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Background and Aims Given the paucity of population-based data on the association between inflammatory bowel diseases [IBD], coeliac disease [CeD], and coeliac autoimmunity [CeA] we aimed to study the associations in a nationwide study. Methods Using health administrative data for all four health maintenance organisations in Israel, covering 98% of the population, we explored the prevalence of CeD in children and adults with IBD versus non-IBD matched controls. CeD was defined by three ICD-9 codes and CeA by positivity for tissue transglutaminase antibodies. Results In total, 34 375 IBD patients (56% Crohn’s disease [CD] and 44% ulcerative colitis [UC]) were compared with 93 603 non-IBD controls. Among IBD patients, 319 [0.93%] had CeD versus 294 [0.31%] non-IBD controls (odds ratio [OR] = 2.97, 95% confidence interval [CI] 2.54-3.48; p Conclusion CeD and CeA are more prevalent in IBD patients, especially in paediatric-onset IBD and in CD. The diagnosis of CeD usually precedes that of IBD. Having CeD is associated with more intensified treatment for IBD.

We aimed to investigate the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescription in children with community-acquired pneumonia (CAP). Antibiotic purchasing data were collected for children aged 3 months to 18 years diagnosed with CAP from November 2016 to April 2017 (pre-intervention period) and from November 2017 to April 2018 (post-intervention period). The intervention was a 1-day seminar for primary care pediatricians on the diagnosis and treatment of CAP in children according to national guidelines. There was a substantial decrease in the use of azithromycin after the intervention. In younger children, there was a 42% decrease, alongside an increased use of amoxicillin ( P < .001). In older children, there was a smaller, non-statistically significant decrease in the use of azithromycin ( P = .45). Our data demonstrate that the implementation of an ASP was associated with a reduction in the use of broad-spectrum antibiotics and macrolides and increased guideline adherence for the safe treatment of CAP.

Background Thiopurines and methotrexate have long been used to maintain remission in Crohn's disease (CD). In this nationwide study, we aimed to compare the effectiveness and safety of these drugs in CD. Methods We utilized data from the epi-IIRN cohort, including all patients with CD diagnosed in Israel. Outcomes were compared by propensity-score matching and included therapeutic failure, hospitalizations, surgeries, steroid-dependency and adverse events. Results Of the 19,264 patients diagnosed with CD since 2005, 3,885 (20%) ever received thiopurines as monotherapy and 553 (2.9%) received methotrexate. While the utilization of thiopurines declined from 22% in 2012-2015 to 12% in 2017-2020, the use of methotrexate remained stable. The probability of sustaining therapy at one, three, and five years was 64%, 51%, and 44% for thiopurines and 56%, 30%, and 23% for methotrexate (p Conclusion Thiopurines demonstrated higher treatment durability than methotrexate but more frequent adverse events. However, disease outcomes were similar, partly due to more frequent escalation to biologics with methotrexate.

Background Data regarding patients with ulcerative colitis (UC) not receiving maintenance treatment are scarce. In this nationwide study, we aimed to explore the frequency and long-term outcomes of untreated patients with UC vs treated patients. Methods We retrieved data from Israel’s Health Maintenance Organizations, covering 98% of the population. No maintenance treatment (NMT) was defined as lack of treatment during the period from 3 to 6 months from diagnosis, allowing at most 3 months for induction treatment. Results A total of 15 111 patients have been diagnosed with UC since 2005, of whom 4410 (29%) have had NMT, with 36 794 person-years of follow-up. NMT was more likely in adults (31%) and in elderly-onset UC (29%) than in pediatric-onset UC (20%; P < .001) and decreased from 38% in 2005 to 18% in 2019 (P < .001). The probability of remaining without treatment was 78%, 49%, and 37% after 1, 3, and 5 years from diagnosis, respectively. In propensity score–matched analysis of 1080 pairs of treated (93% with 5-aminosalicylic acid) and untreated patients, outcomes were comparable for time to biologics (P = .6), surgery (P = .8), steroid dependency (P = .09), and hospitalizations (P = .2). Multivariable modeling indicated that failing NMT was less likely in adults or elderly-onset patients who received at most rectal therapy or antibiotics as induction therapy. Conclusions Nowadays, 18% of patients with UC do not receive maintenance therapy, of whom half remain without treatment after 3 years. Matched pairs of patients on NMT and 5-aminosalicylic acid, representing the mildest patients of the latter, had similar outcomes. Prospective studies are needed to further explore the role of NMT in UC.

