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Objectives The Utah Study of Associated Risks of Stillbirth (SOARS) collects data about stillbirths that are not included in medical records or on fetal death certificates. We describe the design, methods, and survey response rate from the first year of SOARS. Methods The Utah Department of Health identified all Utah women who experienced a stillbirth from June 1, 2018, through May 31, 2019, via fetal death certificates and invited them to participate in SOARS. The research team based the study protocol on the Pregnancy Risk Assessment Monitoring System surveillance of women with live births and modified it to be sensitive to women’s recent experience of a stillbirth. We used fetal death certificates to examine survey response rates overall and by maternal characteristics, gestational age of the fetus, and month in which the loss occurred. Results: Of 288 women invited to participate in the study, 167 (58.0%) completed the survey; 149 (89.2%) responded by mail and 18 (10.8%) by telephone. A higher proportion of women who were non-Hispanic White (vs other races/ethnicities), were married (vs unmarried), and had ≥high school education (vs Conclusions: The response rate suggests that a mail- and telephone-based survey can be successful in collecting self-reported information about risk factors for stillbirths not currently included in medical records or fetal death certificates.

In this study, hospital discharge data from the 2016–2017 Healthcare Cost and Utilization Project were analyzed to describe national and, where data were available, state-specific prevalences of chronic hypertension and pregnancy-associated hypertension at delivery hospitalization. In 2016–2017, the prevalence of chronic hypertension was 216 per 10,000 delivery hospitalizations nationwide, ranging from 125 to 400 per 10,000 delivery hospitalizations in individual states. The prevalence of pregnancy-associated hypertension was 1021 per 10,000 delivery hospitalizations nationwide, ranging from 693 to 1382 per 10,000 delivery hospitalizations in individual states. The burden of hypertensive disorders in pregnancy remains high and varies considerably by jurisdiction.

BACKGROUND Observational studies have improved our understanding of the risk factors for sudden infant death syndrome, but separate examination of risk for sleep-related suffocation and unexplained infant deaths has been limited. We examined the association between unsafe infant sleep practices and sudden infant deaths (sleep-related suffocation and unexplained causes including sudden infant death syndrome). METHODS We conducted a population-based case-control study using 2016 to 2017 Centers for Disease Control and Prevention data. Controls were liveborn infants from the Pregnancy Risk Assessment Monitoring System; cases were from the Sudden Unexpected Infant Death Case Registry. We calculated risk factor prevalence among cases and controls and crude and adjusted odds ratios. RESULTS We included 112 sleep-related suffocation cases with 448 age-matched controls and 300 unexplained infant death cases with 1200 age-matched controls. Adjusted odds for sleep-related suffocation ranged from 18.7 (95% confidence interval [CI]: 6.8–51.3) among infants not sharing a room with their mother or caregiver to 1.9 (95% CI: 0.9–4.1) among infants with nonsupine sleep positioning. Adjusted odds for unexplained death ranged from 7.6 (95% CI: 4.7–12.2) among infants not sharing a room with their mother or caregiver to 1.6 (95% CI: 1.1–2.4) among nonsupine positioned infants. COCLUSIONS We confirmed previously identified risk factors for unexplained infant death and independently estimated risk factors for sleep-related suffocation. Significance of associations for suffocation followed similar patterns but was of larger magnitude. This information can be used to improve messaging about safe infant sleep.

OBJECTIVE: To better understand COVID-19 in newborns, we compared in-hospital illness severity indicators by COVID-19 status during birth hospitalization. STUDY DESIGN: In a retrospective cohort of newborns born March-December 2020 in the Premier Healthcare Database Special COVID-19 Release, we classified COVID-19 status and severe illness indicators using ICD-CM-10 codes, laboratory data, and billing records. Illness severity indicators were compared by COVID-19 status, stratified by gestational age and race/ethnicity. RESULT: Among 701,777 newborns, 209 had a COVID-19 diagnosis during the birth hospitalization. COVID-19 status differed significantly by race/ethnicity, gestational age, payor, and region. Late preterm/term newborns with COVID-19 had increased intensive care unit admission and sepsis risk; early preterm newborns with COVID-19 had increased risk for invasive ventilation. Risk for illness severity varied among racial/ethnic strata. CONCLUSION: From March to December 2020, COVID-19 diagnosis in newborns was rare. More clinical data are needed to describe the risk profiles of newborns with COVID-19.

