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To estimate the effect of childhood trauma on postpartum visit attendance and explore mediation by posttraumatic stress disorder (PTSD) and depressive symptoms.We analyzed data from Grady Trauma Project surveys linked to electronic medical records. We measured childhood trauma using the Childhood Trauma Questionnaire and 4-12 week postpartum visit attendance using outpatient records. We fit log binomial causal mediation models to estimate risk ratios (RR) and 95% confidence intervals (CIs) for the total effect of childhood trauma (categorized as any moderate to severe trauma or not) on postpartum visit attendance and the controlled direct effect, eliminating PTSD or depressive symptoms, controlling for age, parity, income, education, and relationship status.Among 493 birthing people, 54.3% (268) attended the postpartum visit. Individuals without childhood trauma were more likely to attend the visit than those with childhood trauma (56.9% [173/304] v. 50.3% [95/189]). In mediation models, childhood trauma remained associated with reduced likelihood of attendance (adjusted RR: 0.83 [0.68, 1.38]) with possible mediation by PTSD symptoms (controlled direct effect: 0.98 [0.70,1.42]) but not depressive symptoms (controlled direct effect: RR: 0.86 [0.56, 1.38]).Screening and treating PTSD symptoms during pregnancy may slightly increase postpartum care engagement.

BACKGROUND: United States’ federal and subfederal immigrant-related policy activity has increased in recent years. We hypothesize that these policies are structural determinants of health for Latinx communities, operating through access to resources, discriminatory enforcement, and stress. METHODS: We searched seven databases for quantitative studies, published as of September 2021, examining the association between the presence of federal, state, or local immigrant-related policy(ies), over time or cross-sectionally, and mental or physical health outcomes among immigrant or US-born Latinx adults. We rated studies on methodologic quality. RESULTS: Eleven studies were included. Policies included federal and state policies. Health outcomes included mental health (7 studies), self-rated health (n=6), and physical disability (n=1). Among immigrant, noncitizen, or Spanish-preferring Latinx adults, exclusionary policies were associated with poor self-rated health, physical disability, and poor mental health. Inclusive policies were associated with better health, though null findings were more common than among studies of exclusionary policies. Only three studies separately examined policy effects on US-born or citizen Latinx adults and these findings were often null. All studies received a weak overall study quality rating; Among quality domains, studies were strongest in confounding control and weakest in outcome information bias and reporting missing data approaches. CONCLUSIONS: These results support the hypothesis that immigrant-related policies, especially exclusionary policies, are structural drivers of health for immigrant or noncitizen Latinx adults. However, evidence is scant among US-born or citizen Latinx adults. Studies of policies and physical health outcomes besides disability are lacking, as are results disaggregated by nativity and/or citizenship status.

Background: Hypertensive disorders of pregnancy (HDP) cause substantial preventable maternal morbidity and mortality. Postpartum hypertension that worsens after women are discharged is particularly...

Objective To understand perceived quality of obstetric care following changes to the structure of care in a safety-net institution during the COVID-19 pandemic. Methods We conducted a mixed-methods study including a web-based survey (n = 67) and in-depth interviews (n = 16) between October 2020 and January 2021. We present a descriptive analysis of quantitative results and key qualitative themes on reactions to changes and drivers of perceived quality. Results Reported quality was high for in-person and phone visits (median subscale responses: 5/5). Respondents were willing to include phone visits in care for a future pregnancy (77.8% (49)) but preferred in-person visits (84.1% (53)). In interviews, provider communication was the key driver of quality. Respondents found changes to care to be inconvenient but acceptable. Conclusions To improve satisfaction with changes to care, health systems should ensure that relationship building remains a priority and offer patients information about the reason behind changes.

Background Theory and limited empirical research suggest that the neighborhood environment influences maternal health outcomes. The goal of this scoping review is to summarize extant research considering the impact of the built and social environment of resident neighborhood on hypertensive disorders of pregnancy (HDP) globally. Methods We performed a systematic search of the literature using four databases, PubMed, Web of Science, CINAHL, and Embase on July 15, 2020. We excluded articles not in English, that did not consider one or more HDP as a primary or secondary outcome, and that did not include an element of the neighborhood built or social environment as an exposure. We applied a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies to evaluate quality of included studies. Results Our search identified 11,385 unique abstracts for screening. Following exclusions, we included 64 articles in the final review. The majority of articles measured an element of the built environment (70.3% (44)), most commonly traffic-related air pollution (42.2% (27)). A third of articles (31.3% (20)) considered an element of the neighborhood social environment, most commonly neighborhood deprivation (10.9% (7)). Global quality ratings were mostly moderate (29.7% (19)) or weak (68.8% (44)), primarily due to inattention to neighborhood-level confounding. Conclusion Critical gaps remain in understanding how the resident neighborhood may impact HDP. Future research should focus on designing high-quality studies incorporating elements of both the built and social environment to holistically understand how context may impact maternal health.

