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Context: Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth.Objective: To evaluate dissemination strategies aimed at increasing appropriate use of this therapy.Design and Setting: Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13).Subjects: Obstetricians and their preterm delivery cases at participating hospitals.Intervention: Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback.Main Outcome Measure: Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122).Results: Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways.Conclusion: An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices. [ABSTRACT FROM AUTHOR]

Objective: This study's objective was to determine whether the concentrations of beta-human chorionic gonadotropin in the secretions of the cervix and vagina could be used to predict preterm delivery in a group of women at high risk for this complication.Study Design: Women attending a prematurity prevention clinic at an inner-city hospital July 1, 1996-October 1, 1997, were invited to participate. From those who consented, secretions from the cervix and posterior vaginal fornix were sampled every 2 weeks until delivery, beginning at 24 weeks' gestation. Concentrations of beta-human chorionic gonadotropin were measured with a commercially available enzyme-linked immunosorbent assay. Providers of obstetric care were blinded to the results. Levels of beta-human chorionic gonadotropin in those who were delivered before 34 weeks' gestation and those who were delivered at term were compared. A value >50 mIU/mL was considered elevated. This cutoff value was determined according to beta-human chorionic gonadotropin values obtained during pregnancies that were delivered at term.Results: Of the 146 women asked to participate, 77 consented. There was no difference between participants and nonparticipants with respect to age, race, indication for enrollment in the clinic, gestational age at delivery, or parity. Of the 77 participants, 24 (31%) were delivered before 37 weeks' gestation and 12 (16%) were delivered before 34 weeks' gestation. A single beta-human chorionic gonadotropin value >50 mIU/mL obtained between 24 and 28 weeks' gestation was associated with a significant increase in the incidence of delivery before 34 weeks' gestation (P = .03). This cutoff value had sensitivity, specificity, and positive and negative predictive values for predicting delivery before 34 weeks' gestation of 50%, 87%, 33%, and 93%, respectively.Conclusion: These data suggest that the concentration of beta-human chorionic gonadotropin in cervicovaginal secretions may be a useful predictor of preterm delivery. [ABSTRACT FROM AUTHOR]

Based on years of review and analysis of severe maternal morbidity and maternal mortality cases, it is clear that the high rates of maternal mortality in this country are due to more than obstetrical emergencies gone awry. Many nonmedical factors contribute to these poor outcomes including complex and ineffectual health care systems, poor coordination of care, and structural racism. In this article we discuss what physicians can and cannot accomplish on their own, the role of race and racism, and barriers built into the manner in which health care is delivered. We conclude that while obstetricians must continue to focus on the area where their expertise lies, reducing deaths by educating and training physicians to deal with the downstream consequences of upstream events, they must also focus increased attention on educating themselves and their trainees about the effect of racism, social disadvantage, and poor coordination of care on health, as well as their role in resolving these issues. Physicians must also reach out to their representatives in government to partner with them. Those leaders must recognize that when they hear about disparities in maternal mortality, focusing only on events in hospitals ignores the more dispositive issues that put Black women at risk in the first instance. KEY POINTS: · Structural racism contributes to maternal deaths.. · Coordination of postpartum care is critically important.. · U.S. health care system is complex and not patient friendly.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: This study aimed to develop and evaluate a structured peer support program to address the needs of providers involved in obstetric adverse outcomes., Methods: In this pilot randomized controlled trial, participants were providers who experienced an obstetric-related adverse outcome. Providers were randomly assigned to routine support (no further follow-up) or enhanced support (follow-up with a trained peer supporter). Participants completed surveys at baseline, 3 months, and 6 months. The primary outcome was the use of resources and the perception of their helpfulness. Secondary outcomes were the effect on the recovery stages and the duration of use of peer support., Results: Fifty participants were enrolled and randomly assigned 1:1 to each group; 42 completed the program (enhanced, 23; routine, 19). The 2 groups were not significantly different with respect to event type, demographics, or baseline stage; in both groups, most participants started at the stage 6 thriving path. Most participants required less than 3 months of support: 65.2% did not need follow-up after the first contact, and 91.3% did not need follow-up after the second contact. Participants who transitioned from an early stage of recovery (stages 1-3) to the stage 6 thriving path reported that they most often sought support from peers (P = 0.02) and departmental leadership (P = 0.07). Those in the enhanced support group were significantly more likely to consider departmental leadership as one of the most helpful resources (P = 0.02)., Conclusions: For supporting health care providers involved in adverse outcomes, structured peer support is a practicable intervention that can be initiated with limited resources., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: We compared the association between cord arterial catecholamine levels and fetal oxygenation in newborns of mothers with diabetes mellitus to those of nondiabetic pregnancies., Methods: Cord blood obtained at delivery in 25 term appropriate-for-gestational age newborns of women with diabetes and 27 nondiabetic controls were assayed for norepinephrine, epinephrine, insulin, glucose, and blood gases., Results: There was no statistical difference in parity, birth weight, gestational age, delivery mode, use of epidural analgesia, or frequency of low 1-min Apgar scores between the groups. The pO 2 and frequency of cord arterial pH < 7.20 were also similar. Diabetic pregnancies had somewhat higher fetal glucose and substantially higher insulin levels than controls. Regression analysis using cord arterial pH to reflect oxygenation revealed significant inverse relationships between cord artery pH and ln norepinephrine (Prob > F  = .001) and ln epinephrine (Prob > F  = .019) in controls. In newborns of women with diabetes, however, neither relationship was significant., Conclusion: The expected surge in catecholamines associated with diminished oxygenation was attenuated in fetuses of diabetic mothers. This suggests the possibility that fetal exposure to hyperglycemia or other metabolic derangements in pregnant diabetics might compromise the fetal ability to adapt to changes in oxygenation, and might thereby contribute to the risk of fetal death.

