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Having health insurance is associated with better access to healthcare and lower rates of comorbidity in the general population, but data are limited on insurance's impact on adults with congenital heart disease (ACHD). The Congenital Heart Survey To Recognize Outcomes, Needs and well-beinG (CH STRONG) was conducted among ACHD in three locations from 2016 to 2019. We performed multivariable logistic regression to determine the associations between health insurance and both access to healthcare and presence of comorbidities. We also compared health insurance and comorbidities among ACHD to similarly-aged individuals in the Behavioral Risk Factor Surveillance System (BRFSS) as a proxy for the general population. Of 1354 CH STRONG respondents, the majority were ≤ 30 years old (83.5%), and 8.8% were uninsured versus 17.7% in the BRFSS (p < 0.01). Compared to insured ACHD, uninsured were less likely to report regular medical care (adjusted odds ratio [aOR] 0.2, 95% confidence interval [CI] 0.1-0.3) and visited an emergency room more often (aOR 1.6, CI 1.0-2.3). Among all ACHD reporting disability, uninsured individuals less frequently received benefits (aOR 0.1, CI 0.0-0.3). Depression was common among uninsured ACHD (22.5%), but insured ACHD had lower rates of depression than insured in the BRFSS (13.3% vs. 22.5%, p < 0.01). In conclusion, rates of insurance were higher among ACHD compared to the general population. Nonetheless, uninsured ACHD inconsistently accessed healthcare and benefits. Further studies are needed to determine if insurance ameliorates the risk of morbidity as ACHD age., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Socioeconomic factors may lead to a disproportionate impact on health care usage and death among individuals with congenital heart defects (CHD) by race, ethnicity, and socioeconomic factors. How neighborhood poverty affects racial and ethnic disparities in health care usage and death among individuals with CHD across the life span is not well described., Methods and Results: Individuals aged 1 to 64 years, with at least 1 CHD-related International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM ) code were identified from health care encounters between January 1, 2011, and December 31, 2013, from 4 US sites. Residence was classified into lower- or higher-poverty neighborhoods on the basis of zip code tabulation area from the 2014 American Community Survey 5-year estimates. Multivariable logistic regression models, adjusting for site, sex, CHD anatomic severity, and insurance-evaluated associations between race and ethnicity, and health care usage and death, stratified by neighborhood poverty. Of 31 542 individuals, 22.2% were non-Hispanic Black and 17.0% Hispanic. In high-poverty neighborhoods, non-Hispanic Black (44.4%) and Hispanic (47.7%) individuals, respectively, were more likely to be hospitalized (adjusted odds ratio [aOR], 1.2 [95% CI, 1.1-1.3]; and aOR, 1.3 [95% CI, 1.2-1.5]) and have emergency department visits (aOR, 1.3 [95% CI, 1.2-1.5] and aOR, 1.8 [95% CI, 1.5-2.0]) compared with non-Hispanic White individuals. In high poverty neighborhoods, non-Hispanic Black individuals with CHD had 1.7 times the odds of death compared with non-Hispanic White individuals in high-poverty neighborhoods (95% CI, 1.1-2.7). Racial and ethnic disparities in health care usage were similar in low-poverty neighborhoods, but disparities in death were attenuated (aOR for non-Hispanic Black, 1.2 [95% CI=0.9-1.7])., Conclusions: Racial and ethnic disparities in health care usage were found among individuals with CHD in low- and high-poverty neighborhoods, but mortality disparities were larger in high-poverty neighborhoods. Understanding individual- and community-level social determinants of health, including access to health care, may help address racial and ethnic inequities in health care usage and death among individuals with CHD.

Among children with and without heart conditions of different race/ethnicities, upstream social determinants of health, such as socio-economic status, access to care, and healthcare utilisation, may vary. Using caregiver-reported data from the 2016-19 National Survey of Children's Health, we calculated the prevalence of caregiver employment and education, child's health insurance, usual place of medical care in the past 12 months, problems paying for child's care, ≥2 emergency room visits, and unmet healthcare needs by heart condition status and race/ethnicity (Hispanic, non-Hispanic Black, and non-Hispanic White). For each outcome, we used multivariable logistic regression to generate adjusted prevalence ratios controlling for child's age and sex. Of 2632 children with heart conditions and 104,841 without, 65.4% and 58.0% were non-Hispanic White and 52.0% and 51.1% were male, respectively. Children with heart conditions, compared to those without, were 1.7-2.6 times more likely to have problems paying for healthcare, have ≥2 emergency room visits, and have unmet healthcare needs. Hispanic and non-Hispanic Black children with heart conditions, compared to non-Hispanic White, were 1.5-3.2 times as likely to have caregivers employed <50 weeks in the past year and caregivers with ≤ high school education, public or no health insurance, no usual place of care, and ≥2 emergency room visits. Children with heart conditions, compared to those without, may have greater healthcare needs that more commonly go unmet. Among children with heart conditions, Hispanic and non-Hispanic Black children may experience lower socio-economic status and greater barriers to healthcare than non-Hispanic White children.

Many of the estimated 1.4 million adults with congenital heart defects (CHDs) in the United States are lost to follow-up (LTF) despite recommendations for ongoing cardiology care. Using 2016 to 2019 CH STRONG (Congenital Heart Survey To Recognize Outcomes, Needs, and well-beinG) data, we describe cardiac care among community-based adults with CHD, born in 1980 to 1997, identified through state birth defects registries. Our estimates of LTF were standardized to the CH STRONG eligible population and likely more generalizable to adults with CHD than clinic-based data. Half of our sample were LTF and more than 45% had not received cardiology care in over 5 years. Of those who received care, only 1 in 3 saw an adult CHD physician at their last encounter. Not knowing they needed to see a cardiologist, being told they no longer needed cardiology care, and feeling "well" were the top reasons for LTF, and only half of respondents report doctors discussing the need for cardiac follow-up., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The objectives were (1) to characterize patient encounters of opioid use disorder (OUD) using Health Facts ® database; and (2) to identify geographic variation, patient characteristics, and facility characteristics impacting patients' reduced OUD encounters over time., Methods: Patient encounters were included if the patient (1) was 18 years old or greater; (2) had an index encounter; (3) survived at least 30 days after the discharge. The OUD encounter was based on ICD-10 codes. The date at which a patient first had an OUD encounter was the index date. For the first objective, OUD encounters were described according to patient characteristics, facility characteristics, and geographic variation. Patient characteristics were age, gender, marital status, race, health insurance coverage, discharge disposition, and patient type. Facility characteristics were care setting, medical specialty, census region, census division, urban vs. rural, acute vs. non-acute, and teaching hospital status. For the second objective, patients were examined 1 year prior to through 1 year after the index date. A logistic regression was used to determine the likelihood of reduced OUD encounters over time, conditional upon geographic variation, patient characteristics, and facility characteristics., Results: A total of 265,643 OUD encounters were identified. East South Central was associated with the highest population-based rate of OUD among nine census divisions. In the logistic regression (n = 10,762), discharged to home, outpatient, emergency room, psychiatry, East North Central, West North Central, and urban areas were significant positive predictors for reduced OUD encounters over time, whereas age and Mountain were significant negative predictors., Conclusions: East South Central was associated with the highest population-based rate of OUD. Compared with East South Central, East North Central and West North Central had a significantly positive impact on fewer encounters of OUD over time., (© 2022. The Author(s), under exclusive licence to Springer Healthcare Ltd., part of Springer Nature.)