Background Different antibiotic classes were reported to have variable effects on immunogenicity towards anti-tumour necrosis factor [TNF] agents. However, the impact of antibiotic administration on biologic treatment durability was not investigated. We aimed to assess the association between antibiotic treatment and persistence of different classes of biologic therapy in inflammatory bowel disease [IBD] patients. Methods Data from the epi-IIRN, a nationwide registry of all Israeli IBD patients were analysed. All patients who filled a prescription of either infliximab, adalimumab, vedolizumab, or ustekinumab, were included. Treatment cessation was defined as drug discontinuation of at least 6 months. Macrolides, cephalosporins, fluoroquinolones, and penicillins with beta-lactamase inhibitors were selected as primary exposure variables. Survival analysis was performed using marginal structural models for each drug separately. Results In all 13 513 IBD patients, with a total of 39 600 patient-years, were included. Significant differences of overall treatment persistence were demonstrated, with highest persistence rates for ustekinumab and the lowest for infliximab treatment. Macrolides were found to be significantly associated with reduced risk of infliximab cessation (adjusted hazard ratio [aHR] 0.72, 95% CI 0.62-0.89]. Fluoroquinolones and cephalosporins were associated with an elevated risk of adalimumab treatment cessation [aHR 1.33, 95% CI 1.22-1.46; and aHR 1.20, 95% CI 1.08-1.34, respectively]. No significant effects of the studied antibiotics were observed in ustekinumab and vedolizumab users. Conclusions Specific antibiotic classes are associated with duration of anti-TNF treatment, but not with durability of vedolizumab or ustekinumab treatments. Further research is required to study the effect of specific antibiotics on response to biologics.

Background Timely access to quality medical care impacts patient outcomes in inflammatory bowel disease (IBD). In a nationwide study from the epidemiology group of the Israeli IBD research nucleus we aimed to assess the impact of residence and socioeconomic status (SES) on disease outcomes. Methods We utilized data from the 4 health maintenance organizations in Israel, representing 98% of the population. Regions were defined as central, northern and southern; SES was graded from lowest to highest (from 1 to 4) as per Israel Central Bureau of Statistics. The primary outcome was steroid dependency, with secondary outcomes of surgeries and biologic therapy use. Results A total of 28 216 IBD patients were included: 15 818 (56%) Crohn’s disease (CD) and 12 398 (44%) ulcerative colitis; 74%, 12% and 14% resided in central, southern, and northern Israel, respectively (SES 1: 21%, SES 4: 12%). Lower SES was associated with steroid dependency (20% in SES 1 vs 12% in SES 4 in CD; P < .001; and 18% vs 12% in ulcerative colitis; P < .001), and higher surgery rates (12% vs 7%; P < .001, and 1.4% vs 0.7%; P = .115, respectively). There were higher steroid dependency and CD surgery rates in peripheral vs central regions. In multivariable models, both SES and peripheral region were independently associated with poorer outcomes. Conclusions We found that lower SES and peripheral residence were associated with deleterious outcomes in IBD. This should be considered by policymakers and should encourage strategies for improving outcomes in populations at risk.

Background It is still of debate whether the advent of biologics has been associated with a change in the natural history of ulcerative colitis [UC]. In this nationwide study we evaluated trends of long-term outcomes in all patients diagnosed with UC in Israel during the biologic era. Methods Data in the epi-IIRN cohort were retrieved from the four Israeli Health Maintenance Organizations covering 98% of the population, and linked to the Ministry of Health prospective registry on surgeries and hospitalizations. Joinpoint Regression and Kaplan–Meier survival analyses were used, reporting annual average percentage change [AAPC] for each outcome. Results A total of 13 231 patients were diagnosed with UC since 2005 (1426 [11%] paediatric-onset, 10 310 [78%] adults, 1495 [11%] elderly) with 93 675 person-years of follow-up. The probabilities of surgery after 1, 3 and 5 years from diagnosis were 1.1, 2.3 and 4.1%, respectively, and the corresponding rates of hospitalizations were 22, 33 and 41%. The overall utilization of biologics in UC increased from 0.1% in 2005 to 9.6% in 2019 [AAPC 22.1%] and they were prescribed earlier during the disease course (median of 5.6 years [interquartile range 2.8–9.1] in 2005–2008 vs 0.8 years [0.4–1.5] in 2015–2018; p < 0.001]. Annual rates of surgeries [AAPC −1.3; p = 0.6] and steroid-dependency [AAPC −1.2; p = 0.3] remained unchanged, while rates of hospitalizations slightly decreased [AAPC −1.2; p < 0.001]. Outcomes were consistently worse in paediatric-onset disease than in adults, despite higher utilization of biologics [28% vs 12%, respectively; p < 0.001]. Conclusion During the biologic era rates of surgeries and steroid-dependency have remained unchanged in patients with UC, while rates of hospitalizations have slightly decreased.

Background The effectiveness of biologics for improving long-term outcomes in patients with Crohn’s disease [CD] is still controversial. In this nationwide study, we aimed to evaluate trends of long-term outcomes in all CD patients in Israel during the biologics era. Methods Trends of outcomes were analysed using data from the four Israeli health maintenance organisations, covering 98% of the population; joinpoint regression models were used to explore changes of these trends over 2005 to 2019. Results A total of 16 936 patients were diagnosed with CD in Israel since 2005 (2932 [17%] paediatric onset, 14 004 [83%] adult onset) with 114 947 person-years of follow-up. The cumulative rate of any CD related surgery was 5%, 9%, 11%, and 14% at 1, 3, 5, and 10 years from diagnosis. The increase in use of biologics was sharp (from 8.9% to 36%; average annual percent change [AAPC], 14.3%), and the time to biologics was shorter in recent years (median time of 4.8 [1.9–8.1] years in those diagnosed in 2005–2008 compared with 0.5 [0.2–1.1] years in those diagnosed in 2015–2018; p Conclusions The rates of hospitalisations, steroid dependency, and intestinal resections decreased in association with increased use of biologics both in children and in adults, but not the rate of perianal surgeries.

PURPOSE Primary care physicians have an important role in encouraging adequate cancer screening. Disparities in cancer screening by socioeconomic status (SES) may affect presentation stage and cancer survival. This study aimed to examine whether breast, colorectal, and cervical cancer screening rates in women differed by SES and age, and whether screening rates and SES disparities changed after introduction of a primary care–based national quality indicator program. METHODS This repeated cross-sectional study spanning 2002-2017 included all female Israeli residents in age ranges appropriate for each cancer screening assessed. SES was measured both as an individual-level variable based on exemption from copayments and as an area-level variable using census data. RESULTS In 2017, the most recent year in the study period, screening rates among 1,529,233 women were highest for breast cancer (70.5%), followed by colorectal cancer (64.3%) and cervical cancer (49.6%). Women in the highest area-level SES were more likely to undergo cervical cancer screening compared with those in the lowest (odds ratio = 3.56; 99.9% CI, 3.47-3.65). Temporal trends showed that after introduction of quality indicators for breast and colorectal cancer screening in 2004 and 2005, respectively, rates of screening for these cancers increased, with greater reductions in disparities for the former. The quality indicator for cervical cancer screening was introduced in 2015, and no substantial changes have occurred yet for this screening. CONCLUSIONS We found increased uptake and reduced socioeconomic disparities after introduction of cancer screening indicators. Recent introduction of a cervical cancer screening indicator may increase participation and reduce disparities, as has occurred for breast and colorectal cancer screening. These findings related to Israel’s quality indicators program highlight the importance of primary care clinicians in increasing cancer screening rates to improve outcomes and reduce disparities.