BACKGROUND: During October 2016 through May 2018, a learning community was convened to focus on policies and programs to increase access to the full range of contraceptive options for women of reproductive age. The Increasing Access to Contraception (IAC) Learning Community included 27 jurisdictions, with teams from each jurisdiction consisting of state health department leaders, program staff, and provider champions. At the kick-off meeting, teams from each jurisdiction created action plans that outlined their goals. METHODS: We contacted jurisdictions during May–June 2019, 1 year after the learning community ended, and invited them to complete a post-assessment of goal achievement and sustainment through semi-structured interviews over the telephone or via email. RESULTS: Follow-up information was collected from 26 jurisdictions (96%) that participated in the learning community. The teams from these jurisdictions had created 79 total goals. At the time of the learning community closing meeting in May 2018, 35 goals (44%) had been achieved. Three jurisdictions achieved all their goals by the close of the learning community. At the time of the post-assessment 1 year later, jurisdictions were sustaining efforts for 69 (87%) of the total goals. In every jurisdiction, work on at least one goal that originated in the learning community was sustained. CONCLUSIONS: The jurisdictions that participated in the IAC Learning Community continued the work of their action plan goals 1 year after the formal closure of the learning community, indicating sustainability of the learning community activities, beyond what jurisdictions accomplished during formal participation.

Background: Cardiac arrest is a rare and sometimes fatal maternal complication. Severe hypertensive disorders of pregnancy (HDP) including preeclampsia with severe features, eclampsia, and Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome are risk factors for maternal cardiac events. Surveillance on cardiac arrest and severe HDP during delivery is critical to informing evidence-based strategies to reduce pregnancy-related death. Methods: Using pooled data from the National Inpatient Sample from 2017-2019, we identified delivery hospitalizations among women aged 12-55 years. Delivery hospitalizations, cardiac arrest, and maternal medical conditions were identified using ICD-10-CM codes. Survival to hospital discharge was based on patient discharge disposition. Prevalence of cardiac arrest, severe HDP, and survival following cardiac arrest were calculated. We estimated the prevalence of severe HDP among delivery hospitalizations with cardiac arrest, cardiac arrest frequency among delivery hospitalizations with severe HDP, and survival to hospital discharge with co-occurring cardiac arrest and severe HDP. All estimates were weighted to account for complex sampling. Results: During 2017-2019, an estimated 10,921,784 delivery hospitalizations among which 1,465 cardiac arrests were identified. Overall cardiac arrest prevalence was 13.4 per 100,000 delivery hospitalizations (95% CI, 11.9-14.9). Of these, 1,005 (68.6% [95% CI, 63.2-74.0]) survived to hospital discharge. Overall prevalence of severe HDP was 2.7% (95% CI, 2.6-2.7) compared with 15.4% (95% CI 11.2-19.5) of delivery hospitalizations with cardiac arrest. Frequency of cardiac arrest per 100,000 delivery hospitalizations with severe HDP was 76.9 (95% CI, 54.6-99.2). Survival to hospital discharge with co-occurring cardiac arrest and severe HDP was 77.8% (95% CI, 65.6-89.9). Conclusion: Delivery hospitalizations affected by cardiac arrest are rare, and over two thirds survived to hospital discharge. Cardiac arrest disproportionately affected delivery hospitalizations among patients who had severe HDP.

The Increasing Access to Contraception Learning Community was established to disseminate strategies and best practices to support 27 jurisdictions in the development of policies and programs to increase access to the full range of reversible contraceptives. We describe Learning Community activities and identify those that were most useful to participants. Although participation in Learning Community provided jurisdictional teams with structured activities such as virtual learning and peer networking opportunities, some teams struggled with full participation because of staffing turnover and shifts in priorities. (Am J Public Health. 2022;112(S5):S523–S527. https://doi.org/10.2105/AJPH.2022.306823 )

To compare two data sources from Wisconsin—Medicaid claims and Pregnancy Risk Assessment Monitoring System (PRAMS) surveys—for measuring postpartum care utilization and to better understand the incongruence between the sources. We used linked Medicaid claims and PRAMS surveys of Wisconsin residents who delivered a live birth during 2011–2015 to assess women’s postpartum care utilization. Three different definitions of postpartum care from Medicaid claims were employed to better examine bundled service codes and timing of care. We used one question from the PRAMS survey that asks women if they have had a postpartum checkup. Concordance between the two data sources was examined using Cohen’s Kappa value. For women who reported having a postpartum checkup on PRAMS but did not have a Medicaid claim for a traditional postpartum visit, we determined the other types of health care visits these women had after delivery documented in the Medicaid claims. Among the 2313 women with a Medicaid-paid delivery and who completed a PRAMS survey, 86.6% had claims for a postpartum visit during the first 12 weeks postpartum and 90.5% self-reported a postpartum checkup on PRAMS (percent agreement = 79.9%, Kappa = 0.015). The percent agreement and Kappa values varied based on the definition of postpartum care derived from the Medicaid claims data. There was slight agreement between Medicaid claims and PRAMS data. Most women had Medicaid claims for postpartum care at some point in the first 12 weeks postpartum, although the timing of these visits was somewhat unclear due to the use of bundled service codes.

