Experience of care was measured using the PCMC scale. Univariate, bivariate, and multivariable analyses were conducted to examine the associations between the composite and 31 individual PCMC indicators with (1) obstetric complications; (2) severity of complications; and (3) delivery by cesarean section (c-section). Results: 16% (632) of women in the pooled sample reported obstetric complications; and 4% (132) reported having given birth via c-Sect. (10.5% among those with complications). The average standardized PCMC scores (range 0–100) were 63.5 (SD = 14.1) for the full scale, 43.2 (SD = 20.6) for communication and autonomy, 67.8 (SD = 14.1) for supportive care, and 80.1 (SD = 18.2) for dignity and respect sub-scales. Women with complications had higher communication and autonomy scores (45.6 [SD = 20.2]) on average compared to those without complications (42.7 [SD = 20.6]) (p < 0.001), but lower supportive care scores, and about the same scores for dignity and respect and for the overall PCMC. 18 out of 31 experience of care indicators showed statistically significant differences by complications, but the magnitudes of the differences were generally small, and the direction of the associations were inconsistent. In general, women who delivered by c-section reported better experiences. Conclusions: There is insufficient evidence based on our analysis to suggest that women with obstetric complications report consistently better or worse experiences of care than women without. Women with complications appear to experience better care on some indicators and worse care on others. More studies are needed to understand the relationship between obstetric complications and women's experience of care and to explore why women who deliver by c-section may report better experience of care. Plain language summary: In several studies and reports, women have described mistreatment by health providers during childbirth in health facilities. Particularly in low- and middle-income countries, such mistreatment has negative effects on women's decisions to seek maternity care in health facilities. It is unclear if women with complications are more or less likely to experience some forms of mistreatment compared to women without complications. In this study, we examined 31 experience of care indicators in three domains: (1) Supportive Care; (2) Respect and Dignity; and (3) Communication and Autonomy from the validated Person-Centered Maternity Care (PCMC) questionnaire. We compare these experience of care indicators between women who report obstetric complications and those who don't report complications, by the reported severity of the complications, and by their mode of delivery. The study included data from three countries: Ghana, Kenya, and India. The results showed that the experience of care among women who reported obstetric complications was not consistently better or worse than that of those who did not have complications. Therefore, efforts should be made to improve the experience of care in health facilities for every birthing woman. Additionally, women who delivered via c-section had consistently better experiences than women who delivered vaginally. More studies are needed to understand the relationship between mode of delivery and women's experience of care. [ABSTRACT FROM AUTHOR]
- Published
- 2023
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20. Defining definitions: a Delphi study to develop a core outcome set for conditions of severe maternal morbidity.
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Schaap, T, Bloemenkamp, K, Deneux‐Tharaux, C, Knight, M, Langhoff‐Roos, J, Sullivan, E, Akker, T, Rigouzzo, Agnès, Kristufkova, Alexandra, Creanga, Andreea, Koopman, Ankie, Gemert, Van, Tapper, Anna‐Maija, Dijkman, Anneke, Kwee, Anneke, Franx, Arie, Veersema, Bas, Nemethova, Bianka, Seelbach‐Göbel, Birgit, and Bateman, Brian
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MATERNAL health ,PREGNANCY complications ,OBSTETRICS ,DELPHI method ,DATA analysis ,AMNIOTIC fluid embolism ,CARDIAC arrest ,CARDIOVASCULAR diseases in pregnancy ,CONSENSUS (Social sciences) ,DIGESTIVE system diseases ,ECLAMPSIA ,HEMORRHAGE ,HYSTERECTOMY ,INTERNATIONAL relations ,HEALTH outcome assessment ,PLACENTA diseases ,PUERPERAL disorders ,QUALITY assurance ,RESEARCH funding ,UTERINE rupture ,DEVELOPED countries ,SEVERITY of illness index - Abstract
Objective: Develop a core outcome set of international consensus definitions for severe maternal morbidities.Design: Electronic Delphi study.Setting: International.Population: Eight expert panels.Methods: All 13 high-income countries represented in the International Network of Obstetric Surveillance Systems (INOSS) nominated five experts per condition of morbidity, who submitted possible definitions. From these suggestions, a steering committee distilled critical components: eclampsia: 23, amniotic fluid embolism: 15, pregnancy-related hysterectomy: 11, severe primary postpartum haemorrhage: 19, uterine rupture: 20, abnormally invasive placentation: 12, spontaneous haemoperitoneum in pregnancy: 16, and cardiac arrest in pregnancy: 10. These components were assessed by the expert panel using a 5-point Likert scale, following which a framework for an encompassing definition was constructed. Possible definitions were evaluated in rounds until a rate of agreement of more than 70% was reached. Expert commentaries were used in each round to improve definitions.Main Outcome Measures: Definitions with a rate of agreement of more than 70%.Results: The invitation to participate in one or more of eight Delphi processes was accepted by 103 experts from 13 high-income countries. Consensus definitions were developed for all of the conditions.Conclusion: Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process. These should be used in national registrations and international studies, and should be taken up by the Core Outcomes in Women's and Newborn Health initiative.Tweetable Abstract: Consensus definitions for eight morbidity conditions were successfully developed using the Delphi process. [ABSTRACT FROM AUTHOR]- Published
- 2019
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21. Maternal Mortality in the United States: A Review of Contemporary Data and Their Limitations.
