bluuebunny/crossref_metadata_2025 huggingface dataset:
Racial and Ethnic Disparities in Adverse Neonatal Outcomes Persist With Use of Fertility Treatment [ID 2683455]
Authors: Phillips Sara , Kornfield Molly , Garg Bharti , Krieg Sacha A.
Published: May 2024

INTRODUCTION:

Racial/ethnic health disparities are well documented, yet little is known about the effect of fertility treatment on disparities. This study assesses the relationship between fertility treatment and adverse neonatal outcomes by race/ethnicity.

METHODS:

A secondary data analysis was performed using National Vital Statistics (2012–2020) including singleton, non-anomalous births from 23 to 42 weeks of gestation. The primary outcome was an adverse neonatal composite outcome (ANCO) encompassing neonatal intensive care unit admission, assisted ventilation, seizures, and Apgar scores less than 7 at 5 minutes. Multivariable logistic regression assessed whether fertility treatment was associated with ANCO by race/ethnicity after adjusting for maternal age, gestational age at delivery, maternal body mass index, education status, insurance, and delivery year.

RESULTS:

Of 31,975,746 births meeting inclusion criteria, 414,716 (1.3%) were conceived with fertility treatment. Across the entire cohort, fertility treatment was associated with significantly increased odds of ANCO (adjusted odds ratio [aOR] 1.44; 95% CI, 1.43–1.46). Prevalence of ANCO was highest for the non-Hispanic Black (NHB) and American Indian/Alaska Native (AIAN) populations in both nonfertility and fertility treatment groups. Without fertility treatment, the Asian/Pacific Islander (API) and Hispanic groups had the lowest rates of ANCO at 8.3% and 8.9%, respectively. With fertility treatment, ANCO odds increased the most in API (aOR 1.61; 1.56–1.66) and Hispanic populations (aOR 1.60; 1.54–1.65).

CONCLUSION:

Fertility treatment is associated with approximately 1.5 times the odds of adverse neonatal outcomes across all racial/ethnic groups, with the greatest increase among the API and Hispanic populations. The NHB and AIAN groups experienced the highest overall rates of ANCO, supporting the need for targeted interventions for historically marginalized populations.
Extending the Effect of Doulas: Digital Health Platforms as an Effective Mechanism for Improving Nonbirth Outcomes [ID 2683473]
Authors: Henrich Natalie , Karwa Smriti , Jahnke Hannah , Brinson Alison , Moss Christa , Shah Neel
Published: May 2024

INTRODUCTION:

Doulas are nonmedical trained professionals who provide physical, emotional, and educational support to birthing people throughout their pregnancy and postpartum journey including being present at labor and delivery. In this comprehensive role, doulas help patients advocate for their needs and are able to drive effect on birthing and nonbirthing outcomes. Despite their value, there are significant financial, logistical, and geographical challenges to accessing doula services. This analysis evaluated the association between virtual doula use on Maven, a virtual clinic for women’s and family health, with users’ nondelivery outcomes.

METHODS:

This retrospective cohort study used data from 8,989 Maven users who gave birth between January 1, 2020, and April 22, 2023. Logistic regression models estimated the association between total number of doula appointments on the digital health platform with odds of reporting that Maven helped with 1) managing anxiety and/or depression and 2) feeling strongly supported throughout pregnancy. This research was deemed exempt by WCG IRB.

RESULTS:

In adjusted models, attending one or two or more Maven doula appointments was significantly associated with users reporting Maven helped them manage their mental health (one appointment: odds ratio [aOR] 1.28; 95% CI, 1.05–1.56; two or more appointments: aOR 1.78; 95% CI, 1.40–2.26) and helped them feel supported throughout their pregnancy (one appointment: aOR 1.99; 95% CI, 1.74–2.28; two or more appointments: aOR 3.26; 95% CI, 2.70–3.94).

CONCLUSION:

Digitally accessed doulas drive effects beyond labor and delivery outcomes and break down barriers to accessible holistic care.
“She Resolved My Doubts, and I Was a Little Calmer”: A Qualitative Analysis of the HoPE Community-Based Doula Care Program in an Urban Public Hospital [ID 2683480]
Authors: Helm Kaila V. T. , Haq Kanwal L. , Maru Sheela , Rodriguez Alva R. R. , Cooke Caroline , Boychuk Natale A.
Published: May 2024

INTRODUCTION:

Doula care, or trained lay birth support, represents an evidence-based and cost-effective strategy to improve maternal and child health. However, limited studies have focused on implementing doula care, especially in racial and ethnic minoritized communities. This study assessed HoPE (Helping Promote Birth Equity through Community-Based Doula Care), an intervention within two Queens, New York, public hospitals.

METHODS:

This qualitative analysis is part of a mixed-methods evaluation using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation science framework (IRB 21-01571). We conducted interviews in English or Spanish with HoPE doula clients (n=13), doulas (n=10), and health care providers (n=8) to assess acceptability, feasibility, and satisfaction. Interviews were audio-recorded, transcribed, and translated (if needed). Multiple coders analyzed themes and developed an analytical narrative.

RESULTS:

Preliminary findings suggest that HoPE serves a population in critical need of the support offered by community-based doulas. Regarding reach, doula clients were primarily immigrants and first-time mothers with limited social support and financial resources. We observed doula effectiveness in health care navigation, communication with providers, emotional, mental health, and physical support, infant care, health education, and referrals to social resources. Doula clients, doulas, and providers were generally satisfied with the program and found it acceptable and feasible. Implementation challenges, including language capability and timely client matching, hindered reach and effectiveness.

CONCLUSION:

These preliminary findings demonstrate how community-based doula support can improve health care access and quality of care in diverse, underserved communities. Ongoing evaluation will be used to improve HoPE and contribute to the knowledge of community-centered interventions promoting equity in obstetric care.
The Association of Second-Trimester Cervical Length With Mode of Delivery [ID 2683533]
Authors: Pember Nicolette G. , Thayer Sydney M. , Zofkie Amanda C.
Published: May 2024

INTRODUCTION:

Second-trimester transvaginal cervical length (TVCL) under 2.5 cm is a well-established risk factor for preterm birth and mid-trimester loss. However, few studies have investigated birth outcomes associated with increasing lengths of “normal” TVCL (2.5 cm or greater). We aimed to evaluate the association of normal TVCL tertiles with mode of delivery.

METHODS:

This is a retrospective cohort study of patients eligible for vaginal birth with singleton term gestations and normal TVCL (at 16–24 weeks of gestation) delivering at a tertiary care center from June 2022 to June 2023. Mode of delivery was compared by TVCL tertiles: T1, 2.5–3.49 cm; T2, 3.5–4.49 cm; and T3, 4.5 cm or greater. Multivariable logistic regression controlled for potential confounders. Institutional review board approval was obtained.

RESULTS:

Of 1,033 eligible deliveries, 175 (16.9%), 621 (60.1%), and 237 (22.9%) had TVCL in T1, T2, and T3, respectively. Compared to patients with TVCL in T1, those in T2 and T3 were significantly more likely to have an intrapartum cesarean delivery (CD) (T1 3.4% versus T2 8.5%, P=.02; T3 11.8%, P=.002), with odds ratios (ORs) of 2.63 (CI, 1.1–7.6) and 3.77 (CI, 1.5–11.4), respectively. After adjusting for confounders, those with TVCL in T3 remained statistically more likely to undergo CD than those in T1, adjusted OR 6.7 (CI, 2.3–19.2). Of note, no patients with TVCL in T1 had CD for Stage 1 arrest.

CONCLUSION:

Patients with longer TVCL at 16–24 weeks are significantly more likely to undergo an intrapartum CD. This association can be considered during patient counseling on delivery outcome expectations.
Timing of Mifepristone Relative to Misoprostol Critical for Reducing Blood Loss and Need for Surgical Procedure for Induction of Labor in the Second Trimester [ID 2683544]
Authors: Bayer Samantha , Rasmussen Chloe , Pinsky Alana N. , Paul Rachel
Published: May 2024

INTRODUCTION:

Mifepristone is used in combination with misoprostol to facilitate inpatient induction of labor in the second trimester; however, the optimal interval of time between administration of these drugs is not known. Current practice guidelines recommend an interval of 24–48 hours.

METHODS:

In a single-institution retrospective chart review study, we examined whether mifepristone administration practices at that institution improved loss induction duration or adverse outcomes. This study was determined to be exempt from IRB approval.

RESULTS:

Among 267 loss inductions from 2018 to 2022, 54% received mifepristone. When misoprostol-alone inductions are compared to those that also received mifepristone, results demonstrate no difference in time to delivery (15.1 versus 15.9 hours; P=.62) or adverse outcomes, including blood loss greater than 1 L (8.2% versus 13.1%; P=.24) and need for operating room (OR) procedure (15.6% versus 16.6%; P=.86). Importantly, the average interval in this study between administration of mifepristone and misoprostol was 1.3 hours (median, 0.1 hours). Further analysis of those patients who received mifepristone demonstrated improved outcomes only if mifepristone was given at least 3 hours prior to misoprostol, including blood loss greater than 1 L (17.4% versus 0%; P=.0037) and need for OR procedure (21.4% versus 2.7%; P=.0088). There remained no difference in time to delivery (16.0 versus 15.8 hours; P=.94).

CONCLUSION:

These data demonstrate the importance of the timing of mifepristone and misoprostol administration for loss induction and strongly suggest that at least a 3-hour interval is required to improve adverse outcomes. Further prospective study is warranted to broaden the scope of these findings.
Umbilical Cord Blood Collection During Cesarean Section: Effect on Maternal Blood Loss and Morbidity [ID 2683610]
Authors: Lederer Madeline , Coon Aidan , Hopkins Maeve
Published: May 2024

INTRODUCTION:

Umbilical cord blood collection (UCBC) for stem-cell banking is routinely performed during cesarean sections (CS). Few studies have examined the maternal effect. This study's objective is to evaluate whether UCBC during CS is associated with increased maternal blood loss and morbidity.

METHODS:

This was a single-center retrospective cohort study of primary CS (PCS) in 2021. Exclusion criteria were age less than 18, multifetal gestation, gestational age less than 34 weeks, emergency, and infection. Data were compared between participants with and without UCBC during PCS. Extensive demographic data was collected and compared. The primary outcome was quantitative blood loss (QBL). Secondary outcomes were operative time, hemorrhage medication usage, and blood transfusion (BT).

RESULTS:

Eight hundred two PCS were reviewed, and 191 were excluded. Of the remaining 611, UCBC was attempted in 151 (24.7%). The UCBC cohort had higher gestational age (39.1 versus 38.7; P=.007), were less often in labor (P=.004) or on magnesium (P=.022), and were more likely to be scheduled (P=.002). Quantitative blood loss was higher with UCBC (1,091.5 versus 1,007.5 mL; P=.075). In non-labored PCS, the QBL difference was statistically significant (941.8 versus 798 mL; P=.034). Umbilical cord blood collection was associated with increased operative time (62.4 versus 56.8 minutes; P<.001) and postoperative BT (7.2% versus 3.3%; P=.036). There were no associations between UCBC and usage of hemorrhage medications.

CONCLUSION:

Umbilical cord blood collection increases QBL in nonlabored PCS. Umