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Background Twin birthweight discordance is associated with adverse outcomes. Objective To determine what degree of twin birthweight discordance is associated with adverse outcomes. Study Design This is a retrospective cohort study of twins with vertex twin A delivered vaginally at 36 to 40 weeks (U.S. Vital Statistics Natality birth certificate registry data 2012–2014). The primary outcome was a composite of neonatal morbidity: 5-minute Apgar 6 hours, neonatal seizure, and/or neonatal transport to a higher level of care. Effect estimates were expressed as incidence rate and adjusted odds ratio (aOR) controlling for confounding using multivariate clustered analysis for between-pair effects, and multilevel random effect generalized estimating equation regressions to account for within-pair effects. We adjusted for sex discordance, breech delivery of the second twin, maternal race/ethnicity, nulliparity, age, marital status, obesity, and socioeconomic status. Results In comparison to birthweight discordance of ≤20%, aORs with 95% confidence intervals (CIs) by weight discordance of the primary outcome among 27,276 twin deliveries were as follows: 20.01 to 25% (aOR: 1.46 [95% CI: 1.29–1.65]); 25.01 to 30% (aOR: 1.96 [95% CI: 1.68–2.29]); and 30.01 to 60% (aOR: 2.97 [95% CI: 2.52–3.50]). Conclusion Twin birthweight discordance >20% was associated with increased odds of adverse neonatal outcome.

To identify patient and health care provider characteristics associated with receipt of a high amount of prescribed opioids at postpartum discharge.This was a retrospective case-control study of all opioid-naïve women delivering at a single, high-volume tertiary care center between December 1, 2015, and November 30, 2016. Inpatient, outpatient, pharmacy, and billing records were queried for clinical, prescription, and health care provider (training, age, gender) data. The discharging health care provider, whether an opioid prescription was provided, and the details of any opioid prescription were determined. A high amount of prescribed opioids was defined as morphine milligram equivalents greater than the 90th percentile (determined as 300 morphine milligram equivalents for vaginal and 500 morphine milligram equivalents for cesarean delivery). Multivariable logistic regression models with random effects were used to identify patient and health care provider factors independently associated with receipt of a high amount of prescribed opioids at discharge. Findings were analyzed separately by mode of delivery.The analysis included 12,362 women. High amounts of opioids were prescribed for 636 of 9,038 (7.0%) women who delivered vaginally and 241 of 3,288 (7.3%) of those delivering by cesarean. In multivariable analysis, patient factors associated with receipt of a high amount of prescribed opioids at discharge after a vaginal delivery included nulliparity, intrapartum neuraxial anesthesia, major laceration, and infectious complication. Discharge by a trainee physician was associated with decreased odds of receiving a high amount of opioids (8.5% vs 1.9%; adjusted odds ratio [OR] 0.08, 95% CI 0.01-0.53). For women who underwent cesarean delivery, the only patient factor associated with receipt of a high amount of prescribed opioids was hemorrhage. Discharge by a trainee physician was associated with decreased odds of being provided a high-amount opioid prescription (7.9% vs 0.4%; adjusted OR 0.01, 95% CI 0.00-0.36).Even after adjusting for patient factors, discharge by a trainee physician is significantly associated with decreased odds of a high amount of prescribed opioids at postpartum discharge.

Objective To determine whether intimate partner violence (IPV) during pregnancy is associated with increased risk of clinical factors that influence maternal to child transmission (MTCT) of HIV. Study design Retrospective cohort study of pregnant women living with HIV (WLHIV) who received prenatal care in a multidisciplinary perinatal HIV clinic (2007–2014). All women were assessed for IPV status during pregnancy by a social worker and/or health psychologist. Records were abstracted for obstetric information and factors associated with MTCT of HIV, including antenatal visit attendance, adherence to antiretroviral regimen, time until viral suppression after initiation of antiretroviral medications, HIV RNA at 36 weeks and at delivery, and preterm birth. Women who reported IPV were compared to those who did not using bivariable and multivariable logistic and linear regression analyses. Results Of 215 women receiving care during the study period, 91.6% (N = 197) had documentation of IPV history. Of these women, 13.7% (N = 27) reported experiencing IPV during pregnancy. Women who reported IPV were less likely to be completely adherent to antiretroviral doses (38.5% vs. 62.0%, p = 0.039) and required significantly more time to achieve stable virologic suppression (16.0 vs. 8.5 weeks, p = 0.010). Time to achieve suppression remained significant in multivariable models (β 4.68, 95% CI 0.03–9.32). Conclusion IPV during a pregnancy complicated by HIV appears to be associated with decreased antiretroviral adherence. Pregnant WLHIV who reported IPV exhibited delays in achieving virologic suppression. These women represent a vulnerable population who may require additional support and interventions to reduce the risk of MTCT of HIV.

Objective To evaluate racial and ethnic differences in women's postpartum pain scores, inpatient opioid administration, and discharge opioid prescriptions. Methods We conducted a retrospective cohort study of all deliveries at a single high-volume tertiary care center from December 1, 2015, through November 30, 2016. Women were included if they self-identified as non-Hispanic white, non-Hispanic black, or Hispanic; were at least 18 years of age; and did not have documented allergies to nonsteroidal antiinflammatory drugs or morphine. Medical records were queried for three outcomes: 1) patient-reported postpartum pain score (on a scale of 0-10) at discharge (dichotomized less than 5 or 5 or higher), 2) inpatient opioid dosing during postpartum hospitalization (reported as morphine milligram equivalents [MMEs] per postpartum day), and 3) receipt of an opioid prescription at discharge. The associations between each of these outcomes and maternal race-ethnicity were assessed using multivariable logistic regression models with random effects to account for clustering by discharge physician. A sensitivity analysis was conducted in which women of different race and ethnicity were matched using propensity scores. Results A total of 9,900 postpartum women were eligible for analysis. Compared with non-Hispanic white women, Hispanic and non-Hispanic black women had significantly greater odds of reporting a pain score of 5 or higher (adjusted odds ratio [aOR] 1.61, 95% 1.26-2.06 and aOR 2.18, 95% 1.63-2.91, respectively) but received significantly fewer inpatient MMEs/d (adjusted β -5.03, 95% CI -6.91 to -3.15, and adjusted β -3.54, 95% CI -5.88 to -1.20, respectively). Additionally, Hispanic and non-Hispanic black women were significantly less likely to receive an opioid prescription at discharge (aOR 0.80, 95% CI 0.67 to -0.96 and aOR 0.78, 95% CI 0.62-0.98) compared with non-Hispanic white women. Results of the propensity score analysis largely corroborated those of the primary analysis, with the exception that the difference in inpatient MMEs/d between non-Hispanic white and non-Hispanic black women did not reach statistical significance. Conclusion Hispanic and non-Hispanic black women experience disparities in pain management in the postpartum setting that cannot be explained by less perceived pain.

OBJECTIVE To estimate whether there are differences in obstetric interventions or outcomes by the gender of the delivering physician. METHODS We conducted a retrospective cohort study of all nulliparous women delivering singleton, vertex, live births at 37 weeks of gestation or greater at a tertiary care institution (2014-2015). Patient clinical characteristics were analyzed by delivering physician gender. The primary outcomes were delivery mode and episiotomy. Secondary outcomes included major perineal laceration, postpartum hemorrhage, 5-minute Apgar score less than 7, cord umbilical artery pH less than 7.0, and neonatal intensive care unit admission. Univariable and hierarchical multivariable analyses including physician as a random effect were utilized for analyses. RESULTS Of the 7,027 women who met inclusion criteria, 81.3% (n=5,716) were delivered by a female physician. Women delivered by female physicians were slightly younger than those delivered by male physicians and were more likely to be publicly insured (11.7% vs 7.1%, P

Electronic patient portals are increasingly utilized in contemporary health care systems. Patient portal use has been found to be beneficial in multiple specialties, particularly in management of chronic diseases. However, there are disparities within portal use. For example, individuals who are racial and ethnic minorities and persons from lower socioeconomic status are less likely to enroll and use patient portals than non-Hispanic white persons and persons with higher socioeconomic status. Because portal use and, specifically, patient-provider secure messaging has been associated with favorable health outcomes, disparities in use of these portals could affect health outcomes. Electronic patient portal use by childbearing women has not been well studied, and data on portal use during pregnancy are limited. This article reviews the current literature regarding electronic patient portal use and highlights the need for further maternity care-focused research regarding this new avenue of care delivery during pregnancy.

Patient navigation is a patient-centered intervention that uses trained personnel to identify patient-level barriers, including financial, cultural, logistical, and educational obstacles to health care and then mitigate these barriers to facilitate complete and timely access to health services. For example, to assist a woman with Medicaid who is seeking postpartum care, a patient navigator could help her schedule an appointment before her insurance benefits change, coordinate transportation and child care, give her informational pamphlets on contraception options, and accompany her to the appointment to ensure her questions are answered. Existing studies examining the efficacy of patient navigation interventions show particularly striking benefits in the realm of cancer care, including gynecological oncology; patient navigation has been demonstrated to increase access to screening, shorten time to diagnostic resolution, and improve cancer outcomes, particularly in health disparity populations, such as women of color, rural populations, and poor women. Because of the successes in cancer care at reducing disparities in health care access and health outcomes, patient navigation has the potential to improve care and reduce disparities in obstetric and benign gynecological care. We review the concept of patient navigation, offer potential roles for patient navigation in obstetrics and gynecology, and discuss areas for further investigation.