To ascertain the component of the excess preterm birth (

Coronavirus disease 2019 (COVID-19) is a complex clinical illness with potential complications that might require ongoing clinical care (1-3). Few studies have investigated discharge patterns and hospital readmissions among large groups of patients after an initial COVID-19 hospitalization (4-7). Using electronic health record and administrative data from the Premier Healthcare Database,* CDC assessed patterns of hospital discharge, readmission, and demographic and clinical characteristics associated with hospital readmission after a patient's initial COVID-19 hospitalization (index hospitalization). Among 126,137 unique patients with an index COVID-19 admission during March-July 2020, 15% died during the index hospitalization. Among the 106,543 (85%) surviving patients, 9% (9,504) were readmitted to the same hospital within 2 months of discharge through August 2020. More than a single readmission occurred among 1.6% of patients discharged after the index hospitalization. Readmissions occurred more often among patients discharged to a skilled nursing facility (SNF) (15%) or those needing home health care (12%) than among patients discharged to home or self-care (7%). The odds of hospital readmission increased with age among persons aged ≥65 years, presence of certain chronic conditions, hospitalization within the 3 months preceding the index hospitalization, and if discharge from the index hospitalization was to a SNF or to home with health care assistance. These results support recent analyses that found chronic conditions to be significantly associated with hospital readmission (6,7) and could be explained by the complications of underlying conditions in the presence of COVID-19 (8), COVID-19 sequelae (3), or indirect effects of the COVID-19 pandemic (9). Understanding the frequency of, and risk factors for, readmission can inform clinical practice, discharge disposition decisions, and public health priorities such as health care planning to ensure availability of resources needed for acute and follow-up care of COVID-19 patients. With the recent increases in cases nationwide, hospital planning can account for these increasing numbers along with the potential for at least 9% of patients to be readmitted, requiring additional beds and resources.

There is literature suggesting an intergenerational relationship between maternal and infant size for gestational age status and preterm birth, but much less is known about the contribution of paternal birth outcome to infant birth outcome. This study seeks to determine the association between paternal and infant small-for-gestational-age status (weight for gestational age

To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011–2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics. Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82). Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

To determine the proportion of the excess early preterm birth (

Pregnant women are at increased risk for severe COVID-19-related illness, and COVID-19 is associated with an increased risk for adverse pregnancy outcomes and maternal and neonatal complications (1-3). To date, studies assessing whether COVID-19 during pregnancy is associated with increased risk for stillbirth have yielded mixed results (2-4). Since the B.1.617.2 (Delta) variant of SARS-CoV-2 (the virus that causes COVID-19) became the predominant circulating variant,* there have been anecdotal reports of increasing rates of stillbirths in women with COVID-19.† CDC used the Premier Healthcare Database Special COVID-19 Release (PHD-SR), a large hospital-based administrative database,§ to assess whether a maternal COVID-19 diagnosis documented at delivery hospitalization was associated with stillbirth during March 2020-September 2021 as well as before and during the period of Delta variant predominance in the United States (March 2020-June 2021 and July-September 2021, respectively). Among 1,249,634 deliveries during March 2020-September 2021, stillbirths were rare (8,154; 0.65%): 273 (1.26%) occurred among 21,653 deliveries to women with COVID-19 documented at the delivery hospitalization, and 7,881 (0.64%) occurred among 1,227,981 deliveries without COVID-19. The adjusted risk for stillbirth was higher in deliveries with COVID-19 compared with deliveries without COVID-19 during March 2020-September 2021 (adjusted relative risk [aRR] = 1.90; 95% CI = 1.69-2.15), including during the pre-Delta (aRR = 1.47; 95% CI = 1.27-1.71) and Delta periods (aRR = 4.04; 95% CI = 3.28-4.97). COVID-19 documented at delivery was associated with increased risk for stillbirth, with a stronger association during the period of Delta variant predominance. Implementing evidence-based COVID-19 prevention strategies, including vaccination before or during pregnancy, is critical to reducing the impact of COVID-19 on stillbirths.

To examine the number of states with neonatal and maternal transport and reimbursement policies in 2019, compared with 2014.We conducted a systematic review of web-based, publicly available information on neonatal and maternal transport policies for each state in 2019. Information was abstracted from rules, codes, licensure regulations, and planning and program documents, then summarized within two categories: transport and reimbursement policies.In 2019, 42 states had a policy for neonatal transport and 37 states had a policy for maternal transport, increasing by 8 and 7 states respectively. Further, 31 states had a reimbursement policy for neonatal transport and 11 states for maternal transport, increases of 1 state per category. Overall, the number of states with policies increased from 2014 to 2019.The number of state neonatal and maternal transport policies increased; these policies may support provision of care at the most risk-appropriate facilities.

OBJECTIVE: To assess consistency of state neonatal risk-appropriate care policies with the 2012 AAP policy seven years post-publication. STUDY DESIGN: Systematic, web-based review of all publicly available 2019 state neonatal levels of care policies. Information on infant risk (gestational age, birth weight), technology and equipment capabilities, and availability of specialty staffing used to define neonatal levels of care was extracted for review. RESULT: Half of states (50%) had a neonatal risk-appropriate care policy. Of those states, 88% had language consistent with AAP-defined Level I criteria, 80% with Level II, 56% with Level III, and 55% with Level IV. Comparing policies (2014–2019), consistency increased in state policies among all levels of care with the greatest increase among level IV criteria. CONCLUSION: States improved consistency of policy language by each level of care, though half of states still lack policy to provide minimum standards of care to the most vulnerable infants.