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CREANGA, ANDREEA A.
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MATERNAL mortality , *PREGNANCY complications , *RACE - Abstract
This article provides a review of maternal mortality data and their limitations in the United States. National maternal mortality data, which rely heavily on vital statistics, document that the risk of death from pregnancy-related causes has not declined for >25 years and that striking racial disparities persist. State-based maternal mortality reviews, functional in many states, obtain detailed information on medical and nonmedical factors contributing to maternal deaths. Without this detailed knowledge from state-level data and without addressing recognized quality problems with vital statistics data at the national-level, we will have difficulty understanding maternal death trends and preventing future such deaths. [ABSTRACT FROM AUTHOR]
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- 2018
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22. Pregnancy-Related Mortality in the United States, 2011-2013.
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Creanga, Andreea A., Syverson, Carla, Seed, Kristi, and Callaghan, William M.
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MATERNAL mortality , *MORTALITY , *DEATH rate , *MASS surveillance , *OBSTETRICIANS , *ABORTION , *BLACK people , *CARDIOVASCULAR diseases in pregnancy , *CAUSES of death , *ECTOPIC pregnancy , *ETHNIC groups , *HISPANIC Americans , *MATERNAL age , *EVALUATION of medical care , *MISCARRIAGE , *PERINATAL death , *PREGNANCY , *PREGNANCY complications , *PUERPERAL disorders , *RESEARCH funding , *WHITE people - Abstract
Objective: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011-2013.Methods: We conducted an observational study using population-based data from the Pregnancy Mortality Surveillance System to calculate pregnancy-related mortality ratios by year, age group, and race-ethnicity groups. We explored 10 cause-of-death categories by pregnancy outcome during 2011-2013 and compared their distribution with those in our earlier reports since 1987.Results: The 2011-2013 pregnancy-related mortality ratio was 17.0 deaths per 100,000 live births. Pregnancy-related mortality ratios increased with maternal age, and racial-ethnic disparities persisted with non-Hispanic black women having a 3.4 times higher mortality ratio than non-Hispanic white women. Among causes of pregnancy-related deaths, the following groups contributed more than 10%: cardiovascular conditions ranked first (15.5%) followed by other medical conditions often reflecting pre-existing illnesses (14.5%), infection (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%). Relative to the most recent report of Pregnancy Mortality Surveillance System data for 2006-2010, the distribution of cause-of-death categories did not change considerably. However, compared with serial reports before 2006-2010, the contribution of hemorrhage, hypertensive disorders of pregnancy, and anesthesia complications declined, whereas that of cardiovascular and other medical conditions increased (population-level percentage comparison).Conclusion: The pregnancy-related mortality ratio and the distribution of the main causes of pregnancy-related mortality have been relatively stable in recent years. [ABSTRACT FROM AUTHOR]- Published
- 2017
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23. Antepartum complications and perinatal mortality in rural Bangladesh.