BackgroundAdverse maternal outcomes and multimorbidity affect a growing proportion of pregnant individuals in the United States and with racial and ethnic disparities in the rates of multimorbidity. There is limited research on multimorbidity, measured as the co-occurrence of two or more chronic conditions, and how it impacts adverse maternal outcomes.ObjectivesWe sought to: (1) determine how pre-pregnancy conditions and their combined effects contribute to racial disparities in adverse maternal outcomes; and (2) incorporate conditions and their combined effects into predictive modeling algorithms to improve risk prediction using information available in the first trimester, specifically for racial minority subgroups.Study DesignWe used data from the “Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b)” observational cohort study. We defined multimorbidity as the co-occurrence of two or more pre-pregnancy conditions. The primary outcomes of interest were severe preeclampsia, postpartum readmission, and blood transfusion during pregnancy or up to 14 days postpartum. We used weighted Poisson regression with robust variance to estimate adjusted risk ratios and 95% confidence intervals, and we used mediation analysis to evaluate the contribution of the combined effects of pre-pregnancy condition to racial/ethnic disparities. We also evaluated the performance of our models by racial subgroup using the area under the receiver operating characteristic curve (AUC) metric.ResultsIn the nuMoM2b cohort (n=8729), 3.6% (n=318) experienced severe preeclampsia, 1.8% (n=157) experienced blood transfusion, and 1.8% (n=154) experienced postpartum readmission. 22.8% of all participants experienced two or more co-occurring pre-pregnancy conditions. Cardiovascular conditions were associated with an increased relative risk for severe preeclampsia (aRR, 1.71; CI, 1.59-1.84), and this risk was additionally exacerbated when hematologic conditions were co-occurring with cardiovascular conditions (aRR, 1.34; CI, 1.12-1.60). The mediation analysis results were not statistically significant; however, cardiovascular conditions explained 36.6% of non-Hispanic Black individuals’ association with increased risk for severe preeclampsia (p=0.07). The addition of pre-pregnancy conditions increased AUC for the prediction of blood transfusion and severe preeclampsia, and moreover, the multiracial subgroup experienced the greatest improvement in predictive performance of blood transfusion due to this addition (an increase in AUC 0.51 to 0.69). The best subgroup performance was in predicting severe preeclampsia in multiracial individuals using confounders and condition types, with an AUC of 0.74.ConclusionThough there is a greater burden of some pre-pregnancy conditions and co-occurring conditions among minority individuals, these conditions alone do not fully explain the higher rates of adverse maternal outcomes. However, some conditions and their combined effects are associated with adverse maternal outcomes. The incorporation of pre-pregnancy multimorbidity improves the performance of some risk prediction models, especially for correctly classifying individuals of minority race.

Despite the strong link between cardiometabolic pregnancy complications and future heart disease, there are documented gaps in engaging those who experience such conditions in recommended postpartum follow-up and preventive care. The goal of our study was to understand how people in a Medicaid-insured population perceive and manage risks during and after pregnancy related to an ongoing cardiometabolic disorder.We conducted in-depth qualitative interviews with postpartum participants who had a cardiometabolic conditions during pregnancy (chronic or gestational diabetes, chronic or gestational hypertension, or preeclampsia). We recruited postpartum participants from a single safety-net hospital system in Atlanta, Georgia, and conducted virtual interviews during January through May 2021. We conducted a content analysis guided by the Health Belief Model and present themes related to risk management.From the 28 interviews we conducted, we found that during pregnancy, advice and intervention by the clinical care team facilitated management behaviors for high-risk conditions. However, participants described limited understanding of how pregnancy complications might affect future outcomes, and few described engaging in postpartum management behaviors.Improving continuity and content of care during postpartum may improve uptake of preventive behaviors among postpartum patients at risk of heart disease.

Objective Severe maternal morbidity (SMM) may be associated with postpartum psychiatric morbidity. However, the direction and strength of this relationship remain unclear. Our goal was to estimate the association between SMM and postpartum inpatient mental health care utilization. Study Design We examined all liveborn deliveries at a large, safety-net hospital in Atlanta, Georgia, from 2013 to 2021. SMM at or within 42 days of delivery was identified using International Classification of Disease codes. The primary outcome of interest was hospitalization with a psychiatric diagnosis in the year following the delivery. We used inverse probability of treatment weighting based on propensity scores to adjust for demographics, index delivery characteristics, and medical, psychiatric, and obstetric history. We fit log-binomial models with generalized estimating equations to calculate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs). Results Among 22,233 deliveries, the rates of SMM and postpartum hospitalization with a psychiatric diagnosis, respectively, were 6.8% (n = 1,149) and 0.8% (n = 169). The most common psychiatric diagnosis was nonpsychotic mood disorders (without SMM 0.4%, n = 79; with SMM 1.7% n = 24). After weighting, 2.2% of deliveries with SMM had a postpartum readmission with a psychiatric diagnosis, compared with 0.7% of deliveries without SMM (aRR: 3.2, 95% CI: [2.0, 5.2]). Associations were stronger among individuals without previous psychiatric hospitalization. Conclusion Experiencing SMM was associated with an elevated risk of postpartum psychiatric morbidity. These findings support screening and treatment for mild and moderate postpartum psychiatric disorders in the antenatal period. Key Points

Introduction: Limited existing research suggests that immigration climate and enforcement practices represent a social determinant of health for immigrants, their families, and communities. However, national research on the impact of specific policies is limited. The goal of this article is to estimate the effect of county-level participation in a 287(g) immigration enforcement agreement on very preterm birth (VPTB

Objective The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic. Study Design Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts. Results We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p Conclusion Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic. Key Points

Objective Postpartum preeclampsia (PE), defined as de novo PE that develops at least 48 hours following delivery, can be particularly dangerous as many patients are already discharged at that point. The goal of our study was to identify risk factors uniquely associated with the development of late postpartum preeclampsia (PPPE). Study Design In a retrospective cohort study of deliveries between July 1, 2016 and June 30, 2018 at a safety-net hospital in Atlanta, Georgia, we used multinomial logistic regression models to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for associations between demographic, medical, and obstetric factors and development of PE, categorized as a three-level outcome: no PE, antepartum/intrapartum preeclampsia (APE) (diagnosed prior to or Results Among 3,681 deliveries, women were primarily of ages 20 to 35 years (76.4%), identified as non-Hispanic Black (68.5%), and covered by public health insurance (88.6%). PE was diagnosed prior to delivery or within 48-hour postpartum in 12% (n = 477) of the study population, and 1.5% (57) developed PE greater than 48-hour postpartum. In the adjusted models, maternal age ≥ 35, race/ethnicity, nulliparity, a diagnosis of pregestational or gestational diabetes, and chronic hypertension were associated with increased odds of APE only, while maternal obesity (OR: 1.9; 95% CI: 1.0–3.5) and gestational hypertension (OR: 2.7; 95% CI: 1.5–4.8) were uniquely associated with PPPE. Multifetal gestations and cesarean delivery predicted both PPPE and APE; however, the association was stronger for PPPE. Conclusion Patients with obesity, gestational hypertension, multifetal gestations, or cesarean delivery may benefit from additional follow-up in the early postpartum period to detect PPPE. Key Points

In 1995, journalist Gary Taubes published an article in Science titled “Epidemiology faces its limits,” which questioned the utility of nonrandomized epidemiologic research and has since been cited more than 1000 times. He highlighted numerous examples of research topics he viewed as having questionable merit. Studies have since accumulated for these associations. We systematically evaluated current evidence of 53 example associations discussed in the article. Approximately one-quarter of those presented as doubtful are now widely viewed as causal based on current evaluations of the public health consensus. They include associations between alcohol consumption and breast cancer, residential radon exposure and lung cancer, and the use of tanning devices and melanoma. This history should inform current debates about the reproducibility of epidemiologic research results.

Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta. We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma. Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2–1.1)). Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

Objectives Limited evidence suggests racial/ethnic disparities in postpartum visit attendance; however, little is known about patterns in postpartum visit content. We sought to determine whether receipt of screening and counseling varies by race/ethnicity and whether cardiovascular disease (CVD) risk (preconception or pregnancy related) predicts postpartum visit content. Methods We used data from the Pregnancy Risk Assessment Monitoring System 2016-2017 (39 sites) to calculate the prevalence of self-reported receipt of screening, services, and counseling at the postpartum visit by race/ethnicity and CVD risk (unweighted analytic sample n = 59 427). We created a score representing receipt of 5 key screenings or messages at the visit (counseling on healthy eating and exercise, cigarettes, pregnancy spacing, and birth control methods; screening for depression), which we used as a binary indicator of visit content in regression models. We fit a logistic regression model to determine the magnitude of association between CVD risk and receipt of the 5 key messages, prevention screening, or CVD-specific counseling (on healthy eating and exercise, smoking), adjusting for maternal age, race/ethnicity, and health insurance status. Results Overall, 40% of women reported receiving all CVD-specific prevention messages. Both prepregnancy and pregnancy-related CVD risk were associated with increased odds of receipt of CVD prevention messages (adjusted odds ratios [aOR] = 1.2; 95% CI, 1.1-1.3; and 1.1; 95% CI, 1.1-1.2, respectively). Race/ethnicity was a stronger predictor than CVD risk: non-Hispanic Black women were twice as likely as non-Hispanic White women to receive CVD prevention messages, regardless of CVD risk (aOR = 1.9; 95% CI, 1.7-2.0). Conclusions Health systems should consider novel strategies to improve and standardize the content of postpartum visits.

The passage of US immigrant-related policies at the federal, state, and local level is on the rise. These policies may affect child health through several mechanisms. We performed a systematic review of English-language, peer-reviewed, quantitative studies examining US immigrant-related policies and the mental and physical health of youth in immigrant families. We searched PubMed and five social science databases for studies published between 1986 and 2019. Two independent reviewers screened the studies and appraised study quality. Of the final 17 studies, ten studies examined birth outcomes and seven studies examined other outcomes in childhood and adolescence (e.g., self-rated health). Generally, exclusionary policies were associated with worse health outcomes and inclusive policies were associated with better health outcomes. Several studies did not observe an association, but only one study found an association of the opposite direction. In that study, similar trends in different policy environments and across foreign-born and US-born women suggest alternative causes for the observed association. Overall, we find that exclusionary policies are, at best, neutral, but likely harmful towards child wellbeing, while inclusive policies can be beneficial. Supplementary Information The online version contains supplementary material available at 10.1007/s40615-021-00978-w.

Background The use of billing codes (ICD-10) to identify and track cases of gestational and pregestational diabetes during pregnancy is common in clinical quality improvement, research, and surveillance. However, specific diagnoses may be misclassified using ICD-10 codes, potentially biasing estimates. The goal of this study is to provide estimates of validation parameters (sensitivity, specificity, positive predictive value, and negative predictive value) for pregestational and gestational diabetes diagnosis using ICD-10 diagnosis codes compared with medical record abstraction at a large public hospital in Atlanta, Georgia. Methods This study includes 3,654 deliveries to Emory physicians at Grady Memorial Hospital in Atlanta, Georgia, between 2016 and 2018. We linked information abstracted from the medical record to ICD-10 diagnosis codes for gestational and pregestational diabetes during the delivery hospitalization. Using the medical record as the gold standard, we calculated sensitivity, specificity, positive predictive value, and negative predictive value for each. Results For both pregestational and gestational diabetes, ICD-10 codes had a high-negative predictive value (>99%, Table 3) and specificity (>99%). For pregestational diabetes, the sensitivity was 85.9% (95% CI = 78.8, 93.0) and positive predictive value 90.8% (95% CI = 85, 97). For gestational diabetes, the sensitivity was 95% (95% CI = 92, 98) and positive predictive value 86% (95% CI = 81, 90). Conclusions In a large public hospital, ICD-10 codes accurately identified cases of pregestational and gestational diabetes with low numbers of false positives.

Purpose Childhood adversity is associated with increased risk of adult disease, including type II diabetes and hypertension. However, little is known about potential associations between childhood adversity and adverse pregnancy outcomes. The goal of this study was to examine the relationship between adverse childhood experiences (ACEs) and ever experiencing gestational diabetes mellitus (GDM) or a hypertensive disorder of pregnancy (HDP) in a cohort of Hispanic or Latina women. Methods We analyzed data from 2319 women from the Hispanic Community Health Study/Study of Latinos who had ever given birth to a liveborn infant. We fit separate logistic regression models accounting for sample weights to examine the association between ACEs and risk of GDM and HDP adjusting for Hispanic/Latino background, age at immigration to the United States, and education. Results Women who reported four or more ACEs did not show increased odds of GDM or HDP compared with those who reported three or fewer (GDM adjusted odds ratio: 0.8 [0.5, 1.3]; HDP adjusted OR: 1.0 [0.7, 1.5]). Conclusions Unlike previous research with majority non-Hispanic White cohorts, there was no association between ACEs and GDM or HDP. Future research should explore if this relationship varies by race/ethnicity in multiethnic cohorts.