Objectives: To examine population-level associations between paternal jail incarceration during pregnancy and infant birth outcomes using objective measures of health and incarceration., Methods: We use multivariate logistic regression models and linked records on all births and jail incarcerations in New York City between 2010 and 2016., Results: 0.8% of live births were exposed to paternal incarceration during pregnancy or at the time of birth. After accounting for parental sociodemographic characteristics, maternal health behaviors, and maternal health care access, paternal incarceration during pregnancy remains associated with late preterm birth (OR = 1.34, 95% CI = 1.21, 1.48), low birthweight (OR = 1.39, 95% CI = 1.27, 1.53), small size for gestational age (OR = 1.35, 95% CI = 1.17, 1.57), and NICU admission (OR = 1.14, 95% CI = 1.05, 1.24)., Conclusions: We found strong positive baseline associations (p < 0.001) between paternal jail incarceration during pregnancy with probabilities of all adverse outcomes examined. These associations did not appear to be driven purely by duration or frequency of paternal incarceration. These associations were partially explained by parental characteristics, maternal health behavior, and health care. These results indicate the need to consider paternal incarceration as a potential stressor and source of trauma for pregnant women and infants., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Supporting women, families, and clinicians with information, emotional support, and health care resources should be part of an institutional response after a severe maternal event. A multidisciplinary approach is needed for an effective response during and after the event. As a member of the maternity care team, the nurse's role includes coordination, documentation, and ensuring patient safety in emergency situations. The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women's Health Care, has developed interprofessional work groups to develop safety bundles on diverse topics. This article provides the rationale and supporting evidence for the support after a severe maternal event bundle, which includes structure- and evidence-based resources for women, families, and maternity care providers. The bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning, and it may be adapted by nurses and multidisciplinary leaders in birthing facilities for implementation as a standardized approach to providing support for everyone involved in a severe maternal event., (Copyright © 2020 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the effects of the Safe Motherhood Initiative's (SMI) obstetric hemorrhage bundle in New York State (NYS)., Study Design: In 2013, the SMI convened interprofessional workgroups on hemorrhage, venous thromboembolism, and hypertension tasked with developing evidence-based care bundles. Participating hospitals submitted data measured before, during, and after implementation of the hemorrhage bundle: maternal mortality, intensive care unit (ICU) admission, cardiovascular collapse, hysterectomy, and transfusion of ≥4 units of red blood cells (RBCs). Data were analyzed for trends stratified by implementation status., Results: Of the 123 maternity hospitals in NYS, 117 participated, of which 113 submitted data. Of 250,719 births, transfusion of ≥4 units RBCs (1.8 per 1,000) and ICU admissions (1.1 per 1,000) were the most common morbidities. Four hemorrhage-related maternal deaths (1.6 per 100,000) and 10 cases of cardiovascular collapse requiring cardiopulmonary resuscitation (4.0 per 100,000) occurred. Hemorrhage morbidity did not change over the five quarters studied. Risks were similar across hospital level of care and implementation status., Conclusion: Statewide implementation of bundles is feasible with resources critical to success. The low hemorrhage-related maternal death rate makes changes in mortality risk difficult to detect over short time intervals. Long-term and timely data collection with individual expert case review will be required., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To determine whether a state-level initiative to reduce obstetric venous thromboembolism (VTE) risk affected outcomes and process measures., Methods: In 2013, the Safe Motherhood Initiative (SMI) developed a VTE safety bundle to reduce obstetric VTE risk. A total of 117 of 124 hospitals providing obstetrical services in New York participated in SMI. Data evaluating thromboembolism events (deep vein thrombosis and pulmonary embolism) and thromboprophylaxis process measures were collected from March through November 2015., Results: A total of 107 hospitals, in any individual quarter, reported data on each of the VTE bundle outcomes and measures. Centers that provided low-risk care (Level 1 centers) reported the lowest rate of bundle implementation at the end of the study period (55.6%). Mechanical prophylaxis for a cesarean was common at all centers. Hospitals that adopted the bundle were more likely to provide routine pharmacologic prophylaxis for women undergoing cesarean. The risk of VTE did not differ by bundle implementation., Conclusion: While adoption of the SMI VTE bundle occurred at a majority of centers across New York, uptake was less likely at low-acuity centers. Bundle adoption was associated with implementation of recommended practices. The rare nature of VTE events underscores the need for large data samples to determine the best prophylaxis strategies., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Intensive care unit (ICU) outcome prediction models, such as Acute Physiology And Chronic Health Evaluation (APACHE), were designed in general critical care populations and their use in obstetric populations is contentious. The aim of the CIPHER (Collaborative Integrated Pregnancy High-dependency Estimate of Risk) study was to develop and internally validate a multivariable prognostic model calibrated specifically for pregnant or recently delivered women admitted for critical care., Methods: A retrospective observational cohort was created for this study from 13 tertiary facilities across five high-income and six low- or middle-income countries. Women admitted to an ICU for more than 24 h during pregnancy or less than 6 weeks post-partum from 2000 to 2012 were included in the cohort. A composite primary outcome was defined as maternal death or need for organ support for more than 7 days or acute life-saving intervention. Model development involved selection of candidate predictor variables based on prior evidence of effect, availability across study sites, and use of LASSO (Least Absolute Shrinkage and Selection Operator) model building after multiple imputation using chained equations to address missing data for variable selection. The final model was estimated using multivariable logistic regression. Internal validation was completed using bootstrapping to correct for optimism in model performance measures of discrimination and calibration., Results: Overall, 127 out of 769 (16.5%) women experienced an adverse outcome. Predictors included in the final CIPHER model were maternal age, surgery in the preceding 24 h, systolic blood pressure, Glasgow Coma Scale score, serum sodium, serum potassium, activated partial thromboplastin time, arterial blood gas (ABG) pH, serum creatinine, and serum bilirubin. After internal validation, the model maintained excellent discrimination (area under the curve of the receiver operating characteristic (AUROC) 0.82, 95% confidence interval (CI) 0.81 to 0.84) and good calibration (slope of 0.92, 95% CI 0.91 to 0.92 and intercept of -0.11, 95% CI -0.13 to -0.08)., Conclusions: The CIPHER model has the potential to be a pragmatic risk prediction tool. CIPHER can identify critically ill pregnant women at highest risk for adverse outcomes, inform counseling of patients about risk, and facilitate bench-marking of outcomes between centers by adjusting for baseline risk.