Importance Information on underlying conditions and severe COVID-19 illness among children is limited. Objective To examine the risk of severe COVID-19 illness among children associated with underlying medical conditions and medical complexity. Design, setting, and participants This cross-sectional study included patients aged 18 years and younger with International Statistical Classification of Diseases, Tenth Revision, Clinical Modification code U07.1 (COVID-19) or B97.29 (other coronavirus) during an emergency department or inpatient encounter from March 2020 through January 2021. Data were collected from the Premier Healthcare Database Special COVID-19 Release, which included data from more than 800 US hospitals. Multivariable generalized linear models, controlling for patient and hospital characteristics, were used to estimate adjusted risk of severe COVID-19 illness associated with underlying medical conditions and medical complexity. Exposures Underlying medical conditions and medical complexity (ie, presence of complex or noncomplex chronic disease). Main outcomes and measures Hospitalization and severe illness when hospitalized (ie, combined outcome of intensive care unit admission, invasive mechanical ventilation, or death). Results Among 43 465 patients with COVID-19 aged 18 years or younger, the median (interquartile range) age was 12 (4-16) years, 22 943 (52.8%) were female patients, and 12 491 (28.7%) had underlying medical conditions. The most common diagnosed conditions were asthma (4416 [10.2%]), neurodevelopmental disorders (1690 [3.9%]), anxiety and fear-related disorders (1374 [3.2%]), depressive disorders (1209 [2.8%]), and obesity (1071 [2.5%]). The strongest risk factors for hospitalization were type 1 diabetes (adjusted risk ratio [aRR], 4.60; 95% CI, 3.91-5.42) and obesity (aRR, 3.07; 95% CI, 2.66-3.54), and the strongest risk factors for severe COVID-19 illness were type 1 diabetes (aRR, 2.38; 95% CI, 2.06-2.76) and cardiac and circulatory congenital anomalies (aRR, 1.72; 95% CI, 1.48-1.99). Prematurity was a risk factor for severe COVID-19 illness among children younger than 2 years (aRR, 1.83; 95% CI, 1.47-2.29). Chronic and complex chronic disease were risk factors for hospitalization, with aRRs of 2.91 (95% CI, 2.63-3.23) and 7.86 (95% CI, 6.91-8.95), respectively, as well as for severe COVID-19 illness, with aRRs of 1.95 (95% CI, 1.69-2.26) and 2.86 (95% CI, 2.47-3.32), respectively. Conclusions and relevance This cross-sectional study found a higher risk of severe COVID-19 illness among children with medical complexity and certain underlying conditions, such as type 1 diabetes, cardiac and circulatory congenital anomalies, and obesity. Health care practitioners could consider the potential need for close observation and cautious clinical management of children with these conditions and COVID-19.

Electronic cigarettes (e-cigarettes), also called vapes, e-hookas, vape pens, tank systems, mods, and electronic nicotine delivery systems (ENDS), are electronic devices that produce an aerosol by heating a liquid typically containing nicotine, flavorings, and other additives; users inhale this aerosol into their lungs (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis (1). Use of e-cigarettes is commonly called vaping. Lung injury associated with e-cigarette use, or vaping, has recently been reported in most states (2-4). CDC, the Food and Drug Administration (FDA), state and local health departments, and others are investigating this outbreak. This report provides data on patterns of the outbreak and characteristics of patients, including sex, age, and selected substances used in e-cigarette, or vaping, products reported to CDC as part of this ongoing multistate investigation. As of September 24, 2019, 46 state health departments and one territorial health department had reported 805 patients with cases of lung injury associated with use of e-cigarette, or vaping, products to CDC. Sixty-nine percent of patients were males, and the median age was 23 years (range = 13-72 years). To date, 12 deaths have been confirmed in 10 states. Among 514 patients with information on substances used in e-cigarettes, or vaping products, in the 30 days preceding symptom onset, 76.9% reported using THC-containing products, and 56.8% reported using nicotine-containing products; 36.0% reported exclusive use of THC-containing products, and 16.0% reported exclusive use of nicotine-containing products. The specific chemical exposure(s) causing the outbreak is currently unknown. While this investigation is ongoing, CDC recommends that persons consider refraining from using e-cigarette, or vaping, products, particularly those containing THC. CDC will continue to work in collaboration with FDA and state and local partners to investigate cases and advise and alert the public on the investigation as additional information becomes available.

In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation.Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified.The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities.Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.