Legacy for Children™ is a group-based parenting intervention that has been culturally adapted for Spanish-speaking mothers (Legacy Spanish). In the current study, we used qualitative methods to examine how Legacy Spanish informed parenting knowledge and practices related to early development. Fourteen low-income Spanish-speaking Latina mothers of children aged 21–31 months participated in focus groups that explored their experience in Legacy Spanish. A template analysis procedure was used to analyze focus group transcripts and identify themes. We identified five primary themes and two secondary themes. Mothers described gaining new knowledge about parenting and child development from Legacy Spanish and attributed positive changes in their parenting and self-efficacy to the program. Reported changes included use of more sensitive behavioral management strategies, increased maternal investment of time and energy, and improved mother-child communication. Mothers also attributed changes in their child’s cognitive and socioemotional development to Legacy Spanish, perceived long-term benefits of program participation, and shared lessons learned from Legacy Spanish with their social network. Additionally, mothers noted that Legacy Spanish provided a unique opportunity for one-to-one time with their child. To provide additional context for the focus group data, we present scores on an observational measure of parent-child interactions. Mean scores in the Affection, Responsiveness, and Teaching domains, which measure behaviors discussed in the focus groups, fell in the average score range. Together, these findings demonstrate that a culturally adapted parenting intervention has the potential to support nurturing parent-child relationships among low-income Spanish-speaking Latino families.

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. 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. 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)). 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.

Induction of labor is known to be safe and highly effective in low-risk women. However, only limited research considers the relative success rates of induction of labor among women with one or more obstetric comorbidities. Our objective was to determine if the risk of cesarean delivery after induction of labor (IOL) is increased in women with a spectrum of hypertensive disorders of pregnancy compared to women with normotensive pregnancies. We analyzed data from 1842 women undergoing IOL occurring at Grady Memorial Hospital in Atlanta, Georgia 2016–2018. We used multivariable log binomial models to estimate unadjusted and adjusted risk ratios (aRR) describing the association between hypertensive disorder diagnosis (preeclampsia with or without severe features, gestational hypertension, and chronic hypertension) and cesarean delivery, adjusting for demographics, pre-pregnancy conditions, and gestational age at delivery. Overall, 44% (n = 808) of women in our study were diagnosed with any hypertensive disorder. Among women with hypertensive disorders, 74% had a successful vaginal delivery after IOL as compared to 82% of women without a hypertensive disorder. In the fully adjusted model, women with preeclampsia with severe features (aRR: 1.6, 95% CI: (1.3, 2.0)) and chronic hypertension had the largest risk for cesarean delivery (aRR 1.3, 95% CI: 0.9, 1.7)) compared with women with a normotensive pregnancy. Our study suggests that while patients with certain hypertensive diagnoses may be at increased risk for cesarean delivery following IOL, most patients with hypertensive disorders were still able to undergo a successful vaginal delivery following IOL.

Despite growing acceptance of the role of context in shaping perinatal risk, data on how neighborhood factors may identify high-risk obstetric patients is limited. In this study, we evaluated the effect of neighborhood deprivation and neighborhood racial composition on severe maternal morbidity (SMM) among persons delivered in a large public health system in Atlanta, Georgia. We conducted a population cohort study using electronic medical record data on all deliveries at Grady Memorial Hospital during 2011–2020. Using residential zip codes, we calculated neighborhood deprivation index based on data from the US Census. We used log-binomial regression with generalized estimating equations to estimate crude and adjusted relative risks (aRR) and 95% confidence intervals (CI) for the association between tertile of neighborhood deprivation and SMM, adjusting for demographic, clinical, and neighborhood-level (racial composition, food desert, and transit access) covariates. Among 25,257 deliveries, 6.2% (1566) experienced SMM. Approximately 24.0%, 32.0%, and 44.0% of women lived in the lowest, middle, and highest tertile of neighborhood deprivation, respectively and 64.9% lived in a neighborhood with majority non-Hispanic Black residents. After adjustment, there was no association between neighborhood deprivation and SMM (aRR: 1.0 (0.8, 1.1)) or residence in a majority Black neighborhood and SMM (aRR:1.0 (0.9, 1.2)). In this safety-net hospital, residence in a high deprivation or majority Black neighborhood did not predict SMM at or following delivery. Individual-level social determinants may better explain variation in risk, particularly in high-burden populations.

In response to the COVID-19 pandemic, health systems quickly implemented changes in care delivery with a goal of balancing patient-focused obstetric care with the need to protect pregnant persons and health care providers from infection. Yet, there is no consensus within the scientific community on the impact these measures have on obstetric outcomes in vulnerable populations. We aimed to assess the impact of the COVID-19 pandemic on rates of obstetric procedures and severe maternal morbidity (SMM) among births at an urban safety net institution.We used an interrupted time series design to calculate risk ratios (RRs) and 95% confidence intervals (CIs) comparing monthly rates of labor induction, cesarean births (overall and among nulliparous, term, singleton, vertex births), operative vaginal births, and SMM among births occurring at a public hospital before (March 1, 2016, to February 29, 2020) and during (March 1, 2020, to May 31, 2021) the COVID-19 pandemic.There were 10,714 and 2,736 births in the prepandemic and postpandemic periods, respectively. Overall, the rates of obstetric interventions and SMM were constant over the two time periods. There were no significant differences in rates of labor induction (42% during prepandemic period vs. 45% during pandemic period; RR, 1.12; 95% CI, 0.93-1.34), operative vaginal births (5% vs. 6%; RR, 1.24; 95% CI, 0.88-1.76), cesarean births (28% vs. 33%; RR, 1.10; 95% CI, 0.94-1.28), or nulliparous, term, singleton, vertex cesarean births (24% vs. 31%; RR, 1.27; 95% CI, 0.92-1.74). Rates of SMM (7% vs. 8%; RR, 1.19; 95% CI, 0.86-1.65) were also unchanged.Our findings indicate that the rapid implementation of measures to reduce viral transmission in the labor and delivery setting did not materially affect routine clinical management or rates of serious maternal complications.