Objective To determine whether maternal disclosure of HIV serostatus is associated with uptake of perinatal HIV transmission prevention interventions. Study Design Retrospective cohort study of women living with HIV enrolled in a perinatal HIV clinic. Women who disclosed their HIV serostatus to sexual partner(s) prior to delivery were compared to non-disclosers. Multivariable logistic regression was performed. Results Of 209 women, 71.3% (N=149) disclosed. Non-disclosers were more likely to attend

This cohort study evaluates trends over time in the prevalence of self-reported opioid, alcohol, and marijuana use during pregnancy and in the first year postpartum among people living with HIV and assesses the association of marijuana legalization status with substance use., Key Points Question What are the trends over time in marijuana, alcohol, and opioid use during pregnancy and the first year postpartum among US persons living with HIV? Findings In this cohort study including 2310 pregnant and postpartum individuals living with HIV from the Surveillance Monitoring for Antiretroviral Toxicities (SMARTT) study, use of marijuana increased from 2007 to 2019 and was more frequent in locations with medical marijuana legalization. Prevalence of alcohol and opioid use did not change over that time. Meaning These findings of increasing marijuana use among pregnant people living with HIV suggest that further clinical and research attention is warranted, given the potential implications for pregnancy and HIV-related health., Importance Amid the opioid epidemic and evolving legal and social changes with marijuana, little is known about substance use among pregnant and postpartum people living with HIV. Objectives To evaluate trends in marijuana, alcohol, and opioid use during pregnancy and the first year postpartum among US people living with HIV and the differences in substance use based on marijuana legalization status. Design, Setting, and Participants Data from the Surveillance Monitoring for Antiretroviral Toxicities (SMARTT) study of the Pediatric HIV/AIDS Cohort Study were analyzed. SMARTT-enrolled, pregnant people living with HIV at 22 US sites from January 1, 2007, to July 1, 2019, with self-reported substance use data available in pregnancy, 1 year postpartum, or both were assessed. Exposures Calendar year and state marijuana legalization status. Main Outcomes and Measures The prevalence of any use of each of the following substances was calculated by calendar year, separately for pregnancy and postpartum: marijuana, alcohol, opioid, and concomitant alcohol and marijuana. Log binomial models were fit using general estimating equations to evaluate the mean annual change, accounting for repeat pregnancies. The study also evaluated differences in substance use by state recreational or medical marijuana legalization status. Results Substance use data were available for 2926 pregnancies from 2310 people living with HIV (mean [SD] age, 28.8 [6.1] years; 822 [28.1%] Hispanic, 1859 [63.5%] non-Hispanic Black, 185 [6.3%] White, 24 [0.8%] of more than 1 race, 24 [0.8%] of other race or ethnicity [individuals who identified as American Indian, Asian, or Native Hawaiian or other Pacific Islander], and 12 [0.4%] with unknown or unreported race or ethnicity). Between 2007 and 2019, marijuana use during pregnancy increased from 7.1% to 11.7%, whereas alcohol and opioid use in pregnancy were unchanged. Postpartum alcohol (44.4%), marijuana (13.6%), and concomitant alcohol and marijuana (10.0%) use were common; marijuana use increased from 10.2% to 23.7% from 2007 to 2019, whereas postpartum alcohol use was unchanged. The adjusted mean risk of marijuana use increased by 7% (95% CI, 3%-10%) per year during pregnancy and 11% (95% CI, 7%-16%) per year postpartum. Postpartum concomitant alcohol and marijuana use increased by 10% (95% CI, 5%-15%) per year. Differences in substance use were not associated with recreational legalization, but increased marijuana use was associated with medical marijuana legalization. Conclusions and Relevance In this cohort study, opioid use among pregnant people living with HIV remained stable, whereas marijuana use during pregnancy and postpartum increased over time and in states with legalized medical marijuana. These patterns of increasing marijuana use among pregnant and postpartum people living with HIV suggest that enhanced clinical attention is warranted, given the potential maternal and child health implications of substance use.

BACKGROUND There are few population-based studies of antepartum emergency department visits and inpatient hospitalizations and their implications for delivery outcomes. OBJECTIVE The study aimed to analyze the likelihood of pregnant patients's antepartum hospital use using population-based hospital discharge data for births in California. The study analyzed associations between antepartum hospital use and the likelihood of maternal delivery complications and postpartum hospital use. STUDY DESIGN This was a population-based retrospective cohort study of individuals with live births in state-licensed hospitals in California in 2017. Delivery admissions data were linked to antepartum hospital visits within 280 days of a delivery admission and 90 days after a delivery discharge. The most common principal or primary International Classification of Diseases, Tenth Revision–coded diagnoses for antepartum emergency department visits and inpatient hospitalizations were identified and Poisson regression estimates were used to determine the likelihood of antepartum hospital use by maternal demographic and clinical characteristics. Complicated deliveries were defined by International Classification of Diseases, Tenth Revision–coded severe maternal morbidity, vaginal or cesarean delivery complications, or long length of stay after delivery (>4 days for a vaginal delivery and >5 days for a cesarean delivery). Associations between specific types of antepartum visits, complicated deliveries, and postpartum hospital use were analyzed by chi-square tests. Logistic regression estimates were used to determine the significance of associations between antepartum hospital use and likelihood of a complicated delivery. RESULTS Of 348,848 deliveries at 246 hospitals in California, in 2017, with linkable data, almost one-third of the patients (30.4% with emergency department visits and 1.2% with inpatient hospital stays) experienced antepartum hospital use. Those who were younger, identified as a racial or ethnic minority, and with a low income, were the most likely to have antepartum hospital use. The most common primary diagnoses for antepartum emergency department visits were threatened abortions (19.6%), urinary tract infections (11.2%), and hemorrhage (9.3%). The most common principal diagnoses for antepartum hospitalizations were preterm labor (14.3%), pyelonephritis (10.2%), and hyperemesis gravidarum (6.3%). Patients with any antepartum hospital use were significantly more likely to experience a delivery complication, even after controlling for conditions coded during the delivery admission. Although having an antepartum emergency department visit was associated with only modestly increased adjusted odds (odds ratio, 1.04; 95% confidence interval, 1.01–1.08) of a complicated delivery, patients with any antepartum hospitalizations, especially those with preterm prelabor rupture of membranes, hypertension, diabetes, or hemorrhage, were at higher risk (odds ratio, 1.38; 95% confidence interval, 1.28–1.47). CONCLUSION Antepartum hospital use is frequent and is associated with patient clinical and demographic factors. Addressing the high prevalence of antepartum hospital use should be a part of future quality improvement and health equity efforts focused on improving care for patients with the greatest medical and social needs.