In this nationwide study from the Israeli Inflammatory Bowel Disease Research Nucleus, we aimed to describe the incidence of very early onset inflammatory bowel diseases (VEOIBDs) with a focus on infantile-onset disease and to compare management and disease course with older children.Data were retrieved from the 4 Israeli Health Maintenance Organizations covering 98% of the population. Pediatric-onset IBD was categorized as follows: adolescent onset (10 to18 y), early onset (6 to10 y), VEOIBD (0 to6 y), toddler onset (2 to6 y), and infantile onset (2 y).A total of 5243 children with 35,469 person-years of follow-up evaluation, were diagnosed with IBD during 2005 to 2020: 4444 (85%) with adolescent onset, 548 (10%) with early onset, and 251 (4.8%) with VEOIBD, of whom 81 (1.5%) had infantile onset. The incidence of pediatric-onset IBD increased from 10.8 per 100,000 in 2005 to 15.3 per 100,000 in 2019 (average annual percentage change, 2.8%; 95% CI, 2.2%-3.4%), but that of VEOIBD remained stable (average annual percentage change, 0%; 95% CI, -2.5% to 2.6%). The infantile-onset and toddler-onset groups were treated less often with biologics (36% and 35%, respectively) vs the early onset (57%) and adolescent-onset groups (53%; P.001). The time to steroid dependency was shorter in infantile-onset (hazard ratio [HR], 2.1; 95% CI, 1.5-2.9) and toddler-onset disease (HR, 1.6; 95% CI, 1.2-2.0) vs early onset and adolescent-onset disease, but time to hospitalizations, time to surgery, and growth delay were worse only in infantile-onset disease. In a multivariable model, infantile-onset patients had a higher risk for surgery (HR, 1.4; 95% CI, 1.1-1.9) and hospitalization (HR, 1.7; 95% CI, 1.2-2.4) than the toddler-onset group.The incidence of VEOIBD remained stable. Infantile-onset IBD had worse outcomes than older children, while toddler onset had mostly similar outcomes, despite less frequent use of biologics.

ObjectiveAnti-drug antibodies (ADA) to anti-tumour necrosis factor (anti-TNF) therapy drive treatment loss of response. An association between intestinal microbial composition and response to anti-TNF therapy was noted. We therefore aimed to assess the implications of antibiotic treatments on ADA formation in patients with inflammatory bowel disease (IBD).DesignWe analysed data from the epi-IIRN (epidemiology group of the Israeli IBD research nucleus), a nationwide registry of all patients with IBD in Israel. We included all patients treated with anti-TNF who had available ADA levels. Survival analysis with drug use as time varying covariates were used to assess the association between antibiotic use and ADA development. Next, specific pathogen and germ-free C57BL mice were treated with respective antibiotics and challenged with infliximab. ADA were assessed after 14 days.ResultsAmong 1946 eligible patients, with a median follow-up of 651 days from initiation of therapy, 363 had positive ADA. Cox proportional hazard model demonstrated an increased risk of ADA development in patients who used cephalosporins (HR=1.97, 95% CI 1.58 to 2.44), or penicillins with β-lactamase inhibitors (penicillin-BLI, HR=1.4, 95% CI 1.13 to 1.74), whereas a reduced risk was noted in patients treated with macrolides (HR=0.38, 95% CI 0.16 to 0.86) or fluoroquinolones (HR=0.20, 95% CI 0.12 to 0.35). In mice exposed to infliximab, significantly increased ADA production was observed in cephalosporin as compared with macrolide pretreated mice. Germ-free mice produced no ADA.ConclusionADA production is associated with the microbial composition. The risk of ADA development during anti-TNF therapy can possibly be reduced by avoidance of cephalosporins and penicillin-BLIs, or by treatment with fluoroquinolones or macrolides.