Multimorbidity, the presence of two or more chronic disease diagnoses, is associated with an increased risk of mortality and high health care costs in the general population and older adults. However, little evidence is available about the prevalence and impact of multimorbidity in obstetric populations. The goal of this analysis was to estimate the association between multimorbidity and severe maternal morbidity (SMM) and 90-day postpartum readmission in an obstetric cohort in Atlanta, Georgia.We conducted a retrospective cohort study of livebirths and stillbirths at Grady Memorial Hospital, from October 2015 to April 2021. To determine preexisting chronic conditions, we linked information on births to inpatient diagnoses within the prior year. Multimorbidity was defined as the presence of two or more chronic disease diagnoses at birth or within the prior year. We conducted multivariable log binomial regression to estimate risk ratios and 95% confidence intervals for the crude and adjusted (for age, race/ethnicity, parity, and insurance) association between multimorbidity (two or more chronic conditions vs. zero or one) and SMM (at or within 42 days after birth) or 90-day postpartum readmission for any reason.Of 14,225 included births, 10.1% were to patients with multimorbidity. Overall, SMM complicated 7.5% of births, and the 90-day readmission rate was 2.4%. Both SMM and readmission were more common among women with multimorbidity (SMM, 18.6% among women with multimorbidity compared with 6.3% without; 90-day readmission, 5.4% compared with 2.1%). Adjusting for potential confounders, multimorbidity was associated with increased risk of SMM (adjusted risk ratio, 2.9; 95% confidence interval, 2.5-3.0) and readmission (adjusted risk ratio, 2.2; 95% confidence interval, 1.7-2.9).Individuals entering pregnancy with two or more chronic diseases were at an increased risk of SMM and postpartum readmission compared with individuals with one or zero chronic disease diagnoses.

We conducted a cohort study to determine sociodemographic risk factors for severe acute respiratory syndrome coronavirus 2 infection among obstetric patients in 2 urban hospitals in Atlanta, Georgia, USA. Prevalence of infection was highest among women who were Hispanic, were uninsured, or lived in high-density neighborhoods.

Background Identification of hypertensive disorders in pregnancy research often uses hospital International Classification of Diseases v. 10 (ICD-10) codes meant for billing purposes, which may introduce misclassification error relative to medical records. We estimated the validity of ICD-10 codes for hypertensive disorders during pregnancy overall and by subdiagnosis, compared with medical record diagnosis, in a Southeastern United States high disease burden hospital. Methods We linked medical record data with hospital discharge records for deliveries between 1 July 2016, and 30 June 2018, in an Atlanta, Georgia, public hospital. For any hypertensive disorder (with and without unspecified codes) and each subdiagnosis (hemolysis, elevated liver enzymes, and low platelet count [HELLP] syndrome, eclampsia, preeclampsia with and without severe features, chronic hypertension, superimposed preeclampsia, and gestational hypertension), we calculated positive predictive value (PPV), negative predictive value (NPV) sensitivity, and specificity for ICD-10 codes compared with medical record diagnoses (gold standard). Results Thirty-seven percent of 3,654 eligible pregnancies had a clinical diagnosis of any hypertensive disorder during pregnancy. Overall, ICD-10 codes identified medical record diagnoses well (PPV, NPV, specificity >90%; sensitivity >80%). PPV, NPV, and specificity were high for all subindicators (>80%). Sensitivity estimates were high for superimposed preeclampsia, chronic hypertension, and gestational hypertension (>80%); moderate for eclampsia (66.7%; 95% confidence interval [CI] = 22.3%, 95.7%), HELLP (75.0%; 95% CI = 50.9%, 91.3%), and preeclampsia with severe features (58.3%; 95% CI = 52.6%, 63.8%); and low for preeclampsia without severe features (3.2%; 95% CI, 1.4%, 6.2%). Conclusions We provide bias parameters for future US-based studies of hypertensive outcomes during pregnancy in high-burden populations using hospital ICD-10 codes.

Underserved subgroups are less likely to have optimal health prior to pregnancy. We describe preconception health indicators (behavior, pregnancy intention, and obesity) among pregnant Latina women with and without chronic stress in metro Atlanta.We surveyed 110 pregnant Latina women enrolled in prenatal care at three clinics in Atlanta. The survey assessed chronic stress, pregnancy intention, preconception behavior changes (taking folic acid or prenatal vitamins, seeking healthcare advice, any reduction in smoking or drinking), and previous trauma.Specific behaviors to improve health prior to pregnancy were uncommon (e.g., taking vitamins (25.5%) or improving nutrition (20.9%)). Just under half of women were experiencing a chronic stressor at the time of conception (49.5%). Chronically stressed women were more likely to be obese (aOR: 3.0 (1.2, 7.4)), less likely to intend their pregnancy (aOR: 0.3 (0.1, 0.7)), and possibly less likely to report any PHB (45.5% vs. 57.4%; aOR: 0.5 (0.2-1.1)).Chronically stress women were less likely to enter prenatal care with optimal health. However, preconception behaviors were uncommon overall.

Stress across the life course is highly prevalent, particularly among immigrant and racial/ethnic minority women who face adversities associated with structural and interpersonal racism. Understanding how women perceive and describe stress and resilience can provide cultural context to inform interventions to improve health among pregnant women facing adversity. The goal of this project was to examine how external stressors and coping strategies prior to and during pregnancy are reflected in Latina women's narratives about their lives through an Ecosocial framework. This mixed methods research study explores pregnant Latina women's psychosocial well-being before and during pregnancy based on Ecosocial theory. We conducted 111 surveys with Latina women receiving prenatal care in Atlanta, Georgia in 2017-2018. We conducted 24 in-depth interviews, chosen purposively from survey respondents, collecting narratives of stress and resilience over the course of pregnancy. We purposively sampled equal numbers of women who did and did not report an ongoing stressor in the survey. The survey and interview guide were focused on domains of stress, psychosocial being, coping and resilience. The majority of survey participants spoke Spanish (86%) and were born in Mexico (42%) or Guatemala (27%). Less than half (37%) reported ongoing stress, most commonly from a loved one's illness or work-related problem. The majority of women felt they should control emotional responses to external stressors during pregnancy to protect their baby's health. Women described motherhood and previous challenges as sources of maturity and improved coping. Familial financial and emotional support were perceived as critical to women's successful coping.