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Khanam, Rasheda, Ahmed, Saifuddin, Creanga, Andreea A., Begum, Nazma, Koffi, Alain K., Mahmud, Arif, Rosen, Heather, Baqui, Abdullah H., and Projahnmo Study Group in Bangladesh
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PERINATAL death ,PREGNANCY complications ,PUBLIC health ,STILLBIRTH ,HEMORRHAGE ,HYPERTENSION in pregnancy ,INFANT mortality ,LABOR complications (Obstetrics) ,PUERPERAL disorders ,RURAL population - Abstract
Background: Despite impressive improvements in maternal survival throughout the world, rates of antepartum complications remain high. These conditions also contribute to high rates of perinatal deaths, which include stillbirths and early neonatal deaths, but the extent is not well studied. This study examines patterns of antepartum complications and the risk of perinatal deaths associated with such complications in rural Bangladesh.Methods: We used data on self-reported antepartum complications during the last pregnancy and corresponding pregnancy outcomes from a household survey (N = 6,285 women) conducted in Sylhet district, Bangladesh in 2006. We created three binary outcome variables (stillbirths, early neonatal deaths, and perinatal deaths) and three binary exposure variables indicating antepartum complications, which were antepartum hemorrhage (APH), probable infection (PI), and probable pregnancy-induced hypertension (PIH). We then examined patterns of antepartum complications and calculated incidence rate ratios (IRR) to estimate the associated risks of perinatal mortality using Poisson regression analyses. We calculated population attributable fraction (PAF) for the three antepartum complications to estimate potential risk reductions of perinatal mortality associated them.Results: We identified 356 perinatal deaths (195 stillbirths and 161 early neonatal deaths). The highest risk of perinatal death was associated with APH (IRR = 3.5, 95% CI: 2.4-4.9 for perinatal deaths; IRR = 3.7, 95% CI 2.3-5.9 for stillbirths; IRR = 3.5, 95% CI 2.0-6.1 for early neonatal deaths). Pregnancy-induced hypertension was a significant risk factor for stillbirths (IRR = 1.8, 95% CI 1.3-2.5), while PI was a significant risk factor for early neonatal deaths (IRR = 1.5, 95% CI 1.1-2.2). Population attributable fraction of APH and PIH were 6.8% and 10.4% for perinatal mortality and 7.5% and 14.7% for stillbirths respectively. Population attributable fraction of early neonatal mortality due to APH was 6.2% and for PI was 7.8%.Conclusions: Identifying antepartum complications and ensuring access to adequate care for those complications are one of the key strategies in reducing perinatal mortality in settings where most deliveries occur at home. [ABSTRACT FROM AUTHOR]- Published
- 2017
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24. Pregnant Women’s Intentions and Subsequent Behaviors Regarding Maternal and Neonatal Service Utilization: Results from a Cohort Study in Nyanza Province, Kenya.
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Creanga, Andreea A., Odhiambo, George Awino, Odera, Benjamin, Odhiambo, Frank O., Desai, Meghna, Goodwin, Mary, Laserson, Kayla, and Goldberg, Howard
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MATERNAL health , *MATERNAL health services , *NEONATAL mortality , *MATERNAL mortality , *COHORT analysis , *LOGISTIC regression analysis - Abstract
Higher use of maternal and neonatal health (MNH) services may reduce maternal and neonatal mortality in Kenya. This study aims to: 1) prospectively explore women’s intentions to use MNH services (antenatal care, delivery in a facility, postnatal care, neonatal care) at <20 and 30–35 weeks’ gestation and their actual use of these services; 2) identify predictors of intention-behavior discordance among women with positive service use intentions; 3) examine associations between place of delivery, women’s reasons for choosing it, and birthing experiences. We used data from a 2012–2013 population-based cohort of pregnant women in the Demographic Surveillance Site in Nyanza province, Kenya. Of 1,056 women completing the study (89.1% response rate), 948 had live-births and 22 stillbirths, and they represent our analytic sample. Logistic regression analysis identified predictors of intention-behavior discordance regarding delivery in a facility and use of postnatal and neonatal care. At <20 and 30–35 weeks’ gestation, most women intended to seek MNH services (≥93.9% and ≥87.5%, respectively, for all services assessed). Actual service use was high for antenatal (98.1%) and neonatal (88.5%) care, but lower for delivery in a facility (76.9%) and postnatal care (51.8%). Woman’s age >35 and high-school education were significant predictors of intention-behavior discordance regarding delivery in a facility; several delivery-related factors were significantly associated with intention-behavior discordance regarding use of postnatal and neonatal care. Delivery facilities were chosen based on proximity to women’s residence, affordability, and service quality; among women who delivered outside a health facility, 16.3% could not afford going to a facility. Good/very good birth experiences were reported by 93.6% of women who delivered in a facility and 32.6% of women who did not. We found higher MNH service utilization than previously documented in Nyanza province. Further increasing the number of facility deliveries and use of postnatal care may improve MNH in Kenya. [ABSTRACT FROM AUTHOR]
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- 2016
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25. Pregnancy-Related Mortality Resulting From Influenza in the United States During the 2009–2010 Pandemic.