Background The high volume of US-Mexico land border crossings can facilitate international dissemination of influenza viruses. Methods We surveyed adult pedestrians crossing into the United States at two international land ports of entry to assess vaccination coverage during the 2009H1N1 influenza pandemic and 2011–2012 influenza season. Results Of 559 participants in 2010, 23.4% reported receipt of the 2009H1N1 vaccine. Of 1423 participants in 2012, 33.7% received the 2011–2012 influenza vaccine. Both years, those crossing the border ≥8 times per month had lower vaccination coverage than those crossing less frequently. US-border residents had lower H1N1 coverage than those in other locations. Vaccination coverage was higher for persons age ≥65 years and, in 2010 only, those with less than high school education. Although most participants believed it is important to get vaccinated, only half believed the influenza vaccine was safe and effective. The main reasons for not receiving the influenza vaccine were beliefs of low risk of disease, time constraints, and concerns about vaccine safety (in 2010) or efficacy (in 2012). Conclusions International land border crossers are a large and unique category of travelers that require targeted binational strategies for influenza vaccination and education.

Background Evidence on risk for adverse outcomes from coronavirus disease 2019 (COVID-19) among pregnant women is still emerging. We examined the association between COVID-19 at delivery and adverse pregnancy outcomes, maternal complications, and severe illness, and whether these associations differ by race/ethnicity, and describe discharge status by COVID-19 diagnosis and maternal complications. Methods Data from 703 hospitals in the Premier Healthcare Database during March–September 2020 were included. Adjusted risk ratios (aRRs) overall and stratified by race/ethnicity were estimated using Poisson regression with robust standard errors. Proportion not discharged home was calculated by maternal complications, stratified by COVID-19 diagnosis. Results Among 489 471 delivery hospitalizations, 6550 (1.3%) had a COVID-19 diagnosis. In adjusted models, COVID-19 was associated with increased risk for acute respiratory distress syndrome (aRR, 34.4), death (aRR, 17.0), sepsis (aRR, 13.6), mechanical ventilation (aRR, 12.7), shock (aRR, 5.1), intensive care unit admission (aRR, 3.6), acute renal failure (aRR, 3.5), thromboembolic disease (aRR, 2.7), adverse cardiac event/outcome (aRR, 2.2), and preterm labor with preterm delivery (aRR, 1.2). Risk for any maternal complications or for any severe illness did not significantly differ by race/ethnicity. Discharge status did not differ by COVID-19; however, among women with concurrent maternal complications, a greater proportion of those with (vs without) COVID-19 were not discharged home. Conclusions These findings emphasize the importance of implementing recommended prevention strategies to reduce risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and further inform counseling and clinical care for pregnant women during the COVID-19 pandemic.

Objective To assess how often maternal transport preceded pregnancy-related deaths and describe contributing factors and recommendations related to maternal transport. Study design We used Ohio maternal mortality review committee (MMRC) data from 2010 to 2016. We defined two transport types among pregnancy-related deaths: field to hospital and hospital to hospital. We examined deaths determined by the MMRC to be potentially preventable by transfer to a higher level of care and described contributing factors and recommendations. Result Among 136 pregnancy-related deaths, 56 (41.2%) were transported. Among 15 deaths identified as potentially preventable by transfer to a higher level of care, 5 were transported between hospitals. Contributing factors for 14 deaths included inadequate response by Emergency Medical Services and lack of transport to a higher level of care. Conclusion Our results suggest opportunities for examining modification and adherence to existing protocols. Improving risk-appropriate maternal care systems is important for preventing pregnancy-related deaths.

Our objective was to assess differences in pregnancy outcomes during the COVID-19 pandemic compared to the previous year.In a cross-sectional study of delivery hospitalizations in the Premier Healthcare Database Special COVID-19 Release, we assessed differences in selected maternal and pregnancy outcomes occurring April-December in 2019 and 2020 in the United States.Among 663,620 deliveries occurring in 2019 and 614,093 deliveries occurring in 2020, we observed an increase in in-hospital maternal death from 2019 to 2020, which was no longer statistically significant after excluding deliveries with a COVID-19 diagnosis. Intensive care unit admission and preterm birth decreased from 2019 to 2020. There was no difference in the prevalence of most other outcomes examined.The full impact of the COVID-19 pandemic on maternal and pregnancy outcomes remains to be understood. Most outcomes investigated experienced minimal change from 2019 to 2020.

To assess how often maternal transport preceded pregnancy-related deaths and describe contributing factors and recommendations related to maternal transport.We used Ohio maternal mortality review committee (MMRC) data from 2010 to 2016. We defined two transport types among pregnancy-related deaths: field to hospital and hospital to hospital. We examined deaths determined by the MMRC to be potentially preventable by transfer to a higher level of care and described contributing factors and recommendations.Among 136 pregnancy-related deaths, 56 (41.2%) were transported. Among 15 deaths identified as potentially preventable by transfer to a higher level of care, 5 were transported between hospitals. Contributing factors for 14 deaths included inadequate response by Emergency Medical Services and lack of transport to a higher level of care.Our results suggest opportunities for examining modification and adherence to existing protocols. Improving risk-appropriate maternal care systems is important for preventing pregnancy-related deaths.