Objective  To describe the implementation and early results of the American College of Obstetricians and Gynecologists District II Safe Motherhood Initiative's Severe Hypertension in Pregnancy bundle on the timely treatment of severe hypertension in New York State obstetric hospitals. Methods  This is a retrospective comparative study of two time periods during voluntary implementation of the Severe Hypertension in Pregnancy bundle in New York State's obstetric hospitals. The main outcome measure was the administration of an appropriate antihypertensive agent within 1 hour of the second elevated value for all pregnant or postpartum patients with severe hypertension. Results  Of the 117 obstetric hospitals participating in the Safe Motherhood Initiative, 111 (94.9%) submitted data included in this analysis. During the study period, 80 of the 111 (72.0%) hospitals reported implementing the hypertension bundle. Overall, 2.4% of pregnant women were diagnosed with severe hypertension, and 60 to 65% of patients were treated within an hour of the second elevated value. Although not statistically significant, a greater numbers of patients were treated within an hour of the second elevated value in the second time period compared with the first in most obstetric hospitals (overall 64.8 vs. 60.8%; p  = 0.33). Conclusion  There were increasing numbers of patients receiving timely treatment of severe hypertension during early implementation of a Severe Hypertension in Pregnancy bundle in New York State obstetric hospitals. However, bundle implementation requires significant financial and human resources and the long-term impact on maternal morbidity and mortality in our state remains uncertain. Precis There was a tendency toward more timely treatment of severe hypertension following implementation of a Severe Hypertension in Pregnancy bundle in New York obstetric hospitals.