Objective: We examined the relationship between trimester of SARS-CoV-2 infection, illness severity, and risk for preterm birth., Study Design: We analyzed data for 6336 pregnant persons with SARS-CoV-2 infection in 2020 in the United States. Risk ratios for preterm birth were calculated for illness severity, trimester of infection, and illness severity stratified by trimester of infection adjusted for age, selected underlying medical conditions, and pregnancy complications., Result: Pregnant persons with critical COVID-19 or asymptomatic infection, compared to mild COVID-19, in the second or third trimester were at increased risk of preterm birth. Pregnant persons with moderate-to-severe COVID-19 did not show increased risk of preterm birth in any trimester., Conclusion: Critical COVID-19 in the second or third trimester was associated with increased risk of preterm birth. This finding can be used to guide prevention strategies, including vaccination, and inform clinical practices for pregnant persons., (© 2022. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background The Centers for Disease Control and Prevention's Surveillance of Congenital Heart Defects Across the Lifespan project uses large clinical and administrative databases at sites throughout the United States to understand population-based congenital heart defect (CHD) epidemiology and outcomes. These individual databases are also relied upon for accurate coding of CHD to estimate population prevalence. Methods and Results This validation project assessed a sample of 774 cases from 4 surveillance sites to determine the positive predictive value (PPV) for identifying a true CHD case and classifying CHD anatomic group accurately based on 57 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Chi-square tests assessed differences in PPV by CHD severity and age. Overall, PPV was 76.36% (591/774 [95% CI, 73.20-79.31]) for all sites and all CHD-related ICD-9-CM codes. Of patients with a code for complex CHD, 89.85% (177/197 [95% CI, 84.76-93.69]) had CHD; corresponding PPV estimates were 86.73% (170/196 [95% CI, 81.17-91.15]) for shunt, 82.99% (161/194 [95% CI, 76.95-87.99]) for valve, and 44.39% (83/187 [95% CI, 84.76-93.69]) for "Other" CHD anatomic group ( X 2 =142.16, P <0.0001). ICD-9-CM codes had higher PPVs for having CHD in the 3 younger age groups compared with those >64 years of age, ( X 2 =4.23, P <0.0001). Conclusions While CHD ICD-9-CM codes had acceptable PPV (86.54%) (508/587 [95% CI, 83.51-89.20]) for identifying whether a patient has CHD when excluding patients with ICD-9-CM codes for "Other" CHD and code 745.5, further evaluation and algorithm development may help inform and improve accurate identification of CHD in data sets across the CHD ICD-9-CM code groups.

Approximately 900,000 U.S. children have heart conditions, such as congenital heart disease (1). These children might be at increased risk for life-threatening infective endocarditis from oral bacteria in the bloodstream (2). Therefore, preventive dental care (i.e., check-ups, dental cleaning, radiographs, fluoride treatment, or sealant) to maintain oral health is important. Oral health status and receipt of preventive dental care were compared between children with heart conditions (2,928) and without (116,826) using population-based 2016-2019 National Survey of Children's Health (NSCH) data. Approximately 83% of children with and 80% without heart conditions received preventive dental care in the past year (p = 0.06). Children with heart conditions were more likely than were those without to have poor oral health (17.2% versus 13.7%; p = 0.02) and teeth in fair or poor condition (9.9% versus 5.3%; p<0.01). Among those with a heart condition, having low household income; an intellectual or developmental disability; and no well-child visit or medical home were associated with poor oral health. Receipt of preventive dental care was higher among children aged ≥6 years and those with insurance. Public health practitioners and health care providers can implement strategies (e.g., parent and patient education and collaboration between pediatricians, dentists, and cardiologists) to improve oral health and care among children with heart conditions, especially those with fewer resources and intellectual or developmental disabilities., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Within a medical home, primary care providers can identify needs, provide services, and coordinate care for children with heart conditions. Using parent-reported data from the 2016-2017 National Survey of Children's Health, we examined receipt of preventive care in the last 12 months and having a medical home (care that is accessible, continuous, comprehensive, family-centred, coordinated, compassionate, and culturally effective) among US children aged 0-17 years with and without heart conditions. Using the marginal predictions approach to multivariable logistic regression, we examined associations between presence of a heart condition and receipt of preventive care and having a medical home. Among children with heart conditions, we evaluated associations between sociodemographic and health characteristics and receipt of preventive care and having a medical home. Of the 66,971 children included, 2.2% had heart conditions. Receipt of preventive care was reported for more children with heart conditions (91.0%) than without (82.7%) (adjusted prevalence ratio = 1.09, 95% confidence interval: 1.05-1.13). Less than half of children with heart conditions (48.2%) and without (49.5%) had a medical home (adjusted prevalence ratio = 1.02, 95% confidence interval: 0.91-1.14). For children with heart conditions, preventive care was slightly more common among younger children and less common among those with family incomes 200-399% of the federal poverty level. Having a medical home was less common among younger children, non-Hispanic "other" race, and those with ≥2 other health conditions. Most children with heart conditions received preventive care, but less than half had a medical home, with disparities by age, socioeconomic status, race, and concurrent health conditions. These findings highlight opportunities to improve care for children with heart conditions.

Background In women with congenital heart defects (CHD), changes in blood volume, heart rate, respiration, and edema during pregnancy may lead to increased risk of adverse outcomes and conditions. The American Heart Association recommends providers of pregnant women with CHD assess cardiac health and discuss risks and benefits of cardiac-related medications. We described receipt of American Heart Association-recommended cardiac evaluations, filled potentially teratogenic or fetotoxic (Food and Drug Administration pregnancy category D/X) cardiac-related prescriptions, and adverse conditions among pregnant women with CHD compared with those without CHD. Methods and Results Using 2007 to 2014 US healthcare claims data, we ascertained a retrospective cohort of women with and without CHD aged 15 to 44 years with private insurance covering prescriptions during pregnancy. CHD was defined as ≥1 inpatient code or ≥2 outpatient CHD diagnosis codes >30 days apart documented outside of pregnancy and categorized as severe or nonsevere. Log-linear regression, accounting for multiple pregnancies per woman, generated adjusted prevalence ratios (aPRs) for associations between the presence/severity of CHD and stillbirth, preterm birth, and adverse conditions from the last menstrual period to 90 days postpartum. We identified 2056 women with CHD (2334 pregnancies) and 1 374 982 women without (1 524 077 pregnancies). During the last menstrual period to 90 days postpartum, 56% of women with CHD had comprehensive echocardiograms and, during pregnancy, 4% filled potentially teratogenic or fetotoxic cardiac-related prescriptions. Women with CHD, compared with those without, experienced more adverse conditions overall (aPR, 1.9 [95% CI, 1.7-2.1]) and, specifically, obstetric (aPR, 1.3 [95% CI, 1.2-1.4]) and cardiac conditions (aPR, 10.2 [95% CI, 9.1-11.4]), stillbirth (aPR, 1.6 [95% CI, 1.1-2.4]), and preterm delivery (aPR, 1.6 [95% CI, 1.4-1.8]). More women with severe CHD, compared with nonsevere, experienced adverse conditions overall (aPR, 1.5 [95% CI, 1.2-1.9]). Conclusions Women with CHD have elevated prevalence of adverse cardiac and obstetric conditions during pregnancy; 4 in 100 used potentially teratogenic or fetotoxic medications, and only half received an American Heart Association-recommended comprehensive echocardiogram.

Background: The American Heart Association recommends women with congenital heart defects (CHD) receive contraceptive counseling early in their reproductive years, but little is known about contraceptive method use among women with CHD. We describe recent female sterilization and reversible prescription contraceptive method use by presence of CHD and CHD severity in 2014., Methods: Using IBM MarketScan Commercial Databases, we included women aged 15 to 44 years with prescription drug coverage in 2014 who were enrolled ≥11 months annually in employer-sponsored health plans between 2011 and 2014. CHD, CHD severity, contraceptive methods, and obstetrics-gynecology and cardiology provider encounters were identified using billing codes. We used log-binomial regression to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to compare contraceptive method use overall and by effectiveness tier by CHD presence and, for women with CHD, severity., Results: Recent sterilization or current reversible prescription contraceptive method use varied slightly among women with (39.2%) and without (37.3%) CHD, aPR = 1.04, 95% CI [1.01-1.07]. Women with CHD were more likely to use any Tier I method (12.9%) than women without CHD (9.3%), aPR = 1.41, 95% CI [1.33-1.50]. Women with severe, compared to non-severe, CHD were less likely to use any method, aPR = 0.85, 95% CI [0.78-0.92], or Tier I method, aPR = 0.84, 95% CI [0.70-0.99]. Approximately 60% of women with obstetrics-gynecology and <40% with cardiology encounters used any included method., Conclusions: There may be missed opportunities for providers to improve uptake of safe, effective contraceptive methods for women with CHD who wish to avoid pregnancy., (Published by Elsevier Inc.)

Studies of outcomes among adults with congenital heart defects (CHDs) have focused on those receiving cardiac care, limiting generalizability. The Congenital Heart Survey To Recognize Outcomes, Needs, and well-beinG (CH STRONG) will assess comorbidities, health care utilization, quality of life, and social and educational outcomes from a US population-based sample of young adults living with CHD., Methods: Individuals with CHD born between 1980 and 1997 were identified using active, population-based birth defects surveillance systems from 3 US locations (Arkansas [AR]; Arizona [AZ]; and Atlanta, Georgia [GA]) linked to death records. Individuals with current contact information responded to mailed survey materials during 2016 to 2019. Respondents and nonrespondents were compared using χ 2 tests., Results: Sites obtained contact information for 74.6% of the 9,312 eligible individuals alive at recruitment. Of those, 1,656 returned surveys, either online (18.1%) or via paper (81.9%), for a response rate of 23.9% (AR: 18.3%; AZ: 30.7%; Atlanta, GA: 28.0%; P value < .01). For 20.0% of respondents, a proxy completed the survey, with 63.9% reporting that the individual with CHD was mentally unable. Among respondents and nonrespondents, respectively, sex (female: 54.0% and 47.3%), maternal race/ethnicity (non-Hispanic white: 74.3% and 63.0%), CHD severity (severe: 33.8% and 27.9%), and noncardiac congenital anomalies (34.8% and 38.9%) differed significantly (P value < .01); birth year (1991-1997: 56.0% and 57.5%) and presence of Down syndrome (9.2% and 8.9%) did not differ., Conclusions: CH STRONG will provide the first multisite, population-based findings on long-term outcomes among the growing population of US adults with CHD., (Published by Elsevier Inc.)

Background Our objective was to estimate receipt of preconception health care among women with congenital heart defects (CHD), according to 2017 American Heart Association recommendations, as a baseline for evaluating recommendation implementation. Methods and Results Using 2007 to 2013 IBM MarketScan Commercial Databases, we identified women with CHD diagnosis codes ages 15 to 44 years who became pregnant and were enrolled in health insurance for ≥11 months in the year before estimated conception. We assessed documentation of complete blood count, electrolytes, thyroid-stimulating hormone, liver function, ECG, comprehensive echocardiogram, and exercise stress test, using procedural codes, and outpatient prescription claims for US Food and Drug Administration category D and X cardiac-related medications. Differences were examined according to CHD severity, age, region of residence, year of conception, and documented encounters at obstetric and cardiology practices. We found 2524 pregnancies among 2003 women with CHD (14.4% severe CHD). In the 98.3% of women with a healthcare encounter in the year before conception, <1% received all and 22.6% received no American Heart Association-recommended tests or assessments (range: 54.4% for complete blood count to 3.1% for exercise stress test). Women with the highest prevalence of receipt of recommended care were 35 to 44 years old, pregnant in 2012 to 2013, or had a documented obstetric or cardiology encounter in the year before conception ( P <0.05 for all). In 9.0% of pregnancies, ≥1 prescriptions for US Food and Drug Administration category D or X cardiac-related medications were filled in the year before conception. Conclusions A low percentage of women with CHD received American Heart Association-recommended preconception health care in the year before conception.

Background: Ebstein anomaly is a rare congenital heart defect (CHD) that, when severe, requires corrective surgery or other catheter-based intervention in the first year of life. Due to its rarity, risk factors for Ebstein anomaly remain largely unknown. Using national data, we examined 18 potential risk factors for Ebstein anomaly., Methods: Using 1997-2011 data from the National Birth Defects Prevention Study, a population-based case-control study, we calculated crude and adjusted odds ratios and 95% confidence intervals for paternal age, maternal socio-demographics, reproductive history, and modifiable risk factors, and infant characteristics reported by mothers of 135 Ebstein anomaly cases and 11,829 controls., Results: Mothers of Ebstein anomaly cases had 4.1 (95% confidence interval: 1.8, 9.5) times the odds of reporting a family history of CHD compared with mothers of controls. Ebstein anomaly was associated with maternal second-hand cigarette smoke exposure at home (odds ratio = 2.2 [95% confidence interval: 1.1, 4.4]), but not maternal cigarette smoking (odds ratio = 1.3 [95% confidence interval: 0.8, 2.1]). Odds were elevated, but the 95% confidence interval included 1.0, for maternal marijuana use (odds ratio = 1.8 [95% confidence interval: 0.9, 3.8]) and paternal age ≥40 years at delivery (odds ratio = 1.9 [95% confidence interval: 1.0, 3.5])., Conclusions: Maternal exposure to second-hand cigarette smoke at home and a family history of CHD were associated with elevated odds of Ebstein anomaly. Genetic analyses could clarify the potential heritability of Ebstein anomaly.