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Callaghan, William M., Creanga, Andreea A., and Jamieson, Denise J.
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PREGNANCY complications , *MORTALITY , *INFLUENZA complications , *MATERNAL health , *PANDEMICS - Abstract
OBJECTIVE: To estimate the burden of pregnancy-related mortality resulting from influenza A (H1N1) pdm09 virus infection during the 2009–2010 pandemic influenza season. METHODS: Data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System were used to identify women whose death during or shortly after pregnancy was attributed or likely attributed to the influenza A (H1N1)pdm09 virus from April 15, 2009, through June 30, 2010. We report the characteristics of these women and enumerate cases resulting in death as the pandemic began, peaked, and resolved. RESULTS: During the pandemic season, we identified 915 pregnancy-related deaths and 4,911,297 live births. Seventy-five (8.2%) women died as a result of confirmed influenza A (H1N1)pdm09 infection deaths and 34 (3.7%) women as a result of possible influenza A (H1N1)pdm09 infection deaths. The pregnancy-related mortality ratio for confirmed and possible (combined) influenza A (H1N1)pdm09 infection deaths was 2.2 per 100,000 live births. Most deaths occurred during the 2009 calendar year with the peak of the distribution of deaths over time occurring in October 2009. CONCLUSION: Twelve percent of pregnancy-related deaths were attributed to confirmed or possible influenza A (H1N1)pdm09 infection during the 2009–2010 pandemic season. Because prediction of pandemics is difficult, planning for prevention of influenza and care for those women affected are critical for preventing associated severe maternal morbidity and mortality. [ABSTRACT FROM AUTHOR]
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- 2015
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26. Trends in Ectopic Pregnancy Mortality in the United States 1980-2007.
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Creanga, Andreea A., Shapiro-Mendoza, Carrie K., Bish, Connie L., Zane, Suzanne, Berg, Cynthia J., and Callaghan, William M.
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ECTOPIC pregnancy , *MORTALITY , *PREGNANCY complications , *TECHNOLOGICAL innovations , *HOSPITAL care - Abstract
The article discusses a research study which examined trends in ectopic pregnancy mortality in the U.S. from 1980 to 2007. From 1980 to 2007, 876 women died due to ectopic pregnancy. African American women have higher mortality rates than white women. Although mortality related to ectopic pregnancy decreased since the 1980s, the study revealed race and age gaps in ectopic pregnancy mortality.
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- 2011
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27. Seasonal and 2009 pandemic influenza A (H1N1) virus infection during pregnancy: a population-based study of hospitalized cases.
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Creanga, Andreea A., Kamimoto, Laurie, Newsome, Kimberly, D'Mello, Tiffany, Jamieson, Denise J., Zotti, Marianne E., Arnold, Kathryn E., Baumbach, Joan, Bennett, Nancy M., Farley, Monica M., Gershman, Ken, Kirschke, David, Lynfield, Ruth, Meek, James, Morin, Craig, Reingold, Arthur, Ryan, Patricia, Schaffner, William, Thomas, Ann, and Zansky, Shelley
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PREGNANCY complications ,SEASONAL influenza ,H1N1 influenza ,INFLUENZA vaccines ,PANDEMICS ,FISHER exact test ,HOSPITAL care ,PREGNANT women - Abstract
We sought to describe characteristics of hospitalized reproductive-aged (15-44 years) women with seasonal (2005/2006 through 2008/2009) and 2009 pandemic influenza A (H1N1) virus infection. We used population-based data from the Emerging Infections Program in 10 US states, and compared characteristics of pregnant (n = 150) and nonpregnant (n = 489) seasonal, and pregnant (n = 489) and nonpregnant (n = 1088) pandemic influenza cases using χ
2 and Fisher''s exact tests. Pregnant women represented 23.5% and 31.0% of all reproductive-aged women hospitalized for seasonal and pandemic influenza, respectively. Significantly more nonpregnant than pregnant women with seasonal (71.2% vs 36.0%) and pandemic (69.7% vs 31.9%) influenza had an underlying medical condition other than pregnancy. Antiviral treatment was significantly more common with pandemic than seasonal influenza for both pregnant (86.5% vs 24.0%) and nonpregnant (82.0% vs 55.2%) women. Pregnant women comprised a significant proportion of influenza-hospitalized reproductive-aged women, underscoring the importance of influenza vaccination during pregnancy. [Copyright &y& Elsevier]- Published
- 2011
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