Introduction Gestational diabetes (GDM) and hypertensive disorders of pregnancy (HDP) are associated with increased risk of maternal and infant illness and long-term elevated cardiometabolic risk. Little information exists on the prevention of either disorder before pregnancy. Our goal was to describe the association between preconception indicators and risk of gestational diabetes and hypertensive disorders of pregnancy. Methods We used logistic regression to analyze cross-sectional data from the 2016-2017 Pregnancy Risk Assessment Monitoring System (N = 68,493) to quantify the association between 14 preconception health indicators (across domains of health care, nutrition and physical activity, tobacco and alcohol, chronic conditions, mental health, and emotional and social support) and, separately, GDM and HDP. We accounted for sampling weights and controlled for maternal age, race/ethnicity, prepregnancy insurance, prepregnancy body mass index, and report of a check-up in the year before pregnancy. Results Prepregnancy obesity was the strongest predictor of both HDP (adjusted odds ratio [aOR], 3.1; 95% CI, 2.8-3.5) and GDM (aOR, 3.1; 95% CI, 2.7-3.5). Individual behaviors (eg, exercise, attending a check-up) were not associated with either HDP or GDM. A diagnosis of diabetes before pregnancy predicted HDP (aOR, 2.3; 95% CI, 1.7-3.0). Conclusion Prepregnancy chronic disease and obesity predicted pregnancy complications (ie, GDM and HDP). Given the challenges in reversing these conditions in the year before pregnancy, efforts to improve preconception health may be best directed broadly to expand access to primary care for all women.

Objective To identify recommendations for conducting public health research with trauma-exposed populations. Methods Researchers searched Embase, PubMed, Scopus, Web of Science, Open Grey, and Google Scholar for recommendations. Trauma that causes psychological impact was our exposure of interest and we excluded clinical articles on treating physical trauma. We reviewed titles and abstracts of 8,070 articles and full text of 300 articles. We analyzed recommendations with thematic analysis, generated questions from the existing pool of recommendations, and then summarized select gaps. Results We abstracted recommendations from 145 articles in five categories: community benefit, participant benefit, safety, researcher well-being, and recommendations for conduct of trauma research. Conclusions Gold standards to guide the conduct of trauma-informed public health research do not yet exist. The literature suggests participation in trauma research is not inherently harmful, and current recommendations concern using research to benefit communities and participants, protecting participants and researchers from harm, and improving professional practice. As public health researchers increasingly analyze trauma as a determinant of health, gold standards for the conduct of trauma-informed public health research would be appropriate and timely.

Rates of severe maternal morbidity are steadily increasing in the United States and are highest among women who are Black, publicly insured, or deliver at a safety-net hospital. There is limited information on the risk of severe maternal morbidity recurrence in subsequent births, particularly among socially vulnerable women.To estimate the risk of severe maternal morbidity recurrence among singleton births in a large, public hospital system.We conducted a population-based cohort study using electronic medical record data on deliveries occurring at an urban public hospital between 2011 and 2020. We included all women with 2 singleton deliveries at ≥20 weeks of gestation (live or stillborn) during the study period and assessed severe maternal morbidity recorded at delivery or within 42 days postpartum. We used generalized linear models to estimate adjusted risk ratios, adjusted risk differences, and 95% confidence intervals for severe maternal morbidity at the subsequent birth, controlling for age, parity, self-reported race/ethnicity, insurance type, chronic hypertension and diabetes mellitus, and obesity at the index delivery.Between 2011 and 2020, there were 26,994 singleton deliveries to 21,638 women. Among 4368 women with 2 singleton births at ≥20 weeks of gestation, 4.8% (n=211) had severe maternal morbidity at the index birth, and 5.7% (n=250) had severe maternal morbidity at the subsequent birth. Severe maternal morbidity at the index birth was associated with an over 3-fold increased risk of severe maternal morbidity in a subsequent pregnancy (adjusted risk ratio, 3.65; 95% confidence interval, 2.65-5.03) and an excess risk of 12.9 per 100 deliveries (adjusted risk difference, 12.9; 95% confidence interval, 7.7-18.1).The results of our study suggest that women who experienced severe maternal morbidity in a previous birth are at increased risk for severe maternal morbidity recurrence and may warrant additional monitoring in subsequent pregnancies.

Hypertensive disorders of pregnancy (HDP) are a leading cause of severe maternal morbidity (SMM), yet mediation by cesarean delivery is largely unexplored. We investigated the association between HDP and SMM in a cohort of deliveries at a safety-net institution in Atlanta, Georgia, during 2016–2018. Using multivariable generalized linear models, we estimated adjusted risk differences, adjusted risk ratios, and 95% confidence intervals for the association between HDP and SMM. We examined interactions with cesarean delivery and used mediation analysis with 4-way decomposition to estimate excess relative risks. Among 3,723 deliveries, the SMM rate for women with and without HDP was 124.4 per 1,000 and 52.0 per 1,000, respectively. The adjusted risk ratio for the total effect of HDP on SMM was 2.55 (95% confidence interval (CI): 2.15, 3.39). Approximately 55.2% (95% CI: 25.7, 68.5) of excess relative risk was due to neither interaction nor mediation, 24.9% (95% CI: 15.4, 50.0) was due to interaction between HDP and cesarean delivery, 9.6% (95% CI: 3.4, 15.2) was due to mediation, and 10.3% (95% CI: 5.4, 20.3) was due to mediation and interaction. HDP are a potentially modifiable risk factor for SMM; implementing evidence-based interventions for the prevention and treatment of HDP is critical for reducing SMM risk.

This article describes the process and intermediate outcomes from a program implemented in 65 Early Care and Education (ECE) centers serving low-income families throughout Georgia during the 2014-2017 school years.The HealthMPowers' Empowering Healthy Choices in Schools, Homes, and Communities ECE program was based on the organization's previously successful elementary school program and aligns with current early childhood nutrition and physical activity recommendations. Participating centers worked with HealthMPowers for up to 3 years. A team from each center led changes by conducting annual self-assessments, creating and implementing improvement plans, and implementing nutrition and physical activity programs using educational resources and environmental cues. A monitoring and evaluation plan provided ongoing feedback to HealthMPowers and centers. Family and staff surveys provided insights into behaviors of children, families, and staff. Process measures included specific benchmarks (e.g., center leadership team formation, improvement plan implementation). Annual self-assessment results served as intermediate outcome measures.As of 2017, 65 centers had enrolled in the program. All centers formed a health team and completed the baseline self-assessment and most implemented an improvement plan (88%). At the 1-year follow-up self-assessment, centers reported improvements from baseline including never offering food incentives for good behavior (75%-86%), conducting taste testing at least once a month (61%-79%), and rarely/never serving sugar-sweetened beverages (93%-96%).Initial process measures from a multicomponent health promotion program in ECE were promising. An integrated continuous improvement approach to working with child care settings is feasible and likely effective.

Background Implementing rigorous epidemiologic studies in low-resource settings involves challenges in participant recruitment and follow-up (e.g., mobile populations, distrust), biological sample collection (e.g., cold-chain, laboratory equipment scarcity) and data collection (e.g., literacy, staff training, and infrastructure). This article describes the use of a monitoring and evaluation (M&E) framework to improve study efficiency and quality during participant engagement, and biological sample and data collection in a longitudinal cohort study of Bolivian infants. Methods The study occurred between 2013 and 2015 in El Alto, Bolivia, a high-altitude, urban, low-resource community. The study’s M&E framework included indicators for participant engagement (e.g., recruitment, retention, safety), biological sample (e.g., stool and blood), and data (e.g., anthropometry, questionnaires) collection and quality. Monitoring indicators were measured regularly throughout the study and used for course correction, communication, and staff retraining. Results Participant engagement indicators suggested that enrollment objectives were met (461 infants), but 15% loss-to-follow-up resulted in only 364 infants completing the study. Over the course of the study, there were four study-related adverse events (minor swelling and bruising related to a blood draw) and five severe adverse events (infant deaths) not related to study participation. Biological sample indicators demonstrated two blood samples collected from 95% (333 of 350 required) infants and stool collected for 61% of reported infant diarrhea episodes. Anthropometry data quality indicators were extremely high (median SDs for weight-for-length, length-for-age and weight-for-age z-scores 1.01, 0.98, and 1.03, respectively), likely due to extensive training, standardization, and monitoring efforts. Conclusions Conducting human subjects research studies in low-resource settings often presents unique logistical difficulties, and collecting high-quality data is often a challenge. Investing in comprehensive M&E is important to improve participant recruitment, retention and safety, and sample and data quality. The M&E framework from this study can be applied to other longitudinal studies. Electronic supplementary material The online version of this article (10.1186/s12889-017-4904-5) contains supplementary material, which is available to authorized users.

The majority of health research uses a deductive approach to measure stressful life events, despite evidence that perception of what is stressful varies. The goal of this project was to 1) describe the distribution of self-identified most stressful life events in a cohort of women who experienced a perinatal loss (stillbirth or neonatal death) or live birth in the previous three years and 2) test how childhood adversity influences participant selection of their most stressful life event. We used data from 987 women (282 with stillbirth, 657 without loss, and 48 with a neonatal death in the first 28 days) in the Stillbirth Collaborative Research Network – OASIS (Outcomes after Study Index Stillbirth) follow-up study, a population-based sample set in five U.S. states in 2009. We applied an inductive coding process to open-ended responses to a question about the most stressful event or major crisis that participants had ever experienced, resulting in a set of 15 categories. We compare psychologic wellbeing across self-identified most stressful life event, accounting for sampling and loss-to-follow-up weights. Overall, stillbirth was most commonly identified as the most stressful event (18.3% [95% CI: 15.6, 21.5]), followed by loss by death of someone other than a child (17.25 % [95% CI: 13.9, 20.3]). For participants who experienced a perinatal loss, we fit multivariable logistic regression models to quantify the association between report of childhood maltreatment and identifying the perinatal loss as the most stressful life event, calculating risk ratios (RRs). Reporting any moderate or severe childhood maltreatment was associated with 24% lower risk of identifying the perinatal loss as the most stressful life event (adjusted RR: 0.76 [95% CI: 0.58, 1.01]), after adjusting for race/ethnicity, age, and education. These results demonstrate the value of combining standardized measures with open-ended, inductive approaches to measuring stress in large, population-based studies.

Objective The incidence of childhood obesity is highest among children entering kindergarten. Overweight and obesity in early childhood track through adulthood. Programs increasingly target children in early life for obesity prevention. However, the published literature lacks a review on tools available for measuring behaviour and environmental level change in child care. The objective is to describe measurement tools currently in use in evaluating obesity-prevention in preschool-aged children. Methods Literature searches were conducted in PubMed using the keywords "early childhood obesity," "early childhood measurement," "early childhood nutrition" and "early childhood physical activity." Inclusion criteria included a discussion of: (1) obesity prevention, risk assessment or treatment in children ages 1-5 years; and (2) measurement of nutrition or physical activity. Results One hundred thirty-four publications were selected for analysis. Data on measurement tools, population and outcomes were abstracted into tables. Tables are divided by individual and environmental level measures and further divided into physical activity, diet and physical health outcomes. Recommendations are made for weighing advantages and disadvantages of tools. Conclusion Despite rising numbers of interventions targeting obesity-prevention and treatment in preschool-aged children, there is no consensus for which tools represent a gold standard or threshold of accuracy.

Since the decriminalisation of abortion in 2006, women in Colombia have continued to seek clandestine abortions, endangering their health and contributing to maternal mortality and morbidity. The goal of this study was to explore physicians' opinions towards and knowledge about legal abortion in Bogotá, Colombia, and key barriers to the legal abortion access. We conducted 13 key informant interviews followed by a survey with a probability sample of 49 doctors working in public hospitals in Bogotá. Interview and survey data showed lack of technical experience in the provision of abortion and nuanced opinions towards its practice. Key informants described ignorance and lack of abortion training in medical schools as key barriers to provision. In the survey, 16/49 respondents had performed an abortion, 24/49 had referred a woman for an abortion and only 33/49 showed correct knowledge of the law.

Immigration policy climate may have pervasive effects on the health of immigrants and their families. We examine how living in a state at the time of delivery with a more restrictive immigration policy climate impacts risk of very preterm birth (VPTB) among Hispanic mothers in the United States. We used data from the United States live birth files, 2005-2016. We fit generalized linear mixed models predicting VPTB including information on individual (e.g., age, parity, specific Hispanic origin group) and geographic (e.g., county level poverty, ethnic density) risk determinants. Living in a state with a more restrictive immigration policy climate is associated with a slight increase in odds of VPTB for Hispanic women (aOR: 1.07 (1.04-1.10)).