Background Despite Israel’s universal health coverage, disparities in health services provision may still exist. We aimed to assess socioeconomic disparities in diabetes prevalence and quality of care among Israeli children, and to assess whether these changed over time. Methods We used repeated cross-sectional analyses in the setting of the National Program for Quality Indicators in Community Healthcare. The data were derived from electronic medical records from Israel’s four health maintenance organizations. The study population included all Israeli children aged 2–17 years in 2011–2018 (2018: N = 2,404,856). Socio-economic position (SEP) was measured using Central Bureau of Statistics data further updated by a private company (Points Business Mapping Ltd), and grouped into 4 categories, ranging from 1 (lowest) to 4 (highest). We used logistic regression to assess the association of SEP with diabetes prevalence, diabetes clinic visits, hemoglobin A1C (HbA1C) testing, and poor glycemic control (HbA1c > 9%), and assessed whether these changed over time. Results Diabetes prevalence increased with age and SEP, with a total of 3019 children with diabetes. SEP was positively associated with visiting a specialized diabetes clinic (age and sex adjusted Odds Ratio (aORSEP 4 vs. 1 2.45, 95% Confidence Interval (CI) 1.67–3.69)). Although children in higher SEPs were less likely to undergo HbA1c testing (aORSEP 4 vs. 1 0.54, 95% CI 0.40–0.72), they were also less likely to have poor glycemic control (aORSEP 4 vs. 1 0.25, 95% CI 0.18–0.34). Disparities were especially apparent among children aged 2–9 (6.5% poor glycemic control in SEP 4 vs. 38.2% in SEP 1). Poor glycemic control decreased over time, from 44.0% in 2011 to 34.1% in 2018. Conclusions While poor glycemic control rates among children have improved, they remain high compared to rates in adults. Additionally, substantial socioeconomic gaps remain. It is eminent to study the causes of these disparities and develop policies to improve care provided to children in the lower SEP levels, to promote health equity.

IntroductionScarce research is available regarding the association between interbirth intervals (IBI) and long-term maternal health outcomes, particularly cardiovascular disease (CVD) mortality. We aimed to assess whether IBIs were associated with all-cause, CVD-related and cancer-related mortality.MethodsWe conducted a cohort study in the setting of the Jerusalem Perinatal Study. Women with at least two consecutive singleton live births in 1964–1976 (N=18 294) were followed through 2016. IBIs were calculated as the interval between women’s first and second cohort birth. We estimated associations between IBIs and mortality using Cox’s proportional hazards models, adjusting for age, parity, maternal education, maternal origin and paternal socioeconomic status. Date of last menstrual period was available for a subset of women. We assessed the interpregnancy interval (IPI) for these women and compared the models using IPI and IBI.ResultsDuring 868 079 years of follow up (median follow-up: 49.0 years), 3337 women died. Women with IBIs ConclusionOur results support the WHO recommendations for IPIs of ≥24 months and add additional evidence regarding long-term CVD mortality.

Introduction Few studies have compared midwife-led and physician-led care in the United States. Our objective was to compare the frequency of birth interventions and maternal and neonatal outcomes between women who received prenatal care from a midwife and those who received care from a physician, among women who were low risk when they initiated prenatal care. Methods We performed a retrospective cohort study of women giving birth at a large public hospital who had at least one prenatal visit before 20 weeks' gestation in the years 2012 through 2015. We classified women according to prenatal care provider type (midwife vs physician) at first prenatal visit and compared birth outcomes between the groups, using intent-to-treat analyses. We used modified Poisson regression to calculate adjusted risk ratios (aRRs) for common outcomes and logistic regression with Firth's bias correction to produce adjusted odds ratios (aORs) for rare outcomes. As a sensitivity analysis, we performed a matched propensity score analysis to account for potential confounding by indication. Results Midwives provided care to 8.2% of the women; physicians provided care to 91.8% of the women. Women in midwifery care were less likely to be black, have Medicaid insurance, or have a history of pregnancy complications or previous cesarean births compared with women who received care from physicians. Women in midwifery care had lower risks of cesarean (aRR, 0.66; 95% CI, 0.57-0.78) and preterm birth (aRR, 0.58; 95% CI, 0.42-0.79), with no increased odds of neonatal intensive care unit admissions, neonatal deaths, or severe maternal morbidity. Women in midwifery care had increased odds of postpartum hemorrhage and shoulder dystocia (aOR, 3.26; 95% CI, 1.40-7.58, and aOR, 1.80; 95% CI, 1.01-3.22, respectively); however, these did not remain significant in the propensity score analysis. Discussion Among women with low-risk pregnancies, midwifery care was associated with substantially fewer preterm births and labor interventions.

Background Although midwife care is slowly but consistently increasing in the United States, not much is known regarding women who use a midwife. Our objectives were to compare the sociodemographic and health history characteristics, and the quality of patient–provider communication, between women who used a midwife and those who used a physician for prenatal care and/or birth. Methods We performed a cross-sectional analysis of the nationally representative Listening to Mothers III survey. We report descriptive findings using weighted proportions and means with standard deviations. We used the two one-sided tests procedure to assess the equivalence of women who used midwives and those who used physicians. Results Nearly 13% of women used a midwife for prenatal care or as a birth attendant. Women who used a midwife for prenatal care were similar to women who used a physician in most sociodemographic and health history characteristics, as well as their patient–provider communication scores, with the exception of the percentage of White (61.7 ± 5.0 [midwives], 54.3 ± 1.5 [physicians]) and married women (68.7 ± 4.9 [midwives], 60.6 ± 1.5 [physicians]). Women who used a midwife as a birth attendant were similar to women who used a physician as a birth attendant in most characteristics, with the exception of age over 35 years (7.5 ± 1.6 [midwives], 15.7 ± 1.1 [physicians]) and Special Supplemental Nutrition Program for Women, Infants, and Children support (56.8 ± 4.9 [midwives], 50.0 ± 1.6 [physicians]). Conclusions Women who use midwives are similar to those who use physicians and our findings do not confirm the common perception that midwife patients are a self-selected group of wealthier, more educated women.

Objectives Physical intimate partner violence (IPV) and STIs, including HIV, are highly prevalent in east Africa. While we have some evidence about women9s experience with physical IPV, little is known about men9s experience with physical IPV, particularly in sub-Saharan Africa. Our objective was to examine, in Tanzanian male migrant plantation residents, the prevalence of, and associations among, experience and enactment of physical IPV and prevalent STI/HIV. Methods Data from a cross-sectional survey of male plantation residents (n=158) in northern Tanzania were analysed to estimate prevalence of physical IPV experience and enactment. We assessed associations between IPV and sexual risk behaviours, and serodiagnosis of HIV, herpes simplex virus type-2 (HSV-2) and syphilis. Results Overall, 30% of men had experienced and/or enacted physical IPV with their main sexual partner: 19% of men had ever experienced physical IPV with their main sexual partner; 22% had enacted physical IPV with their main sexual partner. Considering overlaps in these groups, 11% of all participants reported reciprocal (both experienced and enacted) physical IPV. 9% of men were HIV seropositive, 51% were HSV-2 seropositive and 10% were syphilis seropositive—54% had at least one STI. Men who reported reciprocal physical IPV had increased odds of STI/HIV (adjusted OR (AOR) 8.85, 95% CI 1.78 to 44.6); the association retained statistical significance (AOR 14.5, 95% CI 1.4 to 147.0) with sexual risk behaviours included in the multivariate model. Discussion Men9s physical IPV experience and enactment was common among these migrant plantation residents. Men reporting reciprocal physical IPV had significantly increased odds of prevalent STI/IPV, and we hypothesise that they have unstable relationships. Physical IPV is an important risk factor for STI/HIV transmission, and programmatic activities are needed to prevent both.

ObjectiveThis study aimed to assess area-level socioeconomic position (SEP) disparities in nutritional status, to determine whether disparities differed by sex and to assess whether nutritional status and disparities changed over time.DesignWe used repeated cross-sectional data from a national programme that evaluates the quality of healthcare in Israel to assess children’s nutritional status.SettingThe study included all Israeli residents aged 7 years during 2014–2018 (n=699 255).MethodsSEP was measured based on the Central Bureau of Statistics’ statistical areas, and grouped into categories, ranging from 1 (lowest) to 10 (highest). We used multivariable multinomial regression to assess the association between SEP and nutritional status and between year and nutritional status. We included interactions between year and SEP to assess whether disparities changed over time.ResultsChildren in SEP 1, comprised entirely of children from the Bedouin population from Southern Israel, had drastically higher odds of thinness compared with those in the highest SEP (Girls: OR 5.02, 99% CI 2.23 to 11.30; Boys: OR 2.03, 99% CI 1.19 to 3.48). Odds of obesity were highest in lower-middle SEPs (ORSEP 5 vs 10 1.84, 99% CI 1.34 to 2.54). Prevalence of overweight and obesity decreased between 2014 and 2018, normal weight increased and thinness did not change. SEP disparities in thinness decreased over time in boys but showed a reverse trend for girls. No substantial improvement was seen in SEP disparities for other weight categories.ConclusionsOur study demonstrates the need to consider initiatives to combat the considerable SEP disparities in both thinness and obesity.

Background Prenatal care provided by midwives provides a safe and cost-effective alternative to care provided by physicians. However, no studies have evaluated the frequency of women who leave midwifery care, in a hospital setting. Our study objectives were to measure the frequency of transfers of care to physicians, to describe the sociodemographic and pregnancy-related characteristics of women who transferred to the care of a physician during prenatal care and at delivery, and to assess correlates of these transfers. Methods We used electronic medical records to perform a retrospective cohort study of women who delivered at The Ohio State University Wexner Medical Center (OSUWMC) and had at least one prenatal care visit within OSUWMC's network. We report descriptive findings, using proportions and means with standard deviations. We used logistic regression, with Firth's bias correction as necessary, to assess correlates of transferring to a physician during prenatal care and at delivery. Results Most women who initiated prenatal care with a midwife remained in midwifery care throughout delivery, with 4.7% transferring to a physician during prenatal care, and an additional 21.4% transferring to a physician during delivery. After adjusting for pregnancy-related factors, the black race was statistically significantly associated with leaving midwifery care during prenatal care (adjusted odds ratio AOR 3.0 [95% CI 1.4–6.6]) and delivery (AOR 2.5 [95% CI 1.5–4.3]). Conclusion Findings indicate that most women remain in midwifery care throughout pregnancy, but raise important questions with respect to the possible role that race has in pregnancy care.

Background Few postpartum women use effective contraception and those who use less effective methods have increased rates of unintended pregnancy. Little is known about postpartum contraception intentions among breastfeeding women. Our objectives were to measure the extent of prenatal contraceptive counseling, to assess contraceptive intentions, and to identify correlates of both among postpartum women who were planning to breastfeed. Methods We conducted a cross-sectional study using a convenience sample of 100 breastfeeding women before their discharge following delivery at a large university hospital in 2015. We used logistic regression to assess three outcomes of interest: not intending to use contraception before 6 months postpartum, reporting receiving counseling on postpartum contraception during prenatal care, and considering the effects of contraception methods on the breastfeeding mother-infant dyad when choosing a postpartum contraception method. Results Most women (91%) intended to use contraception. Prior history of no contraception use was the sole factor related to not intending to use contraception. The most commonly cited reason for the intended choice of contraceptive method was convenience (35%). Few women (21%) reported considering the effects of contraception methods on the breastfeeding dyad when choosing a postpartum contraception method. Nearly half of women reported never discussing postpartum contraception options with their healthcare provider during prenatal care. In the multivariate analysis, receiving public assistance was the only factor that remained statistically significantly associated with reporting having received contraception counseling during prenatal care. Conclusions Although most women intended to use contraception, they did not appear to have received adequate prenatal counseling on postpartum contraception.

For the many millions of migrants, mobility creates vulnerabilities and elevates risk for sexually transmitted infections (STIs). We document, among Tanzanian agricultural plantation residents, migrant characteristics and test associations between migrant status and prevalent STI (HSV-2, syphilis, and HIV). From 623 plantation resident participants, we limit this analysis to participants about whom we know migration status (migrants n = 242, non-migrants n = 291). We collected behavioral data via audio-computer assisted self-interview survey, and clinical data via STI testing. We used multivariate Poisson regression models, stratified by gender and controlling for behavioral risk factors, to measure associations between migrant status and STI. In men, HIV prevalence was 9% for migrants, and 6% for non-migrants. HSV-2 prevalence was 57% for migrants, and 32% for non-migrants. Syphilis prevalence was 12% for migrants, and 3% for non-migrants. Among women, there were few differences in STI prevalence by migrant status: prevalence of HIV was 6% vs. 5% (migrants vs. non-migrants); HSV-2 prevalence was 68% vs. 65%; and syphilis prevalence was 11% vs. 8%. Being a male migrant was significantly associated with increased prevalence of any STI after controlling for sociodemographic and behavioral characteristics (APR = 1.53, 95% CI 1.23–5.25). Migrant women did not have increased prevalence of STI as compared to non-migrant women (APR = 1.03, 95% CI 0.85–1.24). Amongst Tanzanian agricultural workers, male migrants experienced elevated risk for prevalent STI as compared to male non-migrants. We suggest structural interventions to reduce risks associated with migration, especially in male migrants, including workplace-based STI prevention programs, and connecting migrants to resources and support within new communities. The key messages are: migrant men experience significantly elevated risk for prevalent STI, above and beyond sociodemographic and behavioral risk factors, as compared to their non-migrant peers; women in this Tanzanian agricultural plantation community overall had higher prevalence of some STIs than men, migrant women had similar STI risk as non-migrant women; and migration for work, an economic strategy for millions, also creates vulnerabilities, so workplace-based STI prevention programs and connecting migrants to community resources are essential.

Milk expression has become common, but little is known about women's intentions and motivations for pumping. Our objectives were to measure, among newly postpartum women, intentions related to breast milk feeding and pumping, reasons for intending to pump, and timing of pumping initiation.We conducted a cross-sectional study at a large university hospital in 2015 using a convenience sample of 100 women before their discharge following delivery, who intended to feed their infant breast milk for at least 6 months.All participants planned to feed their baby at the breast. Ninety-eight percent said that they would use a breast pump to express milk for their baby, with most of this subset (69%) intending to start within weeks of delivery. Over a quarter of participants (29%) had already initiated pumping or intended to initiate within the subsequent few days. Primiparae were more likely to report having already started pumping at the time of the interview. For all women, the most common reason for pumping was to keep up their milk supply. Women who started pumping while in the hospital also noted that they pumped to increase their milk supply and overcome latch difficulties.The common intention to use a breast pump so early after delivery indicates a need for increased lactation support to reduce concerns about having an insufficient milk supply immediately following delivery. Additionally, clinicians who help facilitate breastfeeding should be aware of how early women intend to use a breast pump.

Objective: Our objectives were to study the association between epidural analgesia and risk of severe perineal tears (SPT), and identify additional risk factors for SPT. Methods: We conducted a historical cohort study of women with term delivery between 2006 and 2011. Inclusion criteria were an uncomplicated singleton pregnancy, cephalic presentation and vaginal delivery. Multivariate logistic regression models were constructed to study the association between epidural analgesia and SPT, controlling for potential confounders. Additional models studied the association between prolonged second stage and instrumental labor and SPT. Results: During the study period, 61 308 eligible women gave birth, 31 631 (51.6%) of whom received epidural analgesia. SPT occurred in 0.3% of births. Deliveries with epidural had significantly higher rates of primiparity, induction and augmentation of labor, prolonged second stage of labor, instrumental births and midline episiotomies. The univariate analysis showed a significant association between the use of epidural and SPT (OR: 1.78, 95% CI: 1.34–2.36); however, this association disappeared when parity was introduced (OR: 0.95, 95% CI: 0.69–1.29). Instrumental deliveries and prolonged second stage of labor were both strongly associated with SPT (ORs of 1.82 and 1.77) Conclusions: Epidural analgesia was not associated with SPT once confounding factors were controlled for.