OBJECTIVE Our objective was to conduct a systematic review of the published literature on housing instability during pregnancy and adverse pregnancy outcomes and perinatal healthcare utilization. DATA SOURCES We performed a systematic search in November 2020 using Embase, MEDLINE, Cochrane Library, and Scopus using terms related to housing instability during pregnancy, adverse pregnancy outcomes, and perinatal healthcare utilization. The search was limited to the United States. STUDY ELIGIBILITY CRITERIA Studies examining housing instability (including homelessness) during pregnancy and adverse pregnancy outcomes (including preterm birth, low birthweight neonates, and maternal morbidity) and perinatal healthcare utilization were included. METHODS Two authors screened abstracts and full-length articles for inclusion. The final cohort consisted of 14 studies. Two authors independently extracted data from each article and assessed the study quality using the Grading of Recommendations, Assessment, Development, and Evaluation tool. Risk of bias was assessed using the National Institutes of Health Study Quality Assessment Tools. RESULTS All included studies were observational, including retrospective cohort (n=10, 71.4%), cross-sectional observational (n=3, 21.4%), or prospective cohort studies (n=1, 7.1%). There was significant heterogeneity in the definitions of housing instability and homelessness. Most of the studies only examined homelessness (n=9, 64.3%) and not lesser degrees of housing instability. Housing instability and homelessness during pregnancy were significantly associated with preterm birth, low birthweight neonates, neonatal intensive care unit admission, and delivery complications. Among studies examining perinatal healthcare utilization, housing instability was associated with inadequate prenatal care and increased hospital utilization. All studies exhibited moderate, low, or very low study quality and fair or poor internal validity. CONCLUSION Although data on housing instability during pregnancy are limited by the lack of a standardized definition, a consistent relationship between housing instability and adverse pregnancy outcomes has been suggested by this systematic review. The evaluation and development of a standardized definition and measurement of housing instability among pregnant individuals is warranted to address future interventions targeted to housing instability during pregnancy.

Key Points Question Is maternal health literacy associated with maternal and neonatal health outcomes? Findings In this cohort study of 10 038 nulliparous individuals, those with inadequate health literacy had greater odds of cesarean delivery, major perineal lacerations, and neonates with small for gestational age status, low birth weight, and low 5-minute Apgar score, although absolute differences were generally small. Meaning These findings suggest that inadequate health literacy is common among pregnant individuals in the US and is associated with a variety of adverse maternal and neonatal outcomes., This cohort study examines the association between maternal health literacy and maternal and neonatal outcomes among nulliparous individuals in the US., Importance Health literacy is considered an important social determinant of health that may underlie many health disparities, but it is unclear whether inadequate health literacy among pregnant individuals is associated with adverse maternal and neonatal outcomes. Objective To assess the association between maternal health literacy and maternal and neonatal outcomes among nulliparous individuals. Design, Setting, and Participants This was a secondary analysis of a large, multicenter cohort study of 10 038 nulliparous individuals in the US (2010-2013). Participants underwent 3 antenatal study visits and had detailed maternal and neonatal data abstracted. Data analysis was performed from July to December 2019. Exposures Between 16 and 21 weeks of gestation, health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine–Short Form, a validated 7-item word recognition test. In accordance with standard scoring, results were dichotomized as inadequate vs adequate health literacy. Main Outcomes and Measures On the basis of theoretical causal pathways between health literacy and health outcomes, a priori maternal and neonatal outcomes (determined via medical records) were selected for this analysis. Multivariable Poisson regression models were constructed to estimate the associations between health literacy and outcomes. Sensitivity analyses in which education was removed from models and that excluded individuals who spoke English as a second language were performed. Results Of 9341 participants who completed the Rapid Estimate of Adult Literacy in Medicine–Short Form, the mean (SD) age was 27.0 (5.6) years, and 2540 (27.4%) had publicly funded prenatal care. Overall, 1638 participants (17.5%) had scores indicative of inadequate health literacy. Participants with inadequate health literacy were more likely to be younger (mean [SD] age, 22.9 [5.0] vs 27.9 [5.3] years), have less educational attainment (some college education or greater, 1149 participants [73.9%] vs 5279 participants [94.5%]), have publicly funded insurance (1008 participants [62.2%] vs 1532 participants [20.0%]), and report they were a member of an underrepresented racial or ethnic group (non-Hispanic Black, 506 participants [30.9%] vs 780 participants [10.1%]; Hispanic, 516 participants [31.5%] vs 948 participants [12.3%]) compared with those with adequate health literacy. Participants who had inadequate health literacy had greater risk of cesarean delivery (adjusted risk ratio [aRR], 1.11; 95% CI, 1.01-1.23) and major perineal laceration (aRR, 1.44; 95% CI, 1.03-2.01). The adjusted risks of small-for-gestational-age status (aRR, 1.34; 95% CI, 1.14-1.58), low birth weight (aRR, 1.33; 95% CI, 1.07-1.65), and 5-minute Apgar score less than 4 (aRR, 2.78; 95% CI, 1.16-6.65) were greater for neonates born to participants with inadequate health literacy. Sensitivity analyses confirmed these findings. Conclusions and Relevance These findings suggest that inadequate maternal health literacy is associated with a variety of adverse maternal and neonatal outcomes.