Objective: Although communication skills represent an increasingly important aspect of medical care, little has been done to assess the best method of teaching these skills. Our study was designed to assess simulation-debriefing compared to lecture in teaching skills for Breaking Bad News (BBN) in obstetrics., Methods: This is a randomized prospective trial of house staff from a large academic medical center. Subjects initially underwent baseline simulation, followed by evaluation on BBN skills by themselves, a faculty observer, and the standardized patient (SP). The subjects were then immediately randomized to a debriefing session by faculty or to a lecture about BBN. Subsequently, both groups underwent a second simulation with the same three assessments, yielding post-intervention data., Results: 35 subjects completed both simulations. Both debriefing and lecture curricula showed improvement in scores by self (p = 0.010) and faculty (p < 0.001). The debriefing group improved significantly more than the lecture group for self-evaluation; additionally, improvements were greater for the debrief group in verbal and nonverbal skills. Long-term follow-up three months after both interventions demonstrated continued improvement in BBN., Conclusions: Simulation training with debriefing is effective for teaching communication skills, and superior to lecture for self-perceived improvement. Long-term follow-up suggested retention of confidence in BBN skills.

Background The World Health Organization's Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To evaluate if an intensive educational intervention in the use of a standardized venous thromboembolism (VTE) risk assessment tool (scorecard) improves physicians' identification and chemoprophylaxis of postpartum patients at risk for VTE., Methods: After implementation of a VTE scorecard and prior to an intensive educational intervention, postpartum patients (n = 140) were evaluated to assess scorecard completion, risk factors, and chemoprophylaxis. A performance improvement campaign focusing on patient safety, VTE prevention, and scorecard utilization was then conducted. Evaluation of the same parameters was subsequently performed for a similar group of patients (n = 133). Differences in scorecard utilization and risk assessment were tested for statistical significance., Results: Population-at-risk rates were similar in both assessment periods (31.4% vs 28.6%; p = NS). The greatest risk factors included cesarean delivery, body mass index (BMI) >30 and age >35. Scorecard completion rates for all patients increased in the postintervention period (15.7% vs 67.7%; p < .001). Postintervention scorecard completion rates for the at-risk population also improved (20% vs 79%; p < .001). In the postintervention group, those at risk with completed scorecards had higher prophylaxis rates than those at risk without scorecards (73% vs 25%; p = .03). At-risk patients with completed scorecards had 2.6 times more orders for chemoprophylaxis than at-risk patients without scorecards in both time periods (odds ratio [OR] = 8.4; 95% confidence interval [CI] 3.1-22.8)., Conclusion: Utilization of a VTE scorecard coupled with an educational intervention for health care providers increases detection and chemoprophylaxis orders for at-risk patients. Encouraging universal scorecard assessment standardizes identification and chemoprophylaxis of at-risk patients who were otherwise not perceived to be at risk., (© 2016 American Society for Healthcare Risk Management of the American Hospital Association.)

New York City was ahead of its time in recognizing the issue of maternal death and the need for proper statistics. New York has also documented since the 1950s the enormous public health challenge of racial disparities in maternal mortality. This paper addresses the history of the first Safe Motherhood Initiative (SMI), a voluntary program in New York State to review reported cases of maternal deaths in hospitals. Review teams found that timely recognition and intervention in patients with serious morbidity could have prevented many of the deaths reviewed. Unfortunately the program was defunded by New York State. The paper then focuses on the revitalization of the SMI in 2013 to establish three safety bundles across the state to be used in the recognition and treatment of obstetric hemorrhage, severe hypertension in pregnancy, and the prevention of venous thromboembolism; and their introduction into 118 hospitals across the state. The paper concludes with a look to the future of the coordinated efforts needed by various organizations involved in women's healthcare in New York City and State to achieve the goal of a review of all maternal deaths in the state by a multidisciplinary team in a timely manner so that appropriate feedback to the clinical team can be given and care can be modified and improved as needed. It is the authors' opinion that we owe this type of review to the women of New York who entrust their care to us., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Postpartum hemorrhage remains the number one cause of maternal death globally despite the fact that it is largely a preventable and most often a treatable condition. While the global problem is appreciated, some may not realize that in the United States postpartum hemorrhage is a leading cause of mortality and unfortunately, the incidence is on the rise. In New York, obstetric hemorrhage is the second leading cause of maternal mortality in the state. National data suggests that hemorrhage is disproportionally overrepresented as a contributor to severe maternal morbidity and we suspect as we explore further this will be true in New York State as well. Given the persistent and significant contribution to maternal mortality, it may be useful to analyze the persistence of this largely preventable cause of death within the framework of the historic "Three Delays" model of maternal mortality. The ongoing national and statewide problem with postpartum hemorrhage will be reviewed in this context of delays in an effort to inform potential solutions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background.  We assessed healthcare workers' (HCWs) attitudes toward care of patients with Ebola virus disease (EVD). Methods.  We provided a self-administered questionnaire-based cross-sectional study of HCWs at 2 urban hospitals. Results.  Of 428 HCWs surveyed, 25.1% believed it was ethical to refuse care to patients with EVD; 25.9% were unwilling to provide care to them. In a multivariate analysis, female gender (32.9% vs 11.9%; odds ratio [OR], 3.2; 95% confidence interval [CI], 1.4-7.7), nursing profession (43.6% vs 12.8%; OR, 2.7; 95% CI, 1.4-5.2), ethical beliefs about refusing care to patients with EVD (39.1% vs 21.3%; OR, 3.71; 95% CI, 2.0-7.0), and increased concern about putting family, friends, and coworkers at risk (28.2% vs 0%; P = .003; OR, 11.1) were independent predictors of unwillingness to care for patients with EVD. Although beliefs about the ethics of refusing care were independently associated with willingness to care for patients with EVD, 21.3% of those who thought it was unethical to refuse care would be unwilling to care for patients with EVD. Healthcare workers in our study had concerns about potentially exposing their families and friends to EVD (90%), which was out of proportion to their degree of concern for personal risk (16.8%). Conclusion.  Healthcare workers' willingness to care for patients with Ebola patients did not precisely mirror their beliefs about the ethics of refusing to provide care, although they were strongly influenced by those beliefs. Healthcare workers may be balancing ethical beliefs about patient care with beliefs about risks entailed in rendering care and consequent risks to their families. Providing a safe work environment and measures to reduce risks to family, perhaps by arranging child care or providing temporary quarters, may help alleviate HCW's concerns.

The relationship between walkable access to healthy food sources and risk of anemia in pregnancy was evaluated for a cohort of 4678 women who initiated prenatal care in the year 2010 at an academic medical center in Bronx, New York. After geocoding patient residences, street network distances were obtained for the closest healthy food sources, which were identified from multiple databases. For lower-income patients, as indicated by Medicaid or lack of health insurance, those who lived less than 0.25miles from a healthy food source were less likely to be anemic when compared to those who lived farther (adjusted OR=0.65, 95% CI 0.48, 0.88). Patients with commercial insurance showed no effect. These results help to understand how a nutritionally-mediated condition such as anemia during pregnancy can be affected by one's built environment, while also highlighting the importance of conditioning on socioeconomic status for these types of studies., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To examine the effect of underlying maternal morbidities on the odds of maternal death during delivery hospitalization., Methods: We used data that linked birth certificates to hospital discharge diagnoses from singleton live births at 22 weeks of gestation or later during 1995-2003 in New York City. Maternal morbidities examined included prepregnancy weight more than 114 kilograms (250 pounds), chronic hypertension, pregestational or gestational diabetes mellitus, chronic cardiovascular disease, pulmonary hypertension, chronic lung disease, human immunodeficiency virus (HIV), and preeclampsia or eclampsia. Associations with maternal mortality were estimated using multivariate logistic regression., Results: During the specified time period, 1,084,862 live singleton births and 132 maternal deaths occurred. Patients with increasing maternal age, non-Hispanic black ethnicity, self-pay or Medicaid, primary cesarean delivery, and premature delivery had higher rates of maternal mortality during delivery hospitalization. From the entire study population, 4.1% had preeclampsia or eclampsia (n=44,004), 1.8% had chronic hypertension (n=19,647), 1.1% of patients were classified as obese (n=11,936), 0.7% had pregestational diabetes (n=7,474), 0.4% had HIV (n=4,665), and 0.01% had pulmonary hypertension (n=166). Preeclampsia or eclampsia (adjusted odds ratio [OR], 8.1; 95% confidence interval [CI], 5.5-12.1), chronic hypertension (adjusted OR, 7.7; 95% CI 4.7-12.5), underlying maternal obesity (adjusted OR, 2.9; 95% CI 1.1-8.1), pregestational diabetes (adjusted OR, 3.3; 95% CI 1.3-8.1), HIV (adjusted OR, 7.7; 95% CI 3.4-17.8), and pulmonary hypertension (adjusted OR, 65.1; 95% CI 15.8-269.3) were associated with an increased risk of death during the delivery hospitalization., Conclusion: The presence of maternal disease significantly increases the odds of maternal mortality at the time of delivery hospitalization., Level of Evidence: II.