To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid METHODS: This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011-2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics.Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82).Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

Few studies have examined contributions of paternal factors to birth outcomes. Weathering is a pattern of increasing rates of adverse birth outcome with increasing maternal age. This study evaluates for an association between paternal involvement and weathering in the context of preterm birth (PTB,37 weeks) among non-Hispanic African-American and non-Hispanic White women with and without lifelong exposure to neighborhood poverty. Using the Illinois transgenerational dataset with appended US census income information of infants (1989-1991) and their mothers (1956-1976), we compared infants of women by degree of paternal involvement: married, unmarried with father named on birth certificate, and unnamed father. Data were stratified by maternal residence in higher or lower income neighborhoods at both the time of mothers' birth and infants' birth, estimating maternal lifelong economic context. We computed race-specific PTB rates according to maternal age, lifelong neighborhood income, and paternal involvement. We calculated Mantel-Haenszel chi-square tests of linear trend from contingency tables to evaluate weathering. Among African-Americans (n = 39,991) with unnamed fathers and lifelong residence in lower income neighborhoods, PTB rate was lowest among teens at 18.8%, compared to 21.5% for 30-35 year-old mothers (p for linear trend0.05). Among African-Americans with unnamed fathers and lifelong residence in higher income neighborhoods, PTB rate among teens was 16%, compared to 25% for 30-35 year-old mothers (p = 0.21). Among married African-Americans with lifelong residence in lower income neighborhoods, PTB rate among teens was 16.4%, compared to 12.5% for 30-35 year-old mothers (p = 0.79). Among married African-Americans with lifelong residence in higher income neighborhoods, PTB rate among teens was 20%, compared to 11.4% for 30-35 year-old mothers (p = 0.40). White mothers (n = 31,981) did not demonstrate weathering, regardless of paternal involvement and neighborhood poverty. We conclude that weathering was not seen among married African-Americans, independent of neighborhood income, suggesting a potentially protective mechanism associated with paternal involvement.

Objectives: Despite knowledge that the Hispanic population is growing in the United States and that birth outcomes may vary by maternal country of birth, data on birth outcomes by maternal country of birth among Hispanic women are scant. We compared the rates of 3 birth outcomes for infants born in the United States—preterm birth, low birth weight, and small for gestational age—between foreign-born Hispanic women and US-born Hispanic women, and then we examined these birth outcomes by mother’s country of birth for foreign-born Hispanic women. Methods: Using the 2013 natality file from the National Vital Statistics System of the National Center for Health Statistics, we examined data on the 3 birth outcomes and maternal characteristics by maternal country of birth. We used log binomial models to calculate unadjusted and adjusted relative risks for preterm birth, low birth weight, and small for gestational age for US-born Hispanic women compared with foreign-born Hispanic women. We also compared the relative risk of each adverse birth outcome for foreign-born Hispanic women by country of birth. Results: US-born Hispanic women had higher rates of the 3 birth outcomes than did foreign-born Hispanic women (preterm birth: 8.0% vs 7.0%; low birth weight: 6.1% vs 5.2%; small for gestational age: 9.2% vs 7.9%). These higher rates persisted after adjusting for maternal characteristics. The rates for these 3 birth outcomes varied significantly by country of birth for foreign-born Hispanic women, with Puerto Rican women consistently having the poorest birth outcomes. Conclusions: Our results demonstrated heterogeneity in rates of adverse birth outcomes by country of birth for foreign-born Hispanic women. Presenting rates for foreign-born mothers as a group masks differences by country. To understand possible changes in data on birth outcomes, states should stratify data by maternal country of birth.

Objectives: Implementation science provides useful tools for guiding and evaluating the integration of evidence-based interventions with standard practice. The objective of our study was to demonstrate the usefulness of applying an implementation science framework—the Consolidated Framework for Implementation Research (CFIR)—to increase understanding of implementation of complex statewide public health initiatives, using the example of Medicaid immediate postpartum long-acting reversible contraception (LARC) policies. Methods: We conducted semistructured telephone interviews with the 13 state teams participating in the Immediate Postpartum LARC Learning Community. We asked teams to describe the implementation facilitators, barriers, and strategies in 8 focus areas of the Learning Community. We audio-recorded and transcribed interviews and then coded each interview according to the domains and constructs (ie, theoretical concepts) of the CFIR. Results: Cosmopolitanism (ie, networking with external organizations) was the most frequently coded construct of the framework. A related construct was networks and communications (ie, the nature and quality of social networks and formal and informal communications in an organization). Within the construct of cost, state teams identified barriers that were often unable to be overcome. Trialability (ie, ability to test the intervention on a small scale) and engaging champions (ie, attracting and involving persons who dedicate themselves to supporting the intervention in an organization) were among the most salient constructs of the framework and were the sources of many implementation strategies. Conclusions: State leaders and program staff members may benefit from considering the CFIR domains and constructs in the planning, implementation, and evaluation of complex statewide public health initiatives.

