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Systematic reviews and meta-analyses are essential for drawing conclusions regarding etiologic associations between exposures or interventions and health outcomes. Observational studies comprise a substantive source of the evidence base. One major threat to their validity is residual confounding, which may occur when component studies adjust for different sets of confounders, fail to control for important confounders, or have classification errors resulting in only partial control of measured confounders. We present the confounder matrix--an approach for defining and summarizing adequate confounding control in systematic reviews of observational studies and incorporating this assessment into meta-analyses. First, an expert group reaches consensus regarding the core confounders that should be controlled and the best available method for their measurement. Second, a matrix graphically depicts how each component study accounted for each confounder. Third, the assessment of control adequacy informs quantitative synthesis. We illustrate the approach with studies of the association between short interpregnancy intervals and preterm birth. Our findings suggest that uncontrolled confounding, notably by reproductive history and sociodemographics, resulted in exaggerated estimates. Moreover, no studies adequately controlled for all core confounders, so we suspect residual confounding is present, even among studies with better control. The confounder matrix serves as an extension of previously published methodological guidance for observational research synthesis, enabling transparent reporting of confounding control and directly informing meta-analysis so that conclusions are drawn from the best available evidence. Widespread application could raise awareness about gaps across a body of work and allow for more valid inference with respect to confounder control.

Background: School-based health centers (SBHCs) provide opportunities for offering quality service to underserved populations. The objectives of this study were to: (1) document the SBHC process at different locations and evaluate their similarities and differences; (2) explore SBHC clinic staff satisfaction; and (3) identify facilitators and barriers to utilizing SBHCs. Methods: Three Georgia SBHCs located in either predominantly Caucasian, African American, or Hispanic elementary schools were included in this study. Mixed methods data collection efforts included: (1) observational assessment of each SBHC; (2) interviews with 7 clinic administrators and staff; and (3) focus group discussions (N = 5) with parents of children that do and do not utilize SBHCs. Results: Observational assessments indicated some clinics have more resources available than others. In-depth interviews found that centers are functioning at capacity, with potential for expansion and greater workload. Focus groups revealed that parents are satisfied with services provided, the price of the care, and the convenience of the centers. However, barriers have made utilization difficult for lower income families. Conclusions: Although most SBHC goals are being met, staff realize that further development and funding must be obtained to meet the needs of their communities.

Objective Delta-like homolog 1 (DLK1) is a growth factor that is reduced in maternal sera in pregnancies with small for gestational age neonates. We sought to determine if DLK1 is associated with stillbirth (SB), with and without placental insufficiency. Study Design A nested case-control study was performed using maternal sera from a multicenter case-control study of SB and live birth (LB). SB and LB were stratified as placental insufficiency cases (small for gestational age <5% or circulatory lesions on placental histopathology) or normal placenta controls (appropriate for gestational age and no circulatory lesions). Enzyme-linked immunosorbent assay (ELISA) was used to measure DLK1. The mean difference in DLK1 was compared on the log scale in an adjusted linear regression model with pairwise differences, stratified by term/preterm deliveries among DLK1 results in the quantifiable range. In exploratory analysis, geometric means were compared among all data and the proportion of "low DLK1" (less than the median value for gestational age) was compared between groups and modeled using linear and logistic regression, respectively. Results Overall, 234 SB and 234 LB were analyzed; 246 DLK1 values were quantifiable within the standard curve. Pairwise comparisons of case and control DLK1 geometric means showed no significant differences between groups. In exploratory analysis of all data, adjusted analysis revealed a significant difference for the LB comparison only (SB: 71.9 vs. 99.1 pg/mL, p = 0.097; LB: 37.6 vs. 98.1 pg/mL, p = 0.005). In exploratory analysis of "low DLK1," there was a significant difference between the odds ratio of having "low DLK1" between preterm cases and controls for both SB and LB. There were no significant differences in geometric means nor "low DLK1" between SB and LB. Conclusion In exploratory analysis, more placental insufficiency cases in preterm SB and LB had "low DLK1." However, low DLK1 levels were not associated with SB. Key Points Maternally circulating DLK1 is correlated with placental insufficiency. Maternally circulating DLK1 is not correlated with SB. DLK1 is a promising marker for placental insufficiency. [ABSTRACT FROM AUTHOR]

