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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: 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

Hypertensive disorders of pregnancy have been identified as a leading contributor to severe maternal morbidity and mortality. Pregnant persons with hypertensive disorders who develop severe hypertension at delivery admission have been shown to experience higher rates of severe maternal morbidity relative to those without severe hypertension. Current guidelines recommend prompt treatment of severe hypertension given known associated maternal and fetal risks; however, only 1 previous study has described an association between timeliness of antihypertensive therapy and risk of severe maternal morbidity.This study aimed to characterize how development of severe intrapartum hypertension and its timely treatment affect the risk of severe maternal morbidity.We conducted a population cohort study of deliveries with and without hypertensive disorders of pregnancy at a single urban hospital between 2016 and 2018. Among deliveries of persons with hypertensive disorders of pregnancy, we identified those with persistent severe hypertension (defined as blood pressure ≥160/105 mm Hg sustained over ≥15 minutes) and further classified individuals with severe hypertension as having received timely (within 60 minutes) or delayed treatment. Severe maternal morbidity was identified using a composite measure developed by the Centers for Disease Control and Prevention. We calculated overall and indicator-specific rates of severe maternal morbidity for 4 categories of deliveries: without hypertensive disorder of pregnancy, with hypertensive disorder of pregnancy without severe hypertension, with severe hypertension and timely treatment, and with severe hypertension and delayed treatment. We assessed the association between hypertensive disorder of pregnancy, severe hypertension, timeliness of treatment, and severe maternal morbidity using multivariable robust Poisson regression, adjusting for demographic and clinical characteristics.Of 3723 delivery hospitalizations within the study time frame, 32.3% (1204/3723) were complicated by presence of a hypertensive disorder without severe hypertension and 5.7% (211/3723) by presence of a hypertensive disorder with severe hypertension. Among those with severe hypertension, 48.8% (103/211) received timely treatment. Compared with deliveries not complicated by a hypertensive disorder, severe maternal morbidity risk was increased for hypertensive disorder of pregnancy without severe hypertension (124.4/1000 vs 52.0/1000; adjusted risk ratio, 1.84; 95% confidence interval, 1.41-2.40), severe hypertension with timely treatment (233.0/1000; adjusted risk ratio, 3.81; 95% confidence interval, 2.45-5.92), and severe hypertension with delayed treatment (305.6/1000; adjusted risk ratio, 5.38; 95% confidence interval, 3.75-7.73).Patients with hypertensive disorders of pregnancy are at an elevated risk of severe maternal morbidity, and development of severe hypertension further increases this risk. Timely antihypertensive treatment is associated with lower risk of severe maternal morbidity among those with severe hypertension. These findings emphasize the importance of provider education and quality improvement efforts aimed at expediting treatment of severe hypertension.

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

Problem/Condition Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to have multiple-birth infants because multiple embryos may be transferred. Multiple births can pose substantial risks for both mothers and infants, including obstetric complications, preterm birth (37 years). This year, single-embryo transfer (SET) rates among all embryo-transfer procedures are presented instead of elective single-embryo transfer procedures previously reported. Nationally, SET rates were 67.3% (range: 38.9% in South Dakota to 90.4% in Delaware), 65.0% (range: 23.6% in Puerto Rico to 89.4% in Delaware), and 60.0% (range: 28.6% in Puerto Rico to 83.1% in Delaware) among women aged 37 years, respectively. In 2017, ART contributed to 1.9% of all infants born in the United States (range: 0.4% in Puerto Rico to 5.0% in Massachusetts). Approximately 73.6% of ART-conceived infants were singleton infants. Overall, ART contributed to 14.7% of all multiple births, including 14.7% of all twin infants and 17.3% of all triplets and higher-order infants. ART-conceived twins accounted for approximately 96.5% (18,890 of 19,570) of all ART-conceived infants born in multiple deliveries. The percentage of multiple births was higher among infants conceived with ART (26.4%) than among all infants born in the total birth population (3.4%). Approximately 25.5% of ART-conceived infants were twins, and 0.9% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 4.5% of all low birthweight (

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.

Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to have multiple births because multiple embryos might be transferred. Multiple births can pose substantial risks for both mothers and infants, including obstetric complications, preterm birth (37 weeks), and low birthweight (2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2018 and compares birth outcomes that occurred in 2018 (resulting from ART procedures performed in 2017 and 2018) with outcomes for all infants born in the United States in 2018.2018.In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from the 50 U.S. states, the District of Columbia, and Puerto Rico.In 2018, a total of 203,119 ART procedures (range: 196 in Alaska to 26,028 in California) were performed in 456 U.S. fertility clinics and reported to CDC. These procedures resulted in 73,831 live-birth deliveries (range: 76 in Puerto Rico and Wyoming to 9,666 in California) and 81,478 infants born (range: 84 in Wyoming to 10,620 in California). Nationally, among women aged 15-44 years, the rate of ART procedures performed was 3,135 per 1 million women. ART use exceeded 1.5 times the national rate in seven states (Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island) and the District of Columbia. ART use rates exceeded the national rate in an additional seven states (California, Delaware, Hawaii, New Hampshire, Utah, Vermont, and Virginia). Nationally, among all ART transfer procedures, the average number of embryos transferred was similar across age groups (1.3 among women aged35 years, 1.3 among women aged 35-37 years, and 1.4 among women aged37 years). The national single-embryo transfer (SET) rate among all embryo-transfer procedures was 74.1% among women aged35 years (range: 28.2% in Puerto Rico to 89.5% in Delaware), 72.8% among women aged 35-37 years (range: 30.6% in Puerto Rico to 93.7% in Delaware), and 66.4% among women aged37 years (range: 27.1% in Puerto Rico to 85.3% in Delaware). In 2018, ART contributed to 2.0% of all infants born in the United States (range: 0.4% in Puerto Rico to 5.1% in Massachusetts) from procedures performed in 2017 and 2018. Approximately 78.6% of ART-conceived infants were singleton infants. Overall, ART contributed to 12.5% of all multiple births, including 12.5% of all twin births and 13.3% of all triplets and higher-order births. ART-conceived twins accounted for approximately 97.1% (15,532 of 16,001) of all ART-conceived multiple births. The percentage of multiple births was higher among infants conceived with ART (21.4%) than among all infants born in the total birth population (3.3%). Approximately 20.7% (15,532 of 74,926) of ART-conceived infants were twins, and 0.6% (469 of 74,926) were triplets and higher-order multiples. Nationally, infants conceived with ART contributed to 4.2% of all low birthweight (2,500 g) infants. Among ART-conceived infants, 18.3% were low birthweight compared with 8.3% among all infants. ART-conceived infants contributed to 5.1% of all preterm (gestational age37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (26.1%) than among all infants born in the total birth population (10.0%). The percentage of low birthweight among singletons was 8.3% among ART-conceived infants and 6.6% among all infants born. The percentage of preterm births among ART-conceived singleton infants was 14.9% compared with 8.3% among all singleton infants. The percentages of small for gestational age infants was 7.3% among ART-conceived infants compared with 9.4% among all infants.Although singleton infants accounted for the majority of ART-conceived infants, multiple births from ART varied substantially among states and nationally, contributing to12% of all twins, triplets, and higher-order multiple infants born in the United States. Because multiple births are associated with higher rates of prematurity than singleton births, the contribution of ART to poor birth outcomes continues to be noteworthy. Although SET rates increased among all age groups, variations in SET rates among states and territories remained, which might reflect variations in embryo-transfer practices among fertility clinics and might in part account for variations in multiple birth rates among states and territories.Reducing the number of embryos transferred and increasing use of SET, when clinically appropriate, can help reduce multiple births and related adverse health consequences for both mothers and infants. Whereas risks to mothers from multiple-birth pregnancy include higher rates of caesarean delivery, gestational hypertension, and gestational diabetes, infants from multiple births are at increased risk for numerous adverse sequelae such as preterm birth, birth defects, and developmental disabilities. Long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes on a population basis.

BACKGROUND: In 2016, the US Food and Drug Administration amended existing regulations to increase access to donated embryos for reproductive use. Current information regarding the characteristics and outcomes of embryo donation cycles could benefit patients and providers during counseling and decision making. OBJECTIVE: This study aimed to examine the trends in the utilization of embryo donation, pregnancy rates, and live birth rates per transfer between 2004 and 2019 and to describe the recipients of donated embryos and outcomes of frozen donated embryo transfer cycles during the most recent time period, that is, 2016 to 2019. STUDY DESIGN: We conducted a retrospective, population-based cohort study of frozen donated embryo transfer cycles in United States fertility clinics reporting to the National Assisted Reproductive Technology Surveillance System during 2004 to 2019. The trends in the annual number and proportion of frozen donated embryo transfers, pregnancy rates, and live birth rates from 2004 to 2019 were described. During 2016 to 2019, the rates of cycle cancellation, pregnancy, miscarriage, live birth, singleton birth, and good perinatal outcome (delivery ≥37 weeks, birthweight ≥2500 g) of frozen donated embryo transfers were also calculated. Transfer and pregnancy outcomes stratified by oocyte source age at the time of oocyte retrieval were also described. RESULTS: From 2004 to 2019, there were 21,060 frozen donated embryo transfers in the United States, resulting in 8457 live births. During this period, the annual number and proportion of frozen donated embryo transfers with respect to all transfers increased, as did the pregnancy rate and live birth rate. Among all initiated cycles during 2016 to 2019, the cancellation rate was 8.2%. Among 8773 transfers with known outcomes, 4685 (53.4%) resulted in pregnancy and 3820 (43.5%) in live birth. Among all pregnancies, 814 (17.4%) resulted in miscarriage. Among all live births, 3223 (84.4%) delivered a singleton, of which 2474 (76.8%) had a good perinatal outcome. The clinical pregnancy rate and live birth rate per frozen donated embryo transfer decreased with increasing age of oocyte source. CONCLUSION: The outcomes of embryo donation cycles reported in this national cohort may aid patients and providers when considering the use of donated embryos.

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.

Objective To evaluate predictors of vaccination among women who received tetanus, diphtheria, and acellular pertussis vaccination (Tdap), influenza vaccination, and Tdap and influenza vaccinations. Study Design In a retrospective cohort study of all full-term (≥37 weeks gestation) deliveries between July 1, 2016 and June 30, 2018 at a single, safety-net institution, we used multinomial logistic regression models to compare predictors of vaccination among women who received Tdap only, influenza only, and both Tdap and influenza vaccines. Results Among 3132 full-term deliveries, women were primarily non-Hispanic black (67.5%), between the ages of 21–34 (65.3%), and multiparous (76.0%). The rates of only influenza or Tdap vaccination were 10.3% and 21.6%, respectively; 43.3% of women received both vaccines, and 24.9% of women did not receive either vaccine. In the adjusted models, Hispanic ethnicity was positively associated with receipt of all types of vaccination and non-Spanish language interpreter use was positively associated with receipt of Tdap vaccination and Tdap and influenza vaccination. A parity of greater than three and inadequate and unknown prenatal care adequacy were negative predictors of all types of vaccination. Pre-existing hypertension was negatively associated with Tdap vaccination, and HIV-positive status was negatively associated with influenza vaccination and Tdap and influenza vaccination. Conclusion Compared to the national rate of both Tdap and influenza vaccination (32.8%), a higher proportion of women received both vaccines in our study population. Vaccine uptake may be affected by race/ethnicity, use of interpreter services, parity, pre-existing comorbidities, and prenatal care adequacy. The lower rate of influenza vaccination compared to Tdap vaccination suggests that other factors, such as vaccine hesitancy and mistrust, may be differentially impacting influenza vaccination uptake in our predominantly minority population. Future provider and public health approaches to vaccine promotion should incorporate culturally appropriate strategies that address vaccine-related beliefs and misconceptions.

Objective To assess national trends in the sex distribution of live-born infants in the assisted reproductive technology (ART) and general population and to identify factors correlated with offspring sex. Design Retrospective cohort study. Setting Fertility treatment centers. Patients All live-born infants included in the National Vital Statistics System and resulting from ART cycles reported to the National ART Surveillance System during 2006–14. Interventions Not applicable. Main Outcome Measure(s) Trends in the proportion of male infants in the general population and proportion of males from fresh ART cycles among all ART live-born infants and singletons after single ET. Result(s) There were 214,274 live-born infants resulting from fresh ART cycles; 53.5% (5,492/10,266) of infants resulting from PGD/PGS cycles were male, as compared with 50.6% (103,228/204,008) in the non-PGD/PGS group. Among non-PGD/PGS cycles, blastocyst transfer was positively associated with male infants (adjusted risk ratio [aRR] = 1.03; 95% confidence interval [CI], 1.02–1.04). Intracytoplasmic sperm injection was negatively associated with male infants (aRR = 0.94; 95% CI, 0.93–0.95) and for singletons after single ET (aRR = 0.93; 95% CI, 0.90–0.95), as was transfer of two embryos (aRR 0.98; 95% CI, 0.97–0.99) or three or more embryos (aRR = 0.98; 95% CI, 0.96–0.99) among all live births from cycles without PGD/PGS use. Conclusion(s) The proportion of male live-born infants among ART population did not change during 2006–14, ranging from 50.5% to 51.2%. Factors such as blastocyst transfer, intracytoplasmic sperm injection use, embryo stage, and number of embryos transferred may be associated with infant sex; further investigation is needed to understand possible underlying causes.

Essentials Venous thromboembolism (VTE) is a known complication in chronic pediatric heart disease (CPHD). The effect of certain VTE risk factors on VTE and its health care burden in CPHD is unknown. VTE in CPHD is associated with significantly increased health care resource utilization. Recent cardiac or noncardiac surgery is a risk factor that infers the highest VTE risk in CPHD. Abstract Background Venous thromboembolism (VTE) is a complication in children with chronic pediatric heart disease (CPHD). The influence of acute VTE risk factors and the health care burden associated with VTE in CPHD is unknown. Methods Children

Problem/Condition Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (37 years). Among women aged 1.5 times the national average. Although other factors might influence ART use, insurance coverage for infertility treatments accounts for some of the difference in per capita ART use observed among states because most states do not mandate any coverage for ART treatment. Public Health Action Twins account for almost all of ART-conceived multiple births born in multiple deliveries. Reducing the number of embryos transferred and increasing use of eSET, when clinically appropriate, could help reduce multiple births and related adverse health consequences for both mothers and infants. Because multiple-birth infants are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes.

BACKGROUND: Smoking near conception has adverse effects on pregnancy outcomes. We estimated the proportion of assisted reproductive technology (ART) cycles with smoking reported and associated clinical outcomes. METHODS: We used a retrospective cohort study (2009–2013) using national data of ART cycles in the United States. We compared patient characteristics, infertility diagnoses, and treatment procedures by self-reported smoking in the 3 months before treatment. Using multivariable logistic regression accounting for clustering by state, clinic, and patient, we assessed adjusted odds ratios (aOR) and 95% confidence intervals (CI) between smoking and clinical outcomes: cycle cancellations among all cycles (cycle stopped before retrieval of eggs or transfer of embryos), treatment outcomes (implantation, ectopic pregnancy, intrauterine pregnancy, and live birth) among cycles with ≥1 fresh embryo transferred, and pregnancy outcomes (miscarriage, stillbirth, and live birth) among intrauterine pregnancies. RESULTS: Smoking was reported in 1.9% of cycles. Higher proportions of cycles among smokers versus non-smokers were younger, non-Hispanic White, multigravida women and had tubal factor and male factor infertility diagnoses; lower proportions had diagnoses of diminished ovarian reserve and unexplained infertility, and used donor eggs. Smoking was associated with higher adjusted odds of cycle cancellation with no embryo transfer (aOR: 1.10; 95% CI: 1.00–1.21) and cancellations before fresh oocyte retrieval or frozen embryo transfer (1.11; 1.02–1.21). Associations between other clinical outcomes were nonsignificant. CONCLUSIONS: Over 12,000 ART cycles in the United States were exposed to smoking during 2009–2013; smoking increased the odds of cycle cancellation. Providers should encourage women to quit smoking before ART treatments.

This study aimed to compare trends and characteristics of assisted reproductive technology (ART) and non-ART perinatal deaths and to evaluate the association of perinatal mortality and method of conception (ART vs. non-ART) among ART and non-ART deliveries in Florida, Massachusetts, and Michigan from 2006 to 2011. Retrospective cohort study using linked ART surveillance and vital records data from Florida, Massachusetts, and Michigan. During 2006 to 2011, a total of 570 ART-conceived perinatal deaths and 25,158 non-ART conceived perinatal deaths were identified from the participating states. Overall, ART perinatal mortality rates were lower than non-ART perinatal mortality rates for both singletons (7.0/1,000 births vs. 10.2/1,000 births) and multiples (22.8/1,000 births vs. 41.2/1,000 births). At28 weeks of gestation, the risk of perinatal death among ART singletons was significantly lower than non-ART singletons (adjusted risk ratio [aRR] = 0.46, 95% confidence interval [CI]: 0.26-0.85). Similar results were observed among multiples at28 weeks of gestation (aRR = 0.64, 95% CI: 0.45-0.89). Our findings suggest that ART use is associated with a decreased risk of perinatal deaths prior to 28 weeks of gestation, which may be explained by earlier detection and management of fetal and maternal conditions among ART-conceived pregnancies. These findings provide valuable information for health care providers, including infertility specialists, obstetricians, and pediatricians when counseling ART users on risk of treatment.· ART use is associated with a decreased risk of perinatal deaths prior to 28 weeks of gestation.. · ART perinatal mortality rates were lower than that for non-ART perinatal mortality.. · This study used linked data to examine associations between use of ART and perinatal deaths..

Research Question Is race/ethnicity or access to care, as defined by insurance coverage, distance to clinic, and zip code, associated with care discontinuation following in vitro fertilization (IVF)? Design A retrospective cohort study of 878 diverse women who underwent 1,689 IVF cycles from 2014-2018 at a Southeastern academic medical center was performed. Women were divided into low (LAC) and high (HAC) access to care groups. HAC was defined as possessing IVF insurance coverage, living ≤25 miles from the clinic, and living in a zip code with a median income ≥$75,000. Access groups and racial/ethnic groups were compared for differences in relative risk of care discontinuation following an unsuccessful IVF cycle. Results Women with HAC had a poorer IVF prognosis than the LAC group, which possibly impacted the association with care discontinuation. Distance to clinic, but not insurance coverage or zip code, was associated with increased risk of care discontinuation. Variation in insurance coverage existed among patients, possibly impacting its association with discontinuation. Among women ≤34 years, HAC was associated with an increased risk of care discontinuation (aRR 2.5, 95% CI: 0.8-8.1). Despite having higher rates of insurance coverage (51.2% vs. 36.5%), non-Hispanic Black women were more likely to discontinue care (58.3% vs. 40.2%) and less likely to achieve a live birth (53% vs. 68%) than non-Hispanic White women. Conclusions HAC women ≤34 years old, identification as non-Hispanic Black, and distance to clinic, but not insurance coverage or zip code, were associated with an increased risk of care discontinuation following an unsuccessful IVF cycle.

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.

Background Multiple births and first pregnancy are associated with higher preeclampsia risk. It is unknown if the transfer of multiple embryos or first embryo transfer with assisted reproductive technology (ART) is also associated with greater preeclampsia risk. Methods We performed a retrospective cohort study of IVF clinics and hospitals in Massachusetts. We used linked ART surveillance, birth certificate, and maternal hospitalization discharge data for 21,188 births, considering resident singleton (12,810) and twin (8378) live-births from autologous or donor eggs from 2005 to 2012. We used log binomial and Poisson regression to calculate adjusted relative risks (aRRs) and 95% confidence intervals (CI) for the association between preeclampsia and predictors of preeclampsia. Outcomes were stratified by singleton and twin birth, donor versus autologous cycles, and use of fresh versus cryopreserved embryos. Results Considering all singleton births, the transfer of multiple embryos increased the risk of preeclampsia [aRR = 1.10 (95% CI: 1.01–1.19)]. Relative risks were greatest for fresh non-donor cycles [aRR = 1.14 (95% CI: 1.03–1.26)]. Vanishing twin and number of prior ART cycles was not associated with preeclampsia among singleton births [aRR = 1.18 (95% CI: 0.91–1.53)], and aRR = 1.01 (95% CI: 0.96–1.05)], respectively. Considering all twin births, the transfer of > 2 embryos increased the risk of preeclampsia [aRR = 1.09 (95% CI: 1.001–1.19)]. Vanishing triplet and number of prior ART cycles were not associated with preeclampsia among twin births [aRR = 0.93 (95% CI: 0.69–1264), and aRR = 0.98 (CI: 0.95–1.02)], respectively. Conclusions Among ART births, the transfer of more than 1 embryo for singleton gestations and more than 2 embryos for twin gestations increased the risk for preeclampsia diagnosis.

Background In women with congenital heart defects (CHD), changes in blood volume, heart rate, respiration, and edema during pregnancy may lead to increased risk of adverse outcomes and conditions. The American Heart Association recommends providers of pregnant women with CHD assess cardiac health and discuss risks and benefits of cardiac-related medications. We described receipt of American Heart Association–recommended cardiac evaluations, filled potentially teratogenic or fetotoxic (Food and Drug Administration pregnancy category D/X) cardiac-related prescriptions, and adverse conditions among pregnant women with CHD compared with those without CHD. Methods and Results Using 2007 to 2014 US healthcare claims data, we ascertained a retrospective cohort of women with and without CHD aged 15 to 44 years with private insurance covering prescriptions during pregnancy. CHD was defined as ≥1 inpatient code or ≥2 outpatient CHD diagnosis codes >30 days apart documented outside of pregnancy and categorized as severe or nonsevere. Log-linear regression, accounting for multiple pregnancies per woman, generated adjusted prevalence ratios (aPRs) for associations between the presence/severity of CHD and stillbirth, preterm birth, and adverse conditions from the last menstrual period to 90 days postpartum. We identified 2056 women with CHD (2334 pregnancies) and 1 374 982 women without (1 524 077 pregnancies). During the last menstrual period to 90 days postpartum, 56% of women with CHD had comprehensive echocardiograms and, during pregnancy, 4% filled potentially teratogenic or fetotoxic cardiac-related prescriptions. Women with CHD, compared with those without, experienced more adverse conditions overall (aPR, 1.9 [95% CI, 1.7–2.1]) and, specifically, obstetric (aPR, 1.3 [95% CI, 1.2–1.4]) and cardiac conditions (aPR, 10.2 [95% CI, 9.1–11.4]), stillbirth (aPR, 1.6 [95% CI, 1.1–2.4]), and preterm delivery (aPR, 1.6 [95% CI, 1.4–1.8]). More women with severe CHD, compared with nonsevere, experienced adverse conditions overall (aPR, 1.5 [95% CI, 1.2–1.9]). Conclusions Women with CHD have elevated prevalence of adverse cardiac and obstetric conditions during pregnancy; 4 in 100 used potentially teratogenic or fetotoxic medications, and only half received an American Heart Association–recommended comprehensive echocardiogram.

Objectives We aimed to examine the extent to which health plan expenditures for infertility services differed by whether women resided in states with mandates requiring coverage of such services and by whether coverage was provided through a self-insured plan subject to state mandates versus fully-insured health plans subject only to federal regulation. Methods This retrospective cohort study used individual-level, de-identified health insurance claims data. We included women 19-45 years of age who were continuously enrolled during 2011 and classified them into three mutually exclusive groups based on highest treatment intensity: in vitro fertilization (IVF), intrauterine insemination (IUI), or ovulation-inducing (OI) medications. Using generalized linear models, we estimated adjusted annual mean, aggregate, and per member per month (PMPM) expenditures among women in states with an infertility insurance mandate and those in states without a mandate, stratified by enrollment in a fully-insured or self-insured health plan. Results Of the 6,006,017 women continuously enrolled during 2011, 9199 (0.15%) had claims for IVF, 10,112 (0.17%) had claims for IUI, and 23,739 (0.40%) had claims for OI medications. Among women enrolled in fully insured plans, PMPM expenditures for infertility treatment were 3.1 times higher for those living in states with a mandate compared with states without a mandate. Among women enrolled in self-insured plans, PMPM infertility treatment expenditures were 1.2 times higher for mandate versus non-mandate states. Conclusions for Practice Recorded infertility treatment expenditures were higher in states with insurance reimbursement mandates versus those without mandates, with most of the difference in expenditures incurred by fully-insured plans.

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.

Objectives: Paternal involvement is associated with improved infant and maternal outcomes. We compared maternal behaviors associated with infant morbidity and mortality among married women, unmarried women with an acknowledgment of paternity (AOP; a proxy for paternal involvement) signed in the hospital, and unmarried women without an AOP in a representative sample of mothers in the United States from 32 sites. Methods: We analyzed 2012-2015 data from the Pregnancy Risk Assessment Monitoring System, which collects site-specific, population-based data on preconception, prenatal and postpartum behaviors, and experiences from women with a recent live birth. We calculated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) to examine associations between level of paternal involvement and maternal perinatal behaviors. Results: Of 113 020 respondents (weighted N = 6 159 027), 61.5% were married, 27.4% were unmarried with an AOP, and 11.1% were unmarried without an AOP. Compared with married women and unmarried women with an AOP, unmarried women without an AOP were less likely to initiate prenatal care during the first trimester (married, aPR [95% CI], 0.94 [0.92-0.95]; unmarried with AOP, 0.97 [0.95-0.98]), ever breastfeed (married, 0.89 [0.87-0.90]; unmarried with AOP, 0.95 [0.94-0.97]), and breastfeed at least 8 weeks (married, 0.76 [0.74-0.79]; unmarried with AOP, 0.93 [0.90-0.96]) and were more likely to use alcohol during pregnancy (married, 1.20 [1.05-1.37]; unmarried with AOP, 1.21 [1.06-1.39]) and smoke during pregnancy (married, 3.18 [2.90-3.49]; unmarried with AOP, 1.23 [1.15-1.32]) and after pregnancy (married, 2.93 [2.72-3.15]; unmarried with AOP, 1.17 [1.10-1.23]). Conclusions: Use of information on the AOP in addition to marital status provides a better understanding of factors that affect maternal behaviors.

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.

Twin births among users of assisted reproductive technology (ART) pose serious risks to both mothers and infants. However, patients may prefer twins and may be unaware of the risks of twin pregnancies. Increasing use of elective single embryo transfers (eSET) through improved patient education could help to reduce twin births and related adverse health consequences. A systematic review of PUBMED and EMBASE databases was conducted to evaluate the effectiveness of patient education among ART users on knowledge of twin pregnancy risks, desire for twins, preference for or use of eSET, and twin pregnancy rates. Of 187 references retrieved, six met the selection criteria. Most focused on patients undergoing their first ART cycle aged

OBJECTIVE: To assess patterns of contraceptive use at last intercourse among women with physical or cognitive disabilities compared to women without disabilities. STUDY DESIGN: We analyzed responses to 12 reproductive health questions added by seven states to their 2013 Behavioral Risk Factor Surveillance System questionnaire. Using responses from female respondents 18–50 years of age, we performed multinomial regression to calculate estimates of contraceptive use among women at risk for unintended pregnancy by disability status and type, adjusted for age, race/ethnicity, marital status, education, health insurance status, and parity. RESULTS: Women with disabilities had similar rates of sexual activity as women without disabilities (90.0% vs. 90.6%, p=.76). Of 5995 reproductive-aged women at risk for unintended pregnancy, 1025 (17.1%) reported one or more disabilities. Contraceptive use at last intercourse was reported by 744 (70.1%) of women with disabilities compared with 3805 (74.3%) of those without disabilities (p=.22). Among women using contraception, women with disabilities used male or female permanent contraception more often than women without disabilities (333 [29.6%] versus 1337 [23.1%], p

PURPOSE: To compare national trends and perinatal outcomes following the use of ejaculated versus surgically acquired sperm among IVF cycles with male factor infertility. METHODS: This retrospective cohort includes US fertility clinics reporting to the National ART Surveillance System between 2004 and 2015. Fresh, non-donor IVF male factor cycles (n = 369,426 cycles) were included. We report the following outcomes: (1) Trends in surgically acquired and ejaculated sperm. (2) Adjusted risk ratios comparing outcomes for intracytoplasmic sperm injection (ICSI) cycles using surgically acquired (epididymal or testicular) versus ejaculated sperm. (3) Outcomes per non-canceled cycle: biochemical pregnancy, intrauterine pregnancy, and live birth (≥ 20 weeks). (4) Outcomes per pregnancy: miscarriage (

Objective To compare indications and trends in intracytoplasmic sperm injection (ICSI) use for in vitro fertilization (IVF) cycles among residents of states with and without insurance mandates for IVF coverage. Design Cross-sectional analysis of the National Assisted Reproductive Technology Surveillance System from 2011 to 2015 for the main outcome and from 2000 to 2015 for trends. Setting IVF cycles performed in U.S. fertility clinics. Patient(s) Fresh IVF cycles. Intervention(s) Residency in a state with an insurance mandate for IVF (n = 8 states) versus no mandate (n = 43 states, including DC). Main Outcome Measure(s) ICSI use by insurance coverage mandate status stratified by male-factor infertility diagnosis. Result(s) During 2000–2015, there were 1,356,377 fresh IVF cycles, of which 25.8% (n = 350,344) were performed for residents of states with an insurance coverage mandate for IVF. ICSI use increased significantly during 2000–2015 in states both with and without a mandate; however, for non–male-factor infertility cycles, the percentage increase in ICSI use was greater among nonmandate states (34.6% in 2000 to 73.9% in 2015) versus mandate states (39.5% in 2000 to 63.5% in 2015). For male-factor infertility cycles, this percentage increase was ∼7.3% regardless of residency in a state with an insurance mandate for IVF. From 2011 to 2015, ICSI use was lower in mandate versus nonmandate states, both for cycles with (91.5% vs. 94.5%), and without (60.3% vs. 70.9%) male-factor infertility. Conclusion(s) Mandates for IVF coverage were associated with lower ICSI use for non–male-factor infertility cycles.

Gestational surrogacy policy in the USA varies by state, but information on state differences is lacking. This study used data from the National Assisted Reproductive Technology Surveillance System from 2010 to 2014 to calculate state differences in gestational carrier cycle characteristics. Of the 662,165 in-vitro fertilization cycles in the USA between 2010 and 2014, 16,148 (2.4%) used gestational carriers. Non-USA residents accounted for 18.3% of gestational carrier cycles, and 29.1% of gestational carrier cycles by USA residents were performed in a state other than the state of residence of the intended parent. USA gestational surrogacy practice varies by state, potentially impacting patients’ access to surrogacy services.

OBJECTIVES: In response to an expressed need for more focused measurement of preconception health, we identify a condensed set of preconception health indicators for state and national surveillance. METHODS: We used a systematic process to evaluate, prioritize, and select 10 preconception health indicators that maternal and child health programs can use for surveillance. For each indicator, we assessed prevalence, whether it was included in professional recommendations, Healthy People 2020 objectives, Centers for Disease Control and Prevention winnable battles, measurement simplicity, data completeness, and stakeholders’ input. RESULTS: A total of 50 preconception health indicators were evaluated and prioritized. The condensed set includes indicators that rely on data from the Pregnancy Risk Assessment Monitoring System (n=4) and the Behavioral Risk Factor Surveillance System (n=6). The content encompasses heavy alcohol consumption, depression, diabetes, folic acid intake, hypertension, normal weight, recommended physical activity, current smoking, unwanted pregnancy, and use of contraception. CONCLUSIONS: Having a condensed set of preconception health indicators can facilitate surveillance of reproductive-aged women’s health status that supports monitoring, comparisons, and benchmarking at the state and national levels.

Problem/Condition Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (37 years). Among women aged

The purpose of this study is to examine the spectrum of infertility diagnoses and assisted reproductive technology (ART) treatments in relation to risk of preterm birth (PTB) in singletons. Population-based assisted reproductive technology surveillance data for 2000–2010 were linked with birth certificates from three states: Florida, Massachusetts, and Michigan, resulting in a sample of 4,370,361 non-ART and 28,430 ART-related singletons. Logistic regression models with robust variance estimators were used to compare PTB risk among singletons conceived with and without ART, the former grouped by parental infertility diagnoses and treatment modalities. Demographic and pregnancy factors were included in adjusted analyses. ART was associated with increased PTB risk across all infertility diagnosis groups and treatment types: for conventional ART, adjusted relative risks ranged from 1.4 (95% CI 1.0, 1.9) for male infertility to 2.4 (95% CI 1.8, 3.3) for tubal ligation. Adding intra-cytoplasmic sperm injection and/or assisted hatching to conventional ART treatment did not alter associated PTB risks. Singletons conceived by mothers without infertility diagnosis and with donor semen had an increased PTB risk relative to non-ART singletons. PTB risk among ART singletons is increased within each treatment type and all underlying infertility diagnosis, including male infertility. Preterm birth in ART singletons may be attributed to parental infertility, ART treatments, or their combination.