Key Points Question How is disease burden associated with female representation in US-based clinical trials, and how are disease category and other clinical trial features associated with female representation in clinical trials? Findings In this cross-sectional study of 20 020 clinical trials enrolling more than 5 million participants between 2000 and 2020, clinical trials in the fields of oncology, neurology, immunology, and nephrology had the lowest female participant representation relative to corresponding disability-adjusted life-years. Clinical trials in cardiology and pediatrics had the greatest negative associations with female enrollment, and clinical trials of preventive interventions had a positive association. Meaning This study’s findings suggest that sex bias persists within clinical trials, with male and female participants underrepresented in different areas of research., Importance Although female representation has increased in clinical trials, little is known about how clinical trial representation compares with burden of disease or is associated with clinical trial features, including disease category. Objective To describe the rate of sex reporting (ie, the presence of clinical trial data according to sex), compare the female burden of disease with the female proportion of clinical trial enrollees, and investigate the associations of disease category and clinical trial features with the female proportion of clinical trial enrollees. Design, Setting, and Participants This cross-sectional study included descriptive analyses and logistic and generalized linear regression analyses with a logit link. Data were downloaded from the Aggregate Analysis of ClinicalTrials.gov database for all studies registered between March 1, 2000, and March 9, 2020. Enrollment was compared with data from the 2016 Global Burden of Disease database. Of 328 452 clinical trials, 70 095 were excluded because they had noninterventional designs, 167 936 because they had recruitment sites outside the US, 69 084 because they had no reported results, 1003 because they received primary funding from the US military, and 314 because they had unclear sex categories. A total of 20 020 interventional studies enrolling approximately 5.11 million participants met inclusion criteria and were divided into those with and without data on participant sex. Exposures The primary exposure variable was clinical trial disease category. Secondary exposure variables included funding, study design, and study phase. Main Outcomes and Measures Sex reporting and female proportion of participants in clinical trials. Results Among 20 020 clinical trials from 2000 to 2020, 19 866 studies (99.2%) reported sex, and 154 studies (0.8%) did not. Clinical trials in the fields of oncology (46% of disability-adjusted life-years [DALYs]; 43% of participants), neurology (56% of DALYs; 53% of participants), immunology (49% of DALYs; 46% of participants), and nephrology (45% of DALYs; 42% of participants) had the lowest female representation relative to corresponding DALYs. Male participants were underrepresented in 8 disease categories, with the greatest disparity in clinical trials of musculoskeletal disease and trauma (11.3% difference between representation and proportion of DALYs). Clinical trials of preventive interventions were associated with greater female enrollment (adjusted relative difference, 8.48%; 95% CI, 3.77%-13.00%). Clinical trials in cardiology (adjusted relative difference, −18.68%; 95% CI, −22.87% to −14.47%) and pediatrics (adjusted relative difference, −20.47%; 95% CI, −25.77% to −15.16%) had the greatest negative association with female enrollment. Conclusions and Relevance In this study, sex differences in clinical trials varied by clinical trial disease category, with male and female participants underrepresented in different medical fields. Although sex equity has progressed, these findings suggest that sex bias in clinical trials persists within medical fields, with negative consequences for the health of all individuals., This cross-sectional study uses data from clinical trials registered in ClinicalTrials.gov between 2000 and 2020 to assess the presence of clinical trial data according to sex, female burden of disease relative to female proportion of enrollees, and associations of disease category and study features with female proportion of enrollees.

OBJECTIVES We evaluated the ability of third-trimester ultrasonography (US) to diagnose disorders of fetal growth among women with diabetes mellitus. METHODS This work was a retrospective cohort study of women with diabetes who delivered term singleton neonates at a single academic medical center and who had a US examination within 5 weeks of delivery. We characterized the sensitivity, specificity, positive predictive value, and negative predictive value of US to detect large-for-gestational age (LGA) and small-for-gestational age (SGA) infants. Large and small for gestational age were defined as a US estimated fetal weight of greater than 90% and less than 10%, respectively, based on the Hadlock formula (Radiology 1991; 181:129-133); US estimates of LGA or SGA were compared with postnatal findings of LGA or SGA based on gestational age-based weight percentiles. Test characteristics were analyzed for the total cohort and by the type of diabetes. We compared the areas under the curve for receiver operating characteristic curves for different types of diabetes. RESULTS Of 521 women, 3 (0.6%) screened positive for SGA, and 64 (12.3%) delivered an SGA neonate. In contrast, 129 (24.8%) screened positive for LGA, and 61 (11.7%) delivered an LGA neonate. The receiver operating characteristic curves did not differ significantly for different types of diabetes (P = .68). CONCLUSIONS Ultrasonography in women with diabetes and term or late preterm pregnancies has high specificity but poor sensitivity for SGA and a low positive predictive value for LGA. The diagnostic capability of US to detect fetal growth abnormalities did not differ significantly by the type of diabetes.

Objective This study aims to examine factors associated with postpartum follow-up and glucose tolerance testing (GTT) in women with gestational diabetes mellitus (GDM). Materials and Methods Case-control study of women with GDM at a single institution with available outpatient records (January 2008–February 2016). Women with pregestational diabetes mellitus were excluded. The postpartum follow-up, GTT completion, and the reason for GTT completion failure (provider vs. patient noncompliance) were assessed. Bivariable and multivariable analyses were performed to identify factors associated with postpartum follow-up and GTT completion. Results Of 683 women, 82.0% (n = 560) returned postpartum, and 49.8% (n = 279) of those completed GTT. Women with Medicaid and late presentation to care were less likely to return (adjusted odds ratio [aOR]: 0.3, 95% confidence interval [CI]: 0.2–0.6 and aOR: 0.4, 95% CI: 0.2–0.7), but if they did, both factors were associated with increased odds of GTT completion (aOR: 2.0, 95% CI: 1.3–2.9 and aOR: 3.5, 95% CI: 1.8–6.6). Patient and provider noncompliance contributed equally to GTT completion failure. Trainee involvement was associated with improved test completion (aOR: 4.6, 95% CI: 2.4–8.8). Conclusion The majority of women with GDM returned postpartum, but many did not receive recommended GTT. Public insurance and late presentation were associated with failure to return postpartum, but better GTT completion when a postpartum visit occurred. Trainee involvement was associated with improved adherence to screening guidelines.

The objective was to assess sustainability of a statewide program of HIV rapid testing (RT) for pregnant women presenting for delivery with unknown HIV status. This is a population-based retrospective cohort study of women delivered in Illinois hospitals (2012–15). Deidentified data on RT metrics from state-mandated surveillance reports were compared using descriptive statistics and non-parametric tests of trend. Over 95% of the 608,408 women delivered had documented HIV status at presentation. The rate of undocumented HIV status rose from 4.19 to 4.75% (p < 0.001). However, overall 99.60% of women with undocumented status appropriately received RT and the proportion who did not receive RT declined (p = 0.003). The number of neonates discharged with unknown HIV status declined (p = 0.011). RT identified 23 new HIV diagnoses, representing 4.62% of maternal HIV diagnoses. In conclusion, statewide perinatal HIV RT resulted in nearly 100% of Illinois mother-infant dyads with known HIV status. Sustained RT completion represents an important prevention safety net.

Objective The objective of this study was to characterize health literacy and cognitive function in a diverse cohort of pregnant women. Methods Pregnant and postpartum women underwent in-depth assessments of health literacy/numeracy and the cognitive domains of verbal ability, working memory, long-term memory, processing speed, and inductive reasoning. Differences by demographic characteristics and gestational age were assessed using chi-square tests and multivariable logistic regression. Results In this cohort of pregnant (N = 77) or postpartum (N = 24) women, 41.6% had limited health literacy/numeracy. Women were more likely to score in the lowest quartile for literacy and verbal ability if they were less educated, younger, nonwhite or had Medicaid. These factors were associated with low scores for long-term memory, processing speed, and inductive reasoning. Although there were no differences in literacy or cognitive function by parity or gestational age, postpartum women were more likely to score in the lowest quartile for processing speed (adjusted odds ratio [aOR]: 3.79, 95% confidence interval [CI]: 1.32–10.93) and inductive reasoning (aOR: 4.07, 95% CI: 1.21–13.70). Conclusion Although postpartum status was associated with reduced inductive reasoning and processing speed, there were no differences in cognitive function across pregnancy. Practice Implications Postpartum maternal learning may require enhanced support. In addition, cognitive skills and health literacy may be a mediator of perinatal outcomes inequities.