Introduction Prior research has identified psychosocial stress as a risk factor for adverse maternal and infant outcomes for non-Hispanic Black and White women. However, whether psychosocial stress differs in its profile and association with preterm birth across diverse racial-ethnic-nativity groups in the Southeast remains unexamined. Both foreign-born and Hispanic women represent important proportions of new mothers in many Southeastern states. The objective of this paper is to describe the prevalence of categories of prenatal life events among Georgia mothers, the variation across race, ethnicity and nativity, and the association of prenatal stress with prevalence of preterm birth. Methods We calculated racial-ethnic-nativity specific prevalence of stress categories (emotional/traumatic, financial, or partner-related) with data from the 2012 to 2015 Georgia PRAMS. Maternal race, ethnicity, and nativity were reported on birth certificates. We used logistic regression to examine the association of different categories of stress with preterm birth. We conducted a bias analysis to estimate the potential impact of recall bias on observed associations. Results The sample was 20.2% foreign born overall, 15.5% non-Hispanic White, 45.7% non-Hispanic Black, 32.3% Hispanic, and 6.5% non-Hispanic other. The prevalence of specific stressors varied by race-ethnicity-nativity. Women who experienced financial stress had a slightly elevated prevalence of preterm birth (prevalence ratio: 1.32 (0.97-1.79)). Discussion Prenatal and preconception stress were common among women who gave birth between 2012 and 2015 in Georgia and may have implications for preterm and postpartum maternal mental health., Author(s): Kaitlyn K. Stanhope [sup.1] , Carol J. Hogue [sup.1] Author Affiliations: (1) grid.189967.8, 0000 0001 0941 6502, Department of Epidemiology, Rollins School of Public Health, Emory University, , 1518 [...]

Objectives Preterm birth (PTB) is a leading cause of infant morbidity and mortality. One goal of Healthy People 2020 is to understand the role of preconception lifecourse exposures in relation to pregnancy outcomes, including PTB. The objective of this study was to examine the relationship between maternal exposure to multiple forms of childhood abuse and PTB and very preterm birth (vPTB), utilizing a national, population-based sample. MethodsThis study utilized retrospective self-reported maternal exposure to parent/adult caregiver perpetrated emotional, physical, and sexual abuse; non-parental/adult caregiver perpetrated sexual abuse; and history of PTB and vPTB in the National Longitudinal Study of Adolescent to Adult Health. The cross-sectional analytic study population consisted of first deliveries to 4181 nulliparous women (mean age at time of delivery = 21.7 years). Results With one exception, we did not observe associations between experiences of child abuse and the likelihood of PTB or vPTB. Only sexual abuse, accompanied by physical force and perpetrated by a non-parent/adult caregiver, was associated with an increased odds of vPTB (aOR = 1.94 (95% CI 1.10, 3.44)), particularly in women for whom abuse began after age 9 (aOR = 2.32 (95% CI 1.25, 4.28)).Conclusions for Practice The relationship between maternal exposure to child abuse and PTB may be limited to specific abuse and PTB subtypes, namely non-parent/caregiver perpetrated sexual abuse by force and vPTB. Future studies should also examine possible effect modifiers, such as maternal age and resilience, which may have the potential to inform interventions that can mitigate effects of maternal early life adversity., Author(s): Alison L. Cammack [sup.1] , Carol J. Hogue [sup.1] , Carolyn D. Drews-Botsch [sup.1] , Michael R. Kramer [sup.1] , Brad D. Pearce [sup.1] Author Affiliations: (Aff1) 0000 0001 [...]