Patient-doctor communication has become a topic of increasing importance and attention, with both personal and public health ramifications. Despite this, formal training in communication is rare in later professional life, and the best way of improving these skills is unknown. Recently, attention has turned to simulation as a way to teach communication skills to medical providers. In this article, we review the history and current evidence behind utilizing simulation for patient-doctor communication teaching, as well as the challenges for future research in this field as it progresses into mainstream practice., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: Obesity is a demonstrated barrier to obtaining health care. Its impact on obtaining prenatal care (PNC) is unknown. Our objective was to determine if obesity is an independent barrier to accessing early and adequate PNC., Study Design: We performed a retrospective cohort study of women who initiated PNC and delivered at our institution in 2005. Body mass index (BMI) was categorized by World Health Organization guidelines: underweight (<18.5 kg/m(2)), normal weight (18.5 to 24.9 kg/m(2)), overweight (25.0 to 29.9 kg/m(2)), and obese (≥30 kg/m(2)). Maternal history and delivery information were obtained through chart abstraction. Differences in gestational age at first visit (GA-1) and adequate PNC were evaluated by BMI category. Data were compared using χ(2) and nonparametric analyses., Results: Overall, 410 women were evaluated. The median GA-1 was 11.1 weeks and 69% had adequate PNC. There was no difference in GA-1 or adequate PNC by BMI category (p = 0.17 and p = 0.66, respectively). When BMI groups were dichotomized into obese and nonobese women, there was no difference in GA-1 or adequate PNC (p = 0.41)., Conclusion: In our population, obesity is not an independent barrier to receiving early and adequate PNC. Future work is warranted in evaluating the association between obesity and PNC and the perceived barriers to obtaining care., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Genital tract secretions exhibit bactericidal activity against Escherichia coli. We hypothesized that this defense may be modulated during pregnancy., Study Design: Secretions were collected by vaginal swab from 70 pregnant women (35-37 weeks' gestation) and 35 nonpregnant controls. We mixed E coli with swab eluants or control buffer and colonies enumerated to measure bactericidal activity. Cytokines, chemokines, and antimicrobial peptides were quantified by multiplex or enzyme-linked immunosorbent assay., Results: Pregnant women had significantly greater bactericidal activity, higher concentrations of proinflammatory cytokines, and lower levels of beta defensins compared to controls. Seven (10%) pregnant and 8 (23%) nonpregnant women were vaginally colonized with E coli; colonization was inversely associated with bactericidal activity., Conclusion: The soluble mucosal immune environment is altered in pregnancy. We speculate that the observed changes may protect against colonization and ascending infection and could provide a biomarker to identify pregnant women at risk for infectious complications including preterm birth., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objective: The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC., Study Design: This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program., Results: Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively., Conclusion: Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC., (Copyright 2010 Mosby, Inc. All rights reserved.)