Objective To evaluate trends in the proportions and outcomes of dichorionic-triamniotic (DT) compared with trichorionic-triamniotic (TT) triplet gestations. Methods This is a retrospective cohort of all triplet gestations identified by first trimester ultrasound at an academic center between 2005 and 2016. Primary outcomes were the change in proportion of DT versus TT triplets over time and the number of fetuses at delivery. Secondary outcomes included differences in mode of conception and maternal/perinatal outcomes by chorionicity. Results Of 258 identified triplet pregnancies, 65.5% (n = 169) were TT. The proportion of DT versus TT triplets increased from 2005 to 2016 (p

Objective Primary prevention of maternal HIV seroconversion requires knowledge of the HIV status of sexual partners, but testing rates, particularly among urban minority heterosexual males, remain low. This study was initiated to understand the attitudes of pregnant women and their partners surrounding partner HIV testing. Methods This was a qualitative study of pregnant women receiving publicly-funded prenatal care in a large urban hospital located in a high HIV prevalence area and their partners. Participants underwent in-depth individual interviews about HIV testing. Semi-structured interview guides were used to elicit participant attitudes. Transcripts were analyzed using the constant comparative method to determine themes and subthemes; analysis was organized by whether participants desired or declined partner testing. Results Of 51 participants, 29 were pregnant women and 22 were male partners of female participants. Reasons for desiring or declining HIV testing aligned within three major themes: risk perception, logistical considerations, and testing history. An individual’s perception of risk included evaluations of fetal safety as well as partner autonomy and fidelity. Logistical considerations included cost, test availability, and male partner geographic location. Individuals’ recent testing histories also influenced testing preferences. One cross-cutting theme was of the pregnant woman taking responsibility for family health, which could serve as a motivator to test or reason to decline. Conclusion Pregnant women are often the linchpin of prevention of HIV transmission in the family unit. These data inform strategies to engage pregnant women and their partners to improve implementation of partner HIV testing in the prenatal setting.

INTRODUCTION Reproductive coercion is a form of intimate partner violence that includes behaviors that interfere with autonomous decision-making over reproductive outcomes. Unintended pregnancy is associated with exposure to reproductive coercion; however, little is known about the outcomes of continued pregnancies. The purpose of this study is to assess whether women who reported reproductive coercion during their last pregnancy experienced differences in birth outcomes compared with women without contemporaneous reproductive coercion. METHODS This was a cross-sectional survey study administered in obstetric and gynecologic offices. A survey comprised of standardized reproductive coercion, birth outcome, and intimate partner violence questions was given to English- or Spanish-speaking women with at least one prior pregnancy. Self-reported birth outcomes of interest included late or no prenatal care, low birth weight, prolonged neonatal hospitalization, preterm birth, and intrauterine fetal demise or neonatal death. Descriptive and bivariable comparisons were performed. RESULTS Of 202 participants, 8.6% of women reported reproductive coercion during their last pregnancy. Women with a reported reproductive coercion history were younger, more likely to be a student, more likely to have anemia and anxiety at the time, and less likely to be married to the father of the incident pregnancy. Women with this history were more likely to express that they never wanted to be pregnant (29.4% vs 6.2%, P = .04), report other forms of intimate partner violence (35.3% vs 11.9%, P = .02), and have low-birth-weight neonates (17.6% vs 3.1%, P = .03). There were no observed differences in other birth outcomes. The response rate was 68%. DISCUSSION In this exploratory study, women who reported reproductive coercion during their most recent completed pregnancy were more likely to report pregnancy ambivalence, other tactics of intimate partner violence, and low-birth-weight neonates. These data provide insight into the impact of violence on women's reproductive outcomes.

Objective This study was aimed to assess patient and provider perceptions of a postpartum patient navigation program. Study Design This was a mixed-method assessment of a postpartum patient navigation program. Navigating New Motherhood (NNM) participants completed a follow-up survey including the Patient Satisfaction with Interpersonal Relationship with Navigator (PSN-I) scale and an open-ended question. PSN-I scores were analyzed descriptively. Eighteen provider stakeholders underwent in-depth interviews to gauge program satisfaction, perceived outcomes, and ideas for improvement. Qualitative data were analyzed by the constant comparative method. Results In this population of low-income, minority women, participants (n = 166) were highly satisfied with NNM. The median PSN-I score was 45 out of 45 (interquartile range [IQR]: 43–45), where a higher score corresponds to higher satisfaction. Patient feedback was also highly positive, though a small number desired more navigator support. Provider stakeholders offered consistently positive program feedback, expressing satisfaction with NNM execution and outcomes. Provider stakeholders noted that navigators avoided inhibiting clinic workflow and eased clinic administrative burden. They perceived NNM improved multiple clinical and satisfaction outcomes. All provider stakeholders believed that NNM should be sustained long-term; suggestions for improvement were offered. Conclusion A postpartum patient navigation program can perceivably improve patient satisfaction, clinical care, and clinic workflow without burden to clinic providers.

Background Electronic patient portals are websites that provide individuals access to their personal health records and allow them to engage through a secure Web-based platform. These portals are becoming increasingly popular in contemporary health care systems. Patient portal use has been found to be beneficial in multiple specialties, especially in the management of chronic disease. However, disparities have been identified in portal use in which racial and ethnic minorities and individuals with lower socioeconomic status have been shown to be less likely to enroll and use patient portals than non-Hispanic white persons and individuals with higher socioeconomic status. Electronic patient portal use by childbearing women has not been well studied, and data on portal use during pregnancy are limited. Objective This study aimed to quantify the use of an electronic patient portal during pregnancy and examine whether disparities related to patients’ demographics or clinical characteristics exist. Methods This was a retrospective cohort study of women who received prenatal care at an academic medical center from 2014 to 2016. Clinical records were reviewed for portal use and patient data. Patients were considered enrolled in the portal if they had an account at the time of delivery, and enrollees were compared with nonenrollees. Enrollees were further categorized based on the number of secure messages sent during pregnancy as active (≥1) or inactive (0) users. Bivariable chi-square and multivariable Poisson regression models were used to calculate the incidence rate ratio of portal enrollment and, if enrolled, of active use based on patients’ characteristics. Results Of the 3450 women eligible for inclusion, 2530 (73.33%) enrolled in the portal. Of these enrollees, 72.09% (1824/2530) were active users. There was no difference in portal enrollment by maternal race and ethnicity on multivariable models. Women with public insurance (adjusted incidence rate ratio; aIRR 0.60, 95% CI 0.49-0.84), late enrollment in prenatal care (aIRR 0.78, 95% CI 0.69-0.89 for second trimester and aIRR 0.50, 95% CI 0.39-0.64 for third trimester), and high-risk pregnancies (aIRR 0.82, 95% CI 0.75-0.89) were significantly less likely to enroll. Conversely, nulliparity (aIRR 1.10, 95% CI 1.02-1.20) and having more than 8 prescription medications at prenatal care initiation (aIRR 1.19, 95% CI 1.06-1.32) were associated with greater likelihood of enrollment. Among portal enrollees, the only factor significantly associated with active portal use (ie, secure messaging) was nulliparity (aIRR 1.11, 95% CI 1.01-1.23). Conclusions Among an obstetric population, multiple clinical and socioeconomic factors were associated with electronic portal enrollment, but not subsequent active use. As portals become more integrated as tools to promote health, efforts should be made to ensure that already vulnerable populations are not further disadvantaged with regard to electronic-based care.

Background Chronic diseases have recently had an increasing effect on maternal-fetal health, especially in high-income countries. However, there remains a lack of discussion regarding health management with technological approaches, including mobile health (mHealth) interventions. Objective This study aimed to systematically evaluate mHealth interventions used in pregnancy in high-income countries and their effects on maternal health behaviors and maternal-fetal health outcomes. Methods This systematic review identified studies published between January 1, 2000, and November 30, 2018, in MEDLINE via PubMed, Cochrane Library, EMBASE, CINAHL, PsycINFO, Web of Science, and gray literature. Studies were eligible for inclusion if they included only pregnant women in high-income countries and evaluated stand-alone mobile phone interventions intended to promote healthy maternal beliefs, behaviors, and/or maternal-fetal health outcomes. Two researchers independently reviewed and categorized aspects of full-text articles, including source, study design, intervention and control, duration, participant age, attrition rate, main outcomes, and risk of bias. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and the study was registered in PROSPERO before initiation. Results Of the 2225 records examined, 28 studies were included and categorized into 4 themes: (1) gestational weight gain, obesity and physical activity (n=9); (2) smoking cessation (n=9); (3) influenza vaccination (n=2); and (4) general prenatal health, preventive strategies, and miscellaneous topics (n=8). Reported sample sizes ranged from 16 to 5243 with a median of 91. Most studies were performed in the United States (18/28, 64%) and were randomized controlled trials (21/28, 75%). All participants in the included studies were pregnant at the time of study initiation. Overall, 14% (4/28) of studies showed association between intervention use and improved health outcomes; all 4 studies focused on healthy gestational weight. Among those, 3 studies showed intervention use was associated with less overall gestational weight gain. These 3 studies involved interventions with text messaging or an app in combination with another communication strategy (Facebook or email). Regarding smoking cessation, influenza vaccination, and miscellaneous topics, there was some evidence of positive effects on health behaviors and beliefs, but very limited correlation with improved health outcomes. Data and interventions were heterogeneous, precluding a meta-analysis. Conclusions In high-income countries, utilization of mobile phone–based health behavior interventions in pregnancy demonstrates some correlation with positive beliefs, behaviors, and health outcomes. More effective interventions are multimodal in terms of features and tend to focus on healthy gestational weight gain.

Perinatal loss, including fetal and infant death, is a devastating experience for parents, resulting in long-term adverse physical and psychosocial outcomes. However, little is known about what services might best support grieving parents. We aimed to understand the role of professional bereavement photography in assisting the grieving process of parents who have lost a fetus or infant, by examining the perspectives of bereaved parents, professional photographers, and health care professionals. Twenty semistructured interviews were conducted, and interview transcripts were analyzed using modified grounded theory. Twenty-three individuals participated, including 6 bereaved parents, 8 photographers, and 9 health care professionals. Analyses generated 5 major themes describing ways in which the photographs were valuable to parents: validation of the experience, permission to share, creation of a permanent and tangible legacy, creation of positive memories, and moving forward after the loss. Hospitals should consider incorporation of professional bereavement photography services into palliative care and bereavement programs.