Objectives Population-based recruitment of a cohort of women who are currently pregnant or who may become pregnant in a given timeframe presents challenges unique to identifying pregnancy status or the likelihood of future pregnancy. Little is known about the performance of individual eligibility items on pregnancy screeners although they are critical to participant recruitment. This paper examined the patterns and respondent characteristics of key pregnancy screener items used in a large national study. Methods Cross-sectional analyses were conducted. Descriptive statistics and multivariable logistic regression models were used to examine nonresponse patterns to three questions (currently pregnant, trying to get pregnant and able to get pregnant). The questions were asked of 50,529 women in 17 locations across the US, as part of eligibility screening for the National Children's Study Vanguard Study household-based recruitment. Results Most respondents were willing to provide information about current pregnancy, trying, and able to get pregnant: 99.3% of respondents answered all three questions and 97.4% provided meaningful answers. Nonresponse ranged from 0.3 to 2.5% for individual items. Multivariable logistic regression results identified small but statistically significant differences in nonresponse by respondent age, marital status, race/ethnicity-language, and household-based recruitment group. Conclusions for Practice The high levels of response to pregnancy-related items are impressive considering that the eligibility questions were fairly sensitive, were administered at households, and were not part of a respondent-initiated encounter., Author(s): Suzanne C. Hughes [sup.1] , Carol J. Hogue [sup.2] , Melissa A. Clark [sup.3] , Jessica E. Graber [sup.4] [sup.7] , Elaine D. Eaker [sup.5] [sup.8] , Amy H. [...]

Objectives The association of stress with pregnancy health is well-known. However, few studies take a mixed methods approach to understand the stressors contributing to a woman's pregnancy-related stress. Among African American women, exposure to stressors during pregnancy likely contributes to disparities in pregnancy health outcomes. This work aimed to understand the types and magnitude of stressors African American women are exposed to during pregnancy. Methods Using a mixed methods research design, we developed and administered the Healthy Pregnancy Stress Scale to measure stressors within the stress environment of African American women living in poverty. Results Exploratory factor analysis with one random split-half sample (N = 85) identified a two-factor model. Factor 1, defined as general pregnancy stressors, had significant loadings for ten items that ranged in magnitude from 0.319 to 0.724. Factor 2, defined as relationship strain, had significant loadings for three items ranging in magnitude from 0.613 to 0.856. Confirmatory factor analysis in the second random split-half sample (N = 88) showed a strong fit for the two factor model with factor loadings similar in magnitude. Standard fit statistics and those that adjust for item non-normality suggested an adequate fit to the data (RMSEA = 0.057, CFI = 0.947, TLI = 0.932; Satorra-Bentler RMSEA = 0.037, CFI = 0.972, TLI = 0.965). Conclusions for Practice Our measurement tool may provide a way to determine differences in pregnancy stress experiences across diverse populations of women. Future research should include a test for construct validity by correlating the scale with other measures that should have a specific directional relationship in diverse populations., Author(s): Tyralynn Frazier [sup.1] , Carol J. Hogue [sup.1] , Kathryn M. Yount [sup.1] Author Affiliations: (1) Emory University School of Public Health, 0000 0001 0941 6502, grid.189967.8, , 1518 [...]

Objectives Each year in the U.S., approximately 7200 infants are born with a critical congenital heart defect (CCHD). The Georgia Department of Public Health (DPH) mandated routine screening for CCHD starting January 2015. The current study evaluated hospital performance of the mandated CCHD screenings in Georgia. Methods Utilizing the DPH newborn screening surveillance system, data from 6 months before and after the mandate were analyzed for reports submitted and positive CCHD screening results. Chi square tests of independence were performed to examine the association between reporting of results for CCHD screening after the mandate and hospital nursery level [level I (well-baby/newborn); level II (special care); level III (neonatal intensive care unit-NICU)] and NICU submissions. Results In the 6 months following implementation, reports of the screening increased, but the DPH had not received information for approximately 40% of newborns. Hospitals with level III nurseries had poorer reporting rates compared to hospitals with level I or II nurseries. Newborn screening (NBS) cards submitted by NICUs were less likely to contain the CCHD screening results compared to cards submitted by regular Labor and Delivery units. Conclusions for Practice Further attention should focus on improving both CCHD screening and reporting of screening results within hospitals with level III nurseries and from NICUs at all hospital levels. Identifying and addressing the root of the issue, whether it be hospital compliance with CCHD screening or reporting of the results, will help to improve screening rates for all newborns, especially those most vulnerable., Author(s): Shelby T. Rentmeester [sup.1] , Johanna Pringle [sup.2] , Carol R. Hogue [sup.1] Author Affiliations: (1) Department of Behavioral Science and Health Education, Rollins School of Public Health, Emory [...]