Objective: To ascertain the association between father’s lifetime socioeconomic status (SES) and rates of small for gestational age (SGA, defined as weight for gestational age

Background Several state Medicaid agencies have recently started reimbursing for long-acting reversible contraception (LARC) placement immediately postpartum. Women’s perspectives are critical for ensuring that this change increases access to LARC while empowering women to choose the method and timing of contraception that best meets their needs. We conducted a pilot study in Georgia, which recently changed its Medicaid reimbursement policy, to assess women’s informed choice and satisfaction with immediate postpartum LARC. Methods We sampled all women with a live birth paid for by Georgia Medicaid during November 2015 through February 2017 who received an immediate postpartum LARC. We then used a one-to-one match to sample women who did not receive immediate postpartum LARC. Women were contacted via telephone for a 25–30 min interview regarding their knowledge, attitudes, and behaviors related to immediate postpartum LARC and their satisfaction with postpartum contraception. We calculated descriptive statistics and components of informed choice overall and by receipt of immediate postpartum LARC, using chi-square tests to calculate differences by group. Results We approached 470 women and completed interviews with 51; 25 (49%) received immediate postpartum LARC (24 implants, 1 intrauterine device). Two-thirds reported their provider discussed the option of receiving immediate postpartum LARC during prenatal care, with over 90% reporting they received all the information they needed to make a decision. Most women believed the ideal time to begin using birth control postpartum is in the hospital immediately after delivery, although this differed significantly by women’s receipt of immediate postpartum LARC. Most women who received immediate postpartum LARC reported they are very or extremely happy with their device, although 40% also reported wanting their device removed at some point. Conclusions Women on Medicaid in Georgia report making informed choices regarding immediate postpartum LARC. Among those who received immediate postpartum LARC, women report high levels of satisfaction.

We evaluated the use of federal public health intervention tools known as the Do Not Board and Border Lookout (BL) for detecting and referring infectious or potentially infectious land border travelers with tuberculosis (TB) back to treatment. We used data about the issuance of BL from April 2007 to September 2013 to examine demographics and TB laboratory results for persons on the list (N = 66) and time on the list before being located and achieving noninfectious status. The majority of case-patients were Hispanic and male, with a median age of 39 years. Most were citizens of the United States or Mexico, and 30.3% were undocumented migrants. One-fifth had multidrug-resistant TB. Nearly two-thirds of case-patients were located and treated as a result of being placed on the list. However, 25.8% of case-patients, primarily undocumented migrants, remain lost to follow-up and remain on the list. For this highly mobile patient population, the use of this novel federal travel intervention tool facilitated the detection and treatment of infectious TB cases that were lost to follow-up.

Background Implementation strategies are imperative for the successful adoption and sustainability of complex evidence-based public health practices. Creating a learning collaborative is one strategy that was part of a recently published compilation of implementation strategy terms and definitions. In partnership with the Centers for Disease Control and Prevention and other partner agencies, the Association of State and Territorial Health Officials recently convened a multi-state Learning Community to support cross-state collaboration and provide technical assistance for improving state capacity to increase access to long-acting reversible contraception (LARC) in the immediate postpartum period, an evidence-based practice with the potential for reducing unintended pregnancy and improving maternal and child health outcomes. During 2015–2016, the Learning Community included multi-disciplinary, multi-agency teams of state health officials, payers, clinicians, and health department staff from 13 states. This qualitative study was conducted to better understand the successes, challenges, and strategies that the 13 US states in the Learning Community used for increasing access to immediate postpartum LARC. Methods We conducted telephone interviews with each team in the Learning Community. Interviews were semi-structured and organized by the eight domains of the Learning Community. We coded transcribed interviews for facilitators, barriers, and implementation strategies, using a recent compilation of expert-defined implementation strategies as a foundation for coding the latter. Results Data analysis showed three ways that the activities of the Learning Community helped in policy implementation work: structure and accountability, validity, and preparing for potential challenges and opportunities. Further, the qualitative data demonstrated that the Learning Community integrated six other implementation strategies from the literature: organize clinician implementation team meetings, conduct educational meetings, facilitation, promote network weaving, provide ongoing consultation, and distribute educational materials. Conclusions Convening a multi-state learning collaborative is a promising approach for facilitating the implementation of new reimbursement policies for evidence-based practices complicated by systems challenges. By integrating several implementation strategies, the Learning Community serves as a meta-strategy for supporting implementation.

Purpose To determine components of excess preterm birth (PTB) rates for U.S.-born black women relative to both foreign-born black women and U.S.-born white women attributable to differences in observed sociodemographic, behavioral, and medical risk factors. Methods Using the 2013 U.S. natality files, we used Oaxaca-Blinder decomposition on the absolute scale to estimate the contribution of the group differences in the prevalence of PTB predictors between U.S.- and foreign-born black women and U.S.-born black and U.S.-born white women. Results U.S.-born blacks had a 3.2 (95% confidence interval: 3.0–3.5) and 4.4 (95% confidence interval: 4.3–4.5) percentage point higher risk of PTB than foreign-born blacks and U.S.-born whites, respectively. The variables in the models explained between 18% and 27% of the PTB disparities. Differences in paternal acknowledgment (about 12%), maternal hypertension (about 7%–11%), and maternal education (about 6%–10%) explained the largest proportion of these disparities. Conclusions Programs and policies that address both distal and proximate factors, including the social determinants of health and the prevention and management of hypertension, may reduce the higher rates of PTB among U.S.-born black women compared to foreign-born black women and U.S.-born white women.