Antidepressant medication use during pregnancy has been increasing in the United States (1). Many women require antidepressants on an ongoing basis, and a clear consensus on the safest medication options for both the mother and her fetus does not exist (2). Given that half of all U.S. pregnancies are unplanned (3), antidepressant use will occur during the first weeks of pregnancy, a critical period for fetal development. To understand trends among women of reproductive age, CDC used Truven Health's MarketScan Commercial Claims and Encounters data* to estimate the number of antidepressant prescriptions filled by women aged 15-44 years with private employer-sponsored insurance. During 2008-2013, an average of 15.4% of women aged 15-44 years filled at least one prescription for an antidepressant in a single year. The most frequently filled antidepressants included sertraline, bupropion, and citalopram. Prescribing of antidepressants is common, and research on antidepressant safety during pregnancy needs to be accelerated to provide evidence-based information to health care providers and women about the potential risks for antidepressant exposure before and during pregnancy and between pregnancies.

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.)

Epidemiologic studies suggest that prenatal stress is associated with preterm birth, low birth weight, and peripartum anxiety and depressive symptoms. The most recent population-based study, assessing trends in stress experienced in the year before an infant's birth, used 1990-1995 data from 11 states participating in the Pregnancy Risk Assessment Monitoring System (PRAMS). That study found that 64% of women surveyed reported experiencing at least one stressful life event (SLE), although the prevalence declined slightly over the study period. PRAMS data for 2000-2010 were used to examine more recent trends and to determine if the prevalence of SLEs has continued to decrease in the past decade. Additionally, 2010 data were used to determine the extent that maternal demographics and state of residence are associated with SLEs. This report describes the results of those analyses, which found that most women in the sample reported experiencing ≥1 SLEs in the year before their infant's birth, although the prevalence of experiencing SLEs decreased during 2000-2010. In 2010, based on data from 27 states, 70.2% of women reported ≥1 SLEs. The mean number of SLEs was 1.81, ranging from 1.41 in New York City to 2.26 in Oklahoma. SLEs were most frequently financial. Prevalence of SLEs varied by PRAMS reporting site and maternal demographics. Younger, less educated, unmarried, and Medicaid-covered women had the highest prevalence of SLEs. Public health practitioners and clinicians can use the information on trends and risk factors for SLEs to determine the likelihood that pregnant women might benefit from screening for stressors during pregnancy.

Background: Secondhand smoke exposure increases an infant's risk of morbidity and mortality. We provide state-specific estimates for and characterize postpartum women with complete smoke-free home rules., Methods: Data were analyzed from 26 states and New York City (n=37,698) from the 2010 Pregnancy Risk Assessment Monitoring System, a population-based survey of women who recently delivered live-born infants. We calculated state-specific estimates of complete rules and assessed associations between complete rules and selected characteristics., Results: Overall, 93.6% (95% CI: 93.1-94.1) of women with recent live births had complete smoke-free home rules (86.8% [West Virginia] to 98.6% [Utah]). Demographic groups with the lowest percentage of rules were women who smoked during pregnancy/postpartum (77.6%), were non-Hispanic Black (86.8%), never initiated breastfeeding (86.8%), < 20 years of age (87.1%), <$15,000 annual income (87.6%), < 12 years of education (88.6%), unmarried (88.6%), initiated prenatal care late/had no prenatal care (88.8%), had Medicaid coverage (89.7%), had an unintended pregnancy (90.3%), and enrolled in WIC (90.6%)., Conclusions: Prevalence of complete smoke-free home rules was high among women with recent live births; however, disparities exist by state and among certain sub-populations. Women, particularly smokers, should be educated during and after pregnancy about secondhand smoke and encouraged to maintain 100% smoke-free homes., (Published by Elsevier Inc.)

Problem/condition: Promoting preconception health can potentially improve women's health and pregnancy outcomes. Evidence-based interventions exist to reduce many maternal behaviors and chronic conditions that are associated with adverse pregnancy outcomes such as tobacco use, alcohol use, inadequate folic acid intake, obesity, hypertension, and diabetes. The 2006 national recommendations to improve preconception health included monitoring improvements in preconception health by maximizing public health surveillance (CDC. Recommendations to improve preconception health and health care-United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR 2006;55[No. RR-6])., Reporting Period Covered: 2009 for 38 indicators; 2008 for one indicator. DESCRIPTION OF SURVEILLANCE SYSTEMS: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected self-reported maternal behaviors, conditions, and experiences that occur shortly before, during, and after pregnancy among women who deliver live-born infants. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based telephone survey of noninstitutionalized adults aged ≥18 years in the United States that collects state-level data on health-related risk behaviors, chronic conditions, and preventive health services. This surveillance summary includes PRAMS data from 29 reporting areas (n = 40,388 respondents) and BRFSS data from 51 reporting areas (n = 62,875 respondents) for nonpregnant women of reproductive age (aged 18-44 years). To establish a comprehensive, nationally recognized set of indicators to be used for monitoring, evaluation, and response, a volunteer group of policy and program leaders and epidemiologists identified 45 core state preconception health indicators, of which 41 rely on PRAMS or BRFSS as data sources. This report includes 39 of the 41 core state preconception health indicators for which data are available through PRAMS or BRFSS. The two indicators from these data sources that are not described in this report are human immunodeficiency virus (HIV) testing within a year before the most recent pregnancy and heavy drinking on at least one occasion during the preceding month. Ten preconception health domains are examined: general health status and life satisfaction, social determinants of health, health care, reproductive health and family planning, tobacco and alcohol use, nutrition and physical activity, mental health, emotional and social support, chronic conditions, and infections. Weighted prevalence estimates and 95% confidence intervals (95% CIs)for 39 indicators are presented overall and for each reporting area and stratified by age group (18-24, 25-34, and 35-44 years) and women's race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, and Hispanic)., Results: This surveillance summary includes data for 39 of 41 indicators: 2009 data for 23 preconception health indicators that were monitored by PRAMS and 16 preconception health indicators that were monitored by BRFSS (one BRFSS indicator uses 2008 data). For two of the indicators that are included in this report (prepregnancy overweight or obesity and current overweight or obesity), separate measures of overweight and obesity were reported. All preconception health indicators varied by reporting area, and most indicators varied significantly by age group and race/ethnicity. Overall, 88.9% of women of reproductive age reported good, very good, or excellent general health status and life satisfaction (BRFSS). A high school/general equivalency diploma or higher education (social determinants of health domain) was reported by 94.7% of non-Hispanic white, 92.9% of non-Hispanic other, 91.1% of non-Hispanic black, and 70.9% of Hispanic women (BRFSS). Overall, health-care insurance coverage during the month before the most recent pregnancy (health-care domain) was 74.9% (PRAMS). A routine checkup during the preceding year was reported by 79.0% of non-Hispanic black, 65.1% of non-Hispanic white, 64.3% of other, and 63.0% of Hispanic women (BRFSS). Among women with a recent live birth (2-9 months since date of delivery), selected PRAMS results for the reproductive health and family planning, tobacco and alcohol use, and nutrition domains included several factors. Although 43% of women reported that their most recent pregnancy was unintended (unwanted or wanted to be pregnant later), approximately half (53%) of those who were not trying to get pregnant reported not using contraception at the time of conception. Smoking during the 3 months before pregnancy was reported by 25.1% of women, and drinking alcohol 3 months before pregnancy was reported by 54.2% of women. Daily use of a multivitamin, prenatal vitamin, or a folic acid supplement during the month before pregnancy was reported by 29.7% of women. Selected BRFSS results included indicators pertaining to the nutrition and physical activity, emotional and social support, and chronic conditions domains among women of reproductive age. Approximately one fourth (24.7%) of women were identified as being obese according to body mass index (BMI) on the basis of self-reported height and weight. Overall, 51.6% of women reported participation in recommended levels of physical activity per U.S. Department of Health and Human Services physical activity guidelines. Non-Hispanic whites reported the highest prevalence (85.0%) of having adequate emotional and social support, followed by other races/ethnicities (74.9%), Hispanics (70.5%), and non-Hispanic blacks (69.7%). Approximately 3.0% of persons reported ever being diagnosed with diabetes, and 10.2% of women reported ever being diagnosed with hypertension., Interpretation: The findings in this report underscore opportunities for improving the preconception health of U.S. women. Preconception health and women's health can be improved by reducing unintended pregnancies, reducing risky behaviors (e.g., smoking and drinking) among women of reproductive age, and ensuring that chronic conditions are under control. Evidence-based interventions and clinical practice guidelines exist to address these risks and to improve pregnancy outcomes and women's health in general. The results also highlight the need to increase access to health care for all nonpregnant women of reproductive age and the need to encourage the use of essential preventive services for women, including preconception health services. In addition, system changes in community settings can alleviate health problems resulting from inadequate social and emotional support and environments that foster unhealthy lifestyles. Policy changes can promote health equity by encouraging environments that promote healthier options in nutrition and physical activity. Finally, variation in the preconception health status of women by age and race/ethnicity underscores the need for implementing and scaling up proven strategies to reduce persistent health disparities among those at highest risk. Ongoing surveillance and research in preconception health are needed to monitor the influence of improved health-care access and coverage on women's prepregnancy and interpregnancy health status, pregnancy and infant outcomes, and health disparities., Public Health Action: Public health decision makers, program planners, researchers, and other key stakeholders can use the state-level PRAMS and BRFSS preconception health indicators to benchmark and monitor preconception health among women of reproductive age. These data also can be used to evaluate the effectiveness of preconception health state and national programs and to assess the need for new programs, program enhancements, and policies.