Background: Testing for illicit drugs may expose women who test positive to severe legal and social consequences. It is unknown whether racial disparities in drug testing practices underlie observed disparities in legal and social consequences of positive tests., Methods: Using administrative hospital and birth certificate data, we analyzed factors associated with both receipt and results of illicit drug testing among women with live births during 2002-2003. We assessed the independent association of race and other sociodemographic factors with both receipt of a drug test by the mother or her newborn infant and positive maternal or neonatal toxicology results, after controlling for obstetrical conditions and birth outcomes associated with maternal substance abuse., Results: Of the 8487 women with live births, 244 mother-newborn pairs (3%) were tested for illicit drug use. Black women and their newborns were 1.5 times more likely to be tested for illicit drugs as nonblack women in multivariable analysis. However, race was not independently associated with a positive result., Conclusions: We identified racial differences in rates of testing for illicit drug use between black and nonblack women. We found equivalent positivity rates among tested black and nonblack women. The prevalence of drug use among untested women is unknown, however, so although tested women had equivalent rates of substance use detected, whether black and nonblack substance users are equally likely to be identified in the course of peripartum care remains uncertain.

Objective: The purpose of this study was to determine whether amniotic fluid levels of annexin A5 (AF-AnxA5) may be associated with intrauterine growth restriction (IUGR)., Study Design: Amniotic fluid was obtained in a cohort of pregnant patients (n = 172) undergoing amniocentesis at 15 to 24 weeks' gestation and annexin A5 (AnxA5) levels were determined with enzyme-linked immunosorbent assay (ELISA). Patients who developed IUGR were compared with the remainder of the cohort., Results: AF-AnxA5 levels significantly increased through gestation (P = .003). The mean level of AF-AnxA5 in IUGR patients (n = 15) was significantly higher (P = .028) than in the remainder of the cohort (n = 130). Elevated AF-AnxA5 > 20 ng/mL was associated with a relative risk of 3.5 for the development of IUGR (P = .023)., Conclusion: AnxA5 is present in amniotic fluid and increases through gestation from 15 to 24 weeks. Elevated AF-AnxA5 levels were present in patients who developed IUGR. AF-AnxA5 may be a useful marker for identifying pregnancy abnormalities.

Objective: Since August 1999, New York has required expedited human immunodeficiency virus (HIV) testing of pregnant women in labor or their newborns, with results available within 48 hours if no intrapregnancy test result was available. We documented the frequency and circumstances of expedited HIV testing, the time required for a result to be available, and hospital factors associated with different intervals., Methods: We conducted chart reviews for women listed in the expedited HIV testing logbook between October 1, 2000 and December 31, 2000, abstracting prenatal care history and the dates and times of hospital admission, blood specimen collection, expedited HIV testing result availability, and the infant's birth., Results: Of 1115 women admitted for labor and delivery during this period, 13.6% were tested under the expedited HIV testing procedure, and none were found to be HIV positive. Twenty-seven percent of women having expedited HIV testing had documentation of testing during prenatal care that was unavailable or overlooked during admission. Expedited HIV testing results were available at 48 hours or less time for 96% of the women, although results for women admitted Friday to Sunday took longer than weekday results (mean +/- standard deviation, 30.4 +/- 11.7 hours versus 21.3 +/- 9.3 hours, P <.001). Expedited HIV testing results were available before delivery for 3.3% of women and less than 12 hours after birth for 31.7% of infants., Conclusion: We found excellent compliance with the 48-hour time limit for expedited HIV testing but report lapses in access to prenatal HIV testing documentation, resulting in frequent duplicative testing. Further, the potential for optimal neonatal prophylaxis within 12 hours of birth was limited, as the turnaround time for HIV results exceeded 12 hours for two thirds of the infants in our sample.

A group of obstetricians and gynecologists, along with physicians from three other medical specialties, nurses, and midwives, developed a curriculum on preconception health care for women. This curriculum was specifically aimed at residents in obstetrics and gynecology, internal medicine, pediatrics, and family medicine. The curriculum was designed to convince these physicians that they needed to participate in promotion of preconception health for many reasons, such as the need to teach women to take folic acid daily because it significantly decreases the incidence of neural tube defects. Because over 50% of all pregnancies are unplanned, it is imperative that all physicians think of themselves as preconception health providers. Our group then taught the curriculum to medical students, residents, fellows, and attending physicians in all specialties at four hospitals affiliated with the medical college. Evaluation of the curriculum in 171 physicians who participated revealed that only a small percentage of physicians took folic acid daily themselves. Almost 36% of the obstetricians did not currently provide preconception care for their patients. Most physicians in all specialties believed that the curriculum provided them with useful information for their practice. The March of Dimes is currently distributing this curriculum on its Web site.