We aimed to qualitatively examine differences in perceptions of addiction, attempts to quit, and successful quitting among nondaily versus daily college student smokers. We conducted 16 focus groups with a total of 73 college student smokers from the southeastern U.S. Focus groups were homogenous in terms of gender, smoking status (nondaily, daily), and type of school (2-year college, 4-year university). Questions centered on perceptions of addiction, their own addiction, what constitutes a quit attempt, and successful quitting. Themes that emerged among all smokers regarding conceptualization of general addiction included physiological and psychological dependence and an inability to quit smoking. In terms of their own addiction, nondaily smokers referenced their ability to quit and sense of choice to smoke as factors indicating a lack of addiction, whereas daily smokers reported dependence symptoms and their inability to control their smoking indicating addiction. Nondaily smokers discussed quit attempts in terms of making the decision to quit and avoiding situational triggers, whereas daily smokers reported taking more behavioral steps toward cessation (e.g., not buying cigarettes, reducing cigarette consumption). With regard to successful cessation, both groups identified losing the desire to smoke as a hallmark. However, nondaily smokers reported that the decision to quit might constitute successful cessation; daily smokers had more strict behavioral criteria such as abstinence for an extended period of time. The different perceptions of one's own addiction, attempting to quit smoking, and successful quitting suggest the need to improve assessments of these factors, particularly among nondaily smokers.

We explored how low-risk, nulliparous pregnant women and their doctors in two contiguous U.S.–Mexico border communities communicate about methods of delivery and how they perceive that the delivery method decision is made. We recruited 18 women through obstetricians in El Paso, Texas (n = 10), and prenatal care providers in Ciudad Juarez, Mexico (n = 8). We observed prenatal care visits, interviewed women prenatally and postpartum, and interviewed the El Paso obstetricians. Qualitative analysis demonstrated that birthing decisions are complex and involve multiple influences, including women's level of knowledge about birth, doctor–patient communication, and women's participation in decision making.

Introduction The true prevalence of gestational diabetes mellitus (GDM) is unknown. The objective of this study was 1) to provide the most current GDM prevalence reported on the birth certificate and the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire and 2) to compare GDM prevalence from PRAMS across 2007-2008 and 2009-2010. Methods We examined 2010 GDM prevalence reported on birth certificate or PRAMS questionnaire and concordance between the sources. We included 16 states that adopted the 2003 revised birth certificate. We also examined trends from 2007 through 2010 and included 21 states that participated in PRAMS for all 4 years. We combined GDM prevalence across 2-year intervals and conducted t tests to examine differences. Data were weighted to represent all women delivering live births in each state. Results GDM prevalence in 2010 was 4.6% as reported on the birth certificate, 8.7% as reported on the PRAMS questionnaire, and 9.2% as reported on either the birth certificate or questionnaire. The agreement between sources was 94.1% (percent positive agreement = 3.7%, percent negative agreement = 90.4%). There was no significant difference in GDM prevalence between 2007-2008 (8.1%) and 2009-2010 (8.5%, P = .15). Conclusion Our results indicate that GDM prevalence is as high as 9.2% and is more likely to be reported on the PRAMS questionnaire than the birth certificate. We found no statistical difference in GDM prevalence between the 2 phases. Further studies are needed to understand discrepancies in reporting GDM by data source.

Purpose Providing long-acting reversible contraception (LARC) in the immediate postpartum period is an evidence-based strategy for expanding women’s access to highly effective contraception and for reducing unintended and rapid repeat pregnancy. The purpose of this article is to demonstrate the application of implementation science methodology to study the complexities of rolling-out policies that promote immediate postpartum LARC use across states. Description The Immediate Postpartum LARC Learning Community, sponsored by the Association of State and Territorial Health Officials (ASTHO), is made up of multi-disciplinary, multi-agency teams from 13 early-adopting states with Medicaid reimbursement policies promoting immediate postpartum LARC. Partners include federal agencies and maternal and child health organizations. The Learning Community discussed barriers, opportunities, strategies, and promising practices at an in-person meeting. Implementation science theory and methods, including the Consolidated Framework for Implementation Research (CFIR), and a recent compilation of implementation strategies, provide useful tools for studying the complexities of implementing immediate postpartum LARC policies in birthing facilities across early adopting states. Assessment To demonstrate the utility of this framework for guiding the expansion of immediate postpartum LARC policies, illustrative examples of barriers and strategies discussed during the in-person ASTHO Learning Community meeting are organized by the five CFIR domains—intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and process. Conclusion States considering adopting policies can learn from ASTHO’s Immediate Postpartum LARC Learning Community. Applying implementation science principles may lead to more effective statewide scale-up of immediate postpartum LARC and other evidence-based strategies to improve women and children’s health.