Objectives Assess risk of preterm birth associated with diabetes mellitus (DM) among American Indian and Alaska Natives (AI/AN), a population with increased risk of DM and preterm birth, and examine whether this association differed by state of residence. Methods We used surveillance data from the Pregnancy Risk Assessment Monitoring System from 12,400 AI/AN respondents with singleton births in Alaska, Minnesota, Nebraska, New Mexico, Oklahoma, Oregon, Utah, and Washington from 2004-2011. We conducted multivariable logistic regression models to estimate the odds ratio adjusted for maternal age and prepregnancy BMI with all observations and then stratified by state. Results DM was reported in 5.92 % of the study population and preterm birth occurred in 8.95 % of births. Women with DM had 1.92 times higher odds of having a preterm birth than women without DM [95 % confidence interval (CI) 1.21-2.78]. After stratifying on state, women with DM in Nebraska had the greatest odds of preterm birth [aOR 6.63, (95 % CI 3.80-11.6)] while women in Alaska saw a protective effect from DM [aOR 0.17, (95 % CI 0.07-0.42)] compared to women without DM. Conclusion Overall, AI/AN women with DM had significantly greater odds of preterm birth compared to AI/AN women without DM across states. Substantial differences in this association between states calls for increased public health efforts in high-risk areas as well as further research to assess whether differences are attributable to diagnosis, reporting, tribal, healthcare or lifestyle factors., Author(s): Haley Dorfman[sup.1] , Meghna Srinath[sup.1] , Karilynn Rockhill[sup.1] , Carol Hogue[sup.1] Author Affiliations: (1) Emory University, 1518 Clifton Road NE, 30324, Atlanta, GA, USA Significance What is already known [...]

Objectives The American Indian/Alaska Native (AI/AN) population is a high-risk group across many health indicators, including fetal macrosomia. We aimed to investigate the effects of prepregnancy body mass index (BMI) and gestational weight gain (GWG) on macrosomia and explore possible racial and geographical variations among AI/AN women. Methods This retrospective cohort study was conducted from the Pregnancy Risk Assessment Monitoring System in eight states (2004-2011) among live, singleton, term births to AI/AN women 20 years or older. Prevalence of macrosomia (birth weight ≥ 4000 g) by select characteristics were estimated; differences were assessed with Chi-squares. Multivariable logistic regression was conducted to calculate adjusted odds ratios (aOR) for effects on macrosomia of BMI and GWG (enumerating the pounds women deviated from the Institute of Medicine guidelines for GWG) controlling for other factors in the total sample and stratified by race and state of residence. Results The prevalence of macrosomia was 14%, ranging from 8 to 21% (Utah-Alaska). Among AI/AN women, 30% were obese prepregnancy and 50% had excess GWG. Significant independent effects were found for macrosomia of prepregnancy overweight (aOR 1.27; 95% Confidence Interval 1.01-1.59), obesity (aOR 1.63; 1.29-2.07), and excess GWG (aOR 1.16; 1.13-1.20 per five pounds gained beyond appropriate). Adjusted estimates varied between race and state. Conclusions Prepregnancy BMI and GWG are independent factors for macrosomia among AI/AN women. Future research should prioritize development, testing, and implementation of weight management programs, which account for variations among AI/AN women, both before and during pregnancy for BMI regulation and GWG control. Keywords Macrosomia * Body mass index * Gestational weight gain * American Indian/Alaska Native * PRAMS, Significance American Indians/Alaska Natives (AI/AN) are a growing population experiencing some of the greatest health disparities. Fetal macrosomia has great risks to the mother and child. High body mass index [...]