Background Academic achievement is influenced by factors at the student, school, and community levels. We estimated the effect of cardiorespiratory fitness performance on academic performance at the school level in Georgia elementary schools and examined effect modification by sociodemographic factors. Methods This study is a repeat cross-sectional analysis of Georgia elementary schools between 2011 and 2014 (approximately 1138 schools per year). Multivariable beta regression estimated the effect of the proportion of 4th and 5th graders meeting cardiorespiratory fitness standards on the proportion of 5th graders passing standardized tests for Reading, English and Language Arts, Mathematics, Science, and Social Studies and considered potential interaction by school-level socioeconomic status (SES), racial composition, and urbanity. Results There was a 0.15 higher estimated odds (OR: 1.15 (1.09, 1.22)) of passing the mathematics standardized test for every 10-percentage-point increase in school-level cardiorespiratory fitness among high-SES schools and 0.04 higher odds (OR: 1.04 (1.02, 1.05)) for low-SES schools. This pattern was similar for other academic subjects. No effect modification by racial composition or urbanity was observed for any academic subject. Conclusions Promoting physical fitness may be effective in improving academic performance among high-SES schools, but additional strategies may be needed among lower-SES schools.

In 2006, the Colombian Constitutional Court partially decriminalized abortion. However, barriers to access, including improper use of conscientious objection, remain.To explore conscientious objection from the objectors' perspectives, in-depth interviews were conducted in 2014 with 13 key informants and with 15 Colombian physicians who self-identified as conscientious objectors. Recruitment included snowball and purposive sampling techniques. Analysis was conducted in tandem with data collection and focused on objectors' attitudes, beliefs and behaviors related to abortion and referral.Objectors had varied perspectives. Three types of objectors were evident: extreme, moderate and partial. Extreme objectors refused to perform abortions or make referrals, and often lectured their patients; they also provided misleading or false medical and legal information, preventing women from accessing abortions to which they were legally entitled. Moderate objectors would not perform abortions, but respected their patients and viewed referral as a way to save "one out of two" lives. Partial objectors performed some abortions but refused to do others on the basis of gestational age or case-by-case circumstances. Across the typology, objectors linked conscientious objection with medical ethics, and many described a duty to protect the fetus, which they conceptualized as a patient.Conscientious objectors exhibit diverse opinions and behaviors. Potential areas for future investigation include identifying factors that lead objectors to refer and estimating the prevalence of each type of objector. Results suggest potential interventions that could reduce the role of conscientious objection as a barrier to care.RESUMEN Contexto: En 2006, la Corte Constitucional de Colombia descriminalizó parcialmente el aborto. Sin embargo, aún existen barreras al acceso, incluido el uso inapropiado de la objeción de conciencia. Métodos: Con el fin de explorar la objeción de conciencia desde las perspectivas de los objetores, en 2014 se llevaron a cabo entrevistas en profundidad con 13 informantes clave y 15 médicos colombianos que se autoidentificaron como objetores de conciencia. El reclutamiento incluyó técnicas de muestreo por bola de nieve e intencional. El análisis se llevó a cabo conjuntamente con la recolección de datos y se focalizó en las actitudes, creencias y conductas de los objetores en relación con el aborto y las referencias a otros proveedores. Resultados: Los objetores tienen perspectivas diversas. Fueron evidentes tres tipos de objetores: extremos, moderados y parciales. Los objetores extremos rechazaron realizar abortos o hacer referencias y, con frecuencia, sermonearon a sus pacientes; también proporcionaron información médica y legal engañosa o falsa, para evitar que las mujeres tuvieran acceso a abortos a los cuales legalmente tenían derecho. Los objetores moderados no realizaron abortos, pero respetaron a sus pacientes y consideraron las referencias como una forma de salvar “una de dos” vidas. Los objetores parciales realizaron algunos abortos pero rechazaron practicar otros en base a la edad gestacional o circunstancias relacionadas con cada caso. A lo largo de esta tipología, los objetores vincularon la objeción de conciencia con la ética médica y muchos describieron un deber de proteger el feto, el cual conceptualizaron como paciente. Conclusión: Los objetores de conciencia exhiben diversas opiniones y conductas. Algunas áreas con potencial para futuras investigaciones incluyen la identificación de factores que conducen a los objetores a referir a otros proveedores y la estimación de la prevalencia de cada tipo de objetor. Los resultados sugieren intervenciones potenciales que podrían reducir el rol de la objeción de conciencia en tanto una barrera a la hora de recibir atención.RÉSUMÉ Contexte: En 2006, le Tribunal constitutionnel de Colombie a décriminalisé partiellement l'avortement. Des obstacles d'accès, notamment l'invocation abusive de l'objection de conscience, persistent cependant. Méthodes: Afin d'explorer l'objection de conscience dans la perspective des intéressés, des entretiens en profondeur ont été menés en 2014 avec 13 informateurs clés et 15 médecins colombiens qui s’étaient dits objecteurs de conscience. Le recrutement a été effectué selon les techniques d’échantillonnage en boule de neige et par choix raisonné. Parallèlement à la collecte de données, l'analyse s'est concentrée sur les attitudes, croyances et comportements des objecteurs concernant l'avortement et l'orientation vers un prestataire. Résultats: Différentes perspectives expliquent la position des objecteurs. Trois grands types d'objection se sont révélés: absolue, modérée et partielle. Les objecteurs absolus refusent toute pratique de l'avortement ou orientation afférente, faisant souvent la leçon à leurs patientes; ils fournissent aussi une information médicale et légale trompeuse ou fausse, empêchant les femmes d'accéder aux procédures d'avortement auxquelles elles ont légalement droit. Les objecteurs modérés refusent de pratiquer l'avortement mais ils respectent leurs patientes et voient dans leur orientation vers un prestataire un moyen de «sauver une vie sur deux». Les objecteurs partiels pratiquent certains avortements mais en refusent d'autres en fonction de l’âge gestationnel ou de circonstances considérées au cas par cas. Dans les trois types, les objecteurs lient l'objection de conscience à l’éthique médicale. Beaucoup parlent d'une obligation de protection du fœtus, qu'ils conceptualisent tel un patient.Les objecteurs de conscience présentent des opinions et des comportements divers. Les points potentiels de recherche future comprennent l'identification des facteurs qui amènent les objecteurs à l'orientation vers un prestataire et l'estimation de la prévalence de chaque type d'objecteur. Les résultats laissent entendre de potentielles interventions aptes à réduire le rôle de l'objection de conscience parmi les obstacles aux soins.