Introduction: The Agency for Healthcare Research and Quality (AHRQ's) Patient Safety Program is responsive to AHRQ's mission of quality improvement in healthcare. As part of this program, AHRQ has invested in projects to prevent healthcare-associated infections (HAIs), and funding has increased significantly over the last decade. AHRQ-funded projects have focused on generating new knowledge and promoting the nationwide implementation of proven HAI prevention measures in diverse healthcare settings., Objectives: To provide insight to AHRQ's HAI prevention strategies by: first, discussing the context and structure of AHRQ's HAI research portfolio and funding decisions; secondly, describing the process of prevention practice implementation and lessons learned; and third, explaining the outcomes and national impact of the AHRQ program., Results and Conclusions: In the early 2000s, AHRQ identified HAIs as an important and preventable public health threat and built their HAI-prevention portfolio based on National Action Plan priorities, available resources, advice from experts, and the state of science. This paper describes major contributions that have emerged from AHRQ-funded HAI projects. The projects examined, many of which focus on implementation of HAI prevention practices, yield useful lessons learned for future implementation and research endeavors and show significant impact of AHRQ's program in reducing HAIs.

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.

Problem: Smoking during pregnancy increases the risk for complications such as fetal growth restriction, preterm delivery, and infant death. In 2002, 5%-8% of preterm deliveries, 13%-19% of term infants with growth restriction, 5%-7% of preterm-related deaths, and 23%-34% of deaths from sudden infant death syndrome were attributable to prenatal smoking in the United States., Reporting Period Covered: 2000-2010., Description of System: The Pregnancy Risk Assessment Monitoring System (PRAMS) was initiated in 1987 and is an ongoing state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and after pregnancy among females who deliver live-born infants in the United States. Self-reported questionnaire data are linked to selected birth certificate data and are weighted to represent all women delivering live infants in the state. Self-reported smoking data were obtained from the PRAMS questionnaire and birth certificates. This report provides data on trends (aggregated and site-specific estimates) in smoking before, during, and after pregnancy from 40 PRAMS sites during 2000-2010., Results: For the majority of sites, smoking prevalence before, during, or after pregnancy did not change over time. During 2000-2010, smoking prevalence decreased in three sites (Minnesota, New York state, and Utah) for all three measures and in eight sites (Colorado, Illinois, New Jersey, New Mexico, New York City, Washington, Wisconsin and Wyoming) for one or two of the measures. Smoking prevalence increased for all three measures in three sites (Louisiana, Mississippi, and West Virginia); an increase in prevalence before pregnancy (only) occurred in Oklahoma, and an increase during and after pregnancy occurred in Maine. For a subgroup of 10 sites for which data were available for the entire 11-year study period (Alaska, Arkansas, Colorado, Hawaii, Maine, Nebraska, Oklahoma, Utah, Washington, and West Virginia), the prevalence of smoking before pregnancy remained unchanged, with approximately one in five women reporting smoking before pregnancy (23.6% in 2000 to 24.7% in 2010). The prevalence of smoking during pregnancy decreased (p = 0.04; linear trend assessed with logistic regression) from 13.3% in 2000 to 12.3% in 2010, and the prevalence of smoking after delivery decreased (p<0.01) from 18.6% in 2000 to 17.2% in 2010., Interpretation: The results indicate that efforts to reduce smoking prevalence among female smokers before pregnancy have not been effective; however, tobacco-control efforts have been minimally effective in reducing smoking prevalence during and after pregnancy. Current tobacco-control efforts in most sites might be insufficient to reach national objectives related to reducing prevalence of smoking during pregnancy., Public Health Action: States with no change in or increasing smoking prevalence before, during, and after pregnancy can help reduce prevalence through sustained and comprehensive tobacco-control efforts (e.g., mass media campaigns, coverage of tobacco cessation, 100% smoke-free policies, and tobacco excise taxes).

Objectives: We compared three measures of maternal smoking status--prepregnancy, during pregnancy, and smoking cessation during pregnancy-between the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire and the 2003 revised birth certificate (BC)., Methods: We analyzed data from 10,485 women with live births in eight states from the 2008 PRAMS survey, a confidential, anonymous survey administered in the postpartum period that is linked to select BC variables. We calculated self-reported prepregnancy and prenatal smoking (last trimester only) prevalence based on the BC, the PRAMS survey, and the two data sources combined, and the percentage of smoking cessation during pregnancy based on the BC and PRAMS survey. We used two-sided t-tests to compare BC and PRAMS estimates., Results: Prepregnancy smoking prevalence estimates were 17.3% from the BC, 24.4% from PRAMS, and 25.4% on one or both data sources. Prenatal smoking prevalence estimates were 11.3% from the BC, 14.0% from PRAMS, and 15.2% on one or both data sources. The percentages of prepregnancy smokers who indicated that they quit smoking by the last trimester were 35.1% from the BC and 42.6% from PRAMS. The PRAMS estimates of prepregnancy and prenatal smoking, and smoking cessation during pregnancy were statistically higher than the corresponding BC estimates (t-tests, p<0.05)., Conclusions: PRAMS captured more women who smoked before and during the last trimester than the revised BC. States implementing PRAMS and the revised BC should consider information from both sources when developing population-based estimates of smoking before pregnancy and during the last trimester of pregnancy.

Purpose: We examined the extent to which mental distress may be associated with a woman's preconception health., Methods: We analyzed population-based, self-reported data from the 2005, 2007, and 2009 Behavioral Risk Factor Surveillance System (BRFSS) and limited analyses to 213,137 women aged 18-44 years. Women whose mental health was not good for ≥14 days during the past month were categorized as having frequent mental distress. For 15 preconception health indicators, we used chi-square tests to measure differences in prevalence by mental distress and the average marginal predictions approach to logistic regression to assess associations between mental distress and each preconception health indicator in separate models, adjusted for demographic characteristics. We conducted analyses using SUDAAN software to account for the complex sampling design and used weights to produce unbiased estimates., Results: The prevalence of good preconception health for each indicator was higher for women reporting infrequent mental distress (chi-square p value<0.001 for all). The greatest disparities in preconception health between women with infrequent and frequent mental distress, respectively, were adequate social and emotional support (adjusted prevalence ratio [aPR]=1.4, prevalence=83.7% and 54.8%), not smoking (aPR=1.2, 82.3% and 62.4%), adequate fruit and vegetable consumption (aPR=1.2, 26.1% and 21.5%), normal weight (aPR=1.2, 50.4% and 39.0%), and good general health (aPR=1.2, 91.7% and 71.5%)., Conclusions: Interventions tailored for women with poor mental health may be needed to target specific preconception health indicators, such as social support, smoking, weight, and nutrition.

Study Question: What characteristics are associated with a Day 5 embryo transfer?, Summary Answer: The use of the Day 5 embryo transfer has increased over time, with clinicians allowing women with typically 'poorer' prognostic characteristics to undergo a Day 5 embryo transfer. The mean number of embryos per Day 5 transfer decreased from 2001 to 2009, although the prevalence of the Day 5 single embryo transfer remains low and the rate of multiple births remains substantial., What Is Known and What This Paper Adds: Day 5 embryo transfer may reduce the rate of multiple gestation pregnancy. US trends over time in the prevalence of the Day 5 transfer, changes in characteristics of patients receiving Day 5 transfer, and number of embryos transferred are unknown., Design: We used 2001-2009 US National assisted reproductive technology (ART) Surveillance System (NASS) data on 620,295 fresh IVF cycles derived from autologous oocytes with a Day 3 or 5 embryo transfer. Trends in the mean number of embryos transferred from 2001 to 2009 were assessed by the day of transfer. For 349,947 cycles from clinics performing both Days 3 and 5 embryo transfers, multivariable logistic regression was used to determine the characteristics associated with the Day 5 embryo transfer. We also compared the characteristics of the Day 5 embryo cycles in 2001 and 2009., Main Results and the Role of Chance: Overall, the proportion of ART cycles using the Day 5 embryo transfer increased from 12% in 2001 to 36% in 2009 (P<0.0001), while the mean number of embryos transferred decreased from 2.4 to 2.1 (P<0.0001). Among Day 5 transfers, the rate of the single embryo transfer tripled from 4.5% in 2001 to 14.8% in 2009 (P<0.0001); and the rate of multiple births decreased from 44.8 to 41.1% (P<0.0001). In cycles initiated after 2001, maternal age<35 years, no prior ART cycles, ≥1 prior pregnancies, baseline follicle stimulating hormone<10 international units and ≥10 oocytes retrieved were associated with the Day 5 embryo transfer. Compared with 2001, in 2009, a broader range of candidates received the Day 5 transfer. BIAS Women undergoing multiple ART cycles over time are not linked., Confounding Factors and Other Reasons for Caution: We ran multivariable logistic regression to lessen the effects of the confounding factors. Cycle cancelation rates by the day of embryo transfer are unknown., Generalizability to Other Populations: Generalizable to ART clinics included in NASS., Study Funding/competing Interests: This study was funded by the Centres for Disease Control. The authors have no competing interests to declare.

Introduction: Depression and chronic disease have implications for women's overall health and future pregnancies. The objective of this study was to estimate the prevalence and predictors of diabetes and chronic disease risk factors among reproductive-age women with depression., Methods: We used population-based data from the 2006, 2008, and 2010 Behavioral Risk Factor Surveillance System to examine prevalence of diabetes and prediabetes, binge and heavy drinking, smoking, overweight and obesity, and physical inactivity among 69,043 women aged 18 to 44 years with current major or minor depression, a past depression diagnosis, or no depression. In a multivariable logistic regression model, we calculated adjusted odds ratios (AORs) and 95% confidence intervals (CIs) of 1, 2, and 3 or more chronic disease risk factors by depression status., Results: We found that 12.8% of reproductive-aged women experienced both current depression and 1 or more chronic disease risk factors. Compared to women with no depression, currently depressed women and those with a past diagnosis had higher prevalence of diabetes, smoking, binge or heavy drinking, obesity, and physical inactivity (P < .001 for all). Odds of 3 or more chronic conditions and risk factors were elevated among women with major (AOR, 5.7; 95% CI, 4.3-7.7), minor (AOR, 4.7; 95% CI, 3.7-6.1), and past diagnosis of depression (AOR, 2.8; 95% CI, 2.4-3.4)., Conclusion: Depressed women of reproductive age have high rates of chronic disease risk factors, which may affect their overall health and future pregnancies.

Introduction: Prenatal smoking prevalence remains high in the United States. To reduce prenatal smoking prevalence, efforts should focus on delivering evidence-based cessation interventions to women who are most likely to smoke before pregnancy. Our objective was to identify groups with the highest prepregnancy smoking prevalence by age within 6 racial/ethnic groups., Methods: We analyzed data from 186,064 women with a recent live birth from 32 states and New York City from the 2004-2008 Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based survey of postpartum women. We calculated self-reported smoking prevalence during the 3 months before pregnancy for 6 maternal racial/ethnic groups by maternal age (18-24 y or ≥25 y). For each racial/ethnic group, we modeled the probability of smoking by age, adjusting for education, Medicaid enrollment, parity, pregnancy intention, state of residence, and year of birth., Results: Younger women had higher prepregnancy smoking prevalence (33.2%) than older women (17.6%), overall and in all racial/ethnic groups. Smoking prevalences were higher among younger non-Hispanic whites (46.4%), younger Alaska Natives (55.6%), and younger American Indians (46.9%). After adjusting for confounders, younger non-Hispanic whites, Hispanics, Alaska Natives, and Asian/Pacific Islanders were 1.12 to 1.50 times as likely to smoke as their older counterparts., Conclusion: Age-appropriate and culturally specific tobacco control interventions should be integrated into reproductive health settings to reach younger non-Hispanic white, Alaska Native, and American Indian women before they become pregnant.

Introduction: The magnitude of chronic conditions and risk factors among American Indian/Alaska Native women of reproductive age is unknown. The objective of our study was to estimate this magnitude., Methods: We analyzed data for 2,821 American Indian/Alaska Native women and 105,664 non-Hispanic white women aged 18 to 44 years from the 2005 and 2007 Behavioral Risk Factor Surveillance System. We examined prevalence of high cholesterol, high blood pressure, diabetes, body mass index (kg/m(2)) ≥25.0, physical inactivity, smoking, excessive alcohol consumption, and frequent mental distress, and the cumulative number of these chronic conditions and risk factors (≥3, 2, 1, or 0). In a multivariable, multinomial logistic regression model, we examined whether American Indian/Alaska Native race was associated with the cumulative number of chronic conditions and risk factors., Results: American Indian/Alaska Native women, compared with white women, had significantly higher rates of high blood pressure, diabetes, obesity, smoking, and frequent mental distress. Of American Indian/Alaska Native women, 41% had 3 or more chronic conditions or risk factors compared with 27% of white women (χ(2), P < .001). After adjustment for income, education, and other demographic variables, American Indian/Alaska Native race was not associated with having either 1, 2, or 3 or more chronic conditions or risk factors., Conclusion: Three out of every 5 American Indian/Alaska Native women aged 18 to 44 years have 3 or more chronic conditions or risk factors. Improving economic status and education for AI/AN women could help eliminate disparities in health status.

Purpose: To compare the prevalence of high out-of-pocket burdens among patients with cancer with other chronically ill and well patients, and to examine the sociodemographic characteristics associated with high burdens among patients with cancer., Methods: The sample included persons 18 to 64 years of age who received treatment for cancer, taken from a nationally representative sample of the US population from the 2001 to 2008 Medical Expenditure Panel Survey. We examined the proportion of persons living in families with high out-of-pocket burdens associated with medical spending, including insurance premiums, relative to income, defining high health care (total) burden as spending more than 20% of income on health care (and premiums)., Results: The risk of high burdens is significantly greater for patients with cancer compared with other chronically ill and well patients. We find that 13.4% of patients with cancer had high total burdens, in contrast to 9.7% among those with other chronic conditions and 4.4% among those without chronic conditions. Among nonelderly persons with cancer, the following were associated with higher out-of-pocket burdens: private nongroup insurance, age 55 to 64 years, non-Hispanic black, never married or widowed, one child or no children, unemployed, lower income, lower education level, living in nonmetropolitan statistical areas, and having other chronic conditions., Conclusion: High burdens may affect treatment choice and deter patients from getting care. Thus, although a detailed patient-physician discussion of costs of care may not be feasible, we believe that an awareness of out-of-pocket burdens among patients with cancer is useful for clinical oncologists.

Background: This study examines whether a woman's mental health is associated with use of contraception., Study Design: We used national data from 2004 and 2006 to calculate the prevalence of contraceptive use among women with frequent mental distress. We examined associations among mental distress and permanent contraception and any highly or moderately effective, reversible contraceptive method., Results: Women with (86%) and without (87%) frequent mental distress reported using contraception, but contraceptive type varied by mental distress and income. Among women who use contraception, those with frequent mental distress had 1.4 times higher odds (95% CI: 1.2-1.6) of using permanent contraception. Among lower income women who use reversible contraception, those with frequent mental distress had lower odds of using highly [adjusted odds ratio (aOR)=0.5, 95% CI: 0.4-0.8] and moderately (aOR=0.6, 95% CI: 0.4-0.9) effective methods than less effective methods., Conclusion: Contraceptive providers should consider mental health when providing counseling about contraception., (Published by Elsevier Inc.)

Objective: The objective of the study was to estimate prevalence of depression and serious psychological distress (SPD) and mental health service receipt among reproductive-age women., Study Design: We used 2006-2007 nationally representative data to estimate the prevalence of depression and SPD among nonpregnant women aged 18 to 44 years. Using logistic regression, we individually examined predictors of depression and SPD and characteristics associated with clinical diagnosis and current treatment., Results: More than 14% of women had current depression and 2.7% had current SPD. Risk factors for major depression and SPD included older age, less education, being unmarried, inability to work/unemployed, and low income. Among depressed women, 18-24 year-olds, nonwhite women, those with children, the employed, and urban women had lower odds of clinical diagnosis. Among women with SPD, Hispanic, employed, and those without health insurance had lower odds of receiving treatment., Conclusion: Mental health conditions are prevalent among women of reproductive age and a substantial proportion goes untreated., (Published by Mosby, Inc.)

Background: Although prenatal smoking continues to decline, it remains one of the most prevalent preventable causes of infant morbidity and mortality in the U.S., Purpose: The aim of this study was to estimate the proportion of preterm deliveries, term low birth weight deliveries, and infant deaths attributable to prenatal smoking., Methods: Associations were estimated for prenatal smoking and preterm deliveries, term low birth weight (<2500 g) deliveries, sudden infant death syndrome (SIDS), and preterm-related deaths among 3,352,756 singleton, live births using the U.S. Linked Birth/Infant Death Data Set, 2002 birth cohort. The 2002 data set is the most recent, in which 49 states used the same standardized smoking-related question on the birth certificate. Logistic regression models estimated ORs of prenatal smoking for each outcome, and the prenatal smoking population attributable fraction was calculated for each outcome., Results: Prenatal smoking (11.5% of all births) was significantly associated with very (AOR=1.5, 95% CI=1.4, 1.6); moderate (AOR=1.4, 95% CI=1.4, 1.4); and late (AOR=1.2, 95% CI=1.2, 1.3) preterm deliveries; term low birth weight deliveries (AOR=2.3, 95% CI=2.3, 2.5); SIDS (AOR=2.7, 95% CI=2.4, 3.0); and preterm-related deaths (AOR=1.5, 95% CI=1.4, 1.6). It was estimated that 5.3%-7.7% of preterm deliveries, 13.1%-19.0% of term low birth weight deliveries, 23.2%-33.6% of SIDS, and 5.0%-7.3% of preterm-related deaths were attributable to prenatal smoking. Assuming prenatal smoking rates continued to decline after 2002, these PAFs would be slightly lower for 2009 (4.4%-6.3% for preterm-related deaths, 20.2%-29.3% for SIDS deaths)., Conclusions: Despite recent declines in the prenatal smoking prevalence, prenatal smoking continues to cause a substantial number of infant deaths in the U.S., (Published by Elsevier Inc.)

Objective: To evaluate the presence of and estimate risk factors for reactivation of latent high-risk human papillomavirus (HPV) cervical infection in human immunodeficiency virus (HIV)-infected and HIV-uninfected women., Methods: Data from 898 women in the HIV Epidemiology Research Study (HERS) were used to evaluate cervical HPV latency and reactivation. Prior exposure to HPV types (16, 18, 31, 35, and 45) was determined by serologic testing at enrollment, and cervical shedding of HPV was detected by polymerase chain reaction at 6-month intervals. Human papillomavirus cervical shedding and sexual history were used to estimate rates of reactivation and recurrence. Repeated measures survival analysis was used to estimate hazard ratios and 95% confidence intervals for reactivation and recurrence. Rates of total HPV shedding (recurrence and reactivation) during follow-up were assessed by HIV status and rate ratios were calculated., Results: Reactivation of latent HPV infections was observed in HIV-infected women, but few reactivation events were identified in HIV-uninfected women. Factors consistently associated with reactivation in HIV-infected women included CD4 count less than 200/mm and age younger than 35 years. Women infected with HIV had 1.8 to 8.2 times higher rates of viral shedding (reactivation plus recurrence) compared with HIV-uninfected women., Conclusion: Women with a history of cervical HPV infection may be at risk of reactivation of latent viral infection even in the absence of sexual activity, and this risk is higher in women with HIV infection., Level of Evidence: II.

In 2002, 2 million American women of reproductive age were infertile. Infertility is also common among men. The Centers for Disease Control and Prevention (CDC) conducts surveillance and research on the causes of infertility, monitors the safety and efficacy of infertility treatment, and sponsors national prevention programs. A CDC-wide working group found that, despite this effort, considerable gaps and opportunities exist in surveillance, research, communication, and program and policy development. We intend to consult with other federal agencies, professional and consumer organizations, the scientific community, the health care community, industry, and other stakeholders, and participate in the development of a national public health plan for the prevention, detection, and management of infertility., (Published by Elsevier Inc.)

Objective: The purpose of this study was to estimate the national prevalence and predictors of sexually transmitted disease/human immunodeficiency virus (STD/HIV) service receipt in the preceding year among young women who received contraceptive services., Study Design: Weighted self-reported data from the 2002 National Survey of Family Growth was used to estimate the prevalence and multivariable odds ratios for the receipt of STD/HIV services among 1009 unmarried, sexually active 15- to 24-year-old women who received contraceptive services., Results: Of the women who received contraceptive services, 35% (2.7 million) did not receive STD/HIV services. Predictors of the receipt of STD/HIV services included younger age at first sexual intercourse (< or = 14 years; adjusted odds ratio [aOR], 2.0; 15-17 years; aOR, 1.7), having ever been pregnant (aOR, 2.2); having had > or = 2 partners in the past year (aOR, 2.6), receipt of a pregnancy test or abortion in the past year (aOR, 2.3), and having visited a Title X clinic in the last 12 months (aOR, 3.3)., Conclusion: Interventions are needed to help integrate contraceptive and STD/HIV services.

Objective: To describe the extent to which men report they or their partners had made use of infertility services, what services and conditions were reported, and what factors were associated with their use of services., Design: Analysis of the male sample of the 2002 National Survey of Family Growth, a nationally-representative household survey of men 15-44. Analysis involved estimation of percentages, chi-squared tests of difference, and multivariate logistic regression analysis., Setting: The 2002 National Survey of Family Growth, Cycle 6., Patient(s): A total of 4109 sexually experienced men aged 15-44 years in the 2002 National Survey of Family Growth who had received infertility services., Intervention(s): None., Main Outcome Measure(s): Percentage of men reporting that they had sought help with having a baby., Result(s): A total of 7.5% of all sexually experienced men reported a visit for help with having a child; 2.2% reported a visit in the past year, equivalent to 3.3-4.7 million men reporting a lifetime visit and 787,000-1.5 million a past-year visit. Visits were reported more frequently by older men, those currently or previously married, and the more highly educated. Male-related infertility conditions were reported by 18.1% of those who sought help, the most frequent being sperm or semen problems and varicocele., Conclusion(s): Previous estimates of infertility help-seeking were based on data from women. Men report a percentage seeking help that appears to be somewhat lower than reported by women. About 1 in 5 of those seeking help reported male-related infertility conditions.

Approximately 30% of pregnancies in the United States may end in miscarriage or stillbirth. Whether pregnancies conceived through assisted reproductive technology (ART) are at an increased risk of loss is inconclusive, and data on maternal age-, ART type-, and gestational age-specific risk of loss are limited. Data on 148,494 ART pregnancies conceived from 1999 through 2002 were analyzed by use of the Kaplan-Meier method to estimate risks of pregnancy loss after specified gestational ages (conditional risk) for 14 groups stratified by maternal age and ART procedure. Births, maternal deaths, and induced abortions were censored. The Kaplan-Meier estimate of total risk of pregnancy loss was 29% but ranged from 22% to 63% depending on patient age and ART procedure. By 6 weeks' gestation, 58% of all pregnancy losses occurred. Conditional risk of pregnancy loss ranged from 10% to 45% at 6 weeks' gestation and from 2% to 7% at the first trimester; it was less than 2% after 20 weeks' gestation. Results can be used to counsel ART patients and inform future research on the etiology of pregnancy loss.

Objective: The rate of primary cesarean delivery in Puerto Rico in 2002 was 52% higher than in 1996 and 85% higher than among Puerto Rican women delivering on the U.S. mainland. Reasons for these differences were explored using birth certificate data., Methods: Distributions of mothers' age, education, parity, level of prenatal care, pregnancy weight gain, medical risk factors, labor induction, labor or delivery complications, and infant birth weight among births in Puerto Rico in 2002 (n=40,489) were compared with births in Puerto Rico in 1996 (n=51,357) and births to Puerto Rican women delivering on the mainland in 2002 (n=47,800). Multivariable log-linear regression models were used to estimate relative risks for primary cesarean delivery by year, place of delivery, and selected risk factors., Results: Risk for cesarean delivery was higher in Puerto Rico in 2002 than in both 1996 (relative risk 2.1, 95% confidence interval 2.0, 2.3) and on the mainland in 2002 (relative risk 2.4, 95% confidence interval 2.2, 2.6). This translates into one additional cesarean delivery in Puerto Rico in 2002 for every 4.2 live births, controlled for examined risk factors. Higher rates of cesarean delivery in Puerto Rico in 2002 could not be explained by examined risk factors., Conclusion: Until further research reveals ways to safely reduce the rate of cesarean delivery in Puerto Rico, physicians, public health practitioners, and other stakeholders may want to focus their efforts on reducing rates among low-risk women and those with no labor complications., Level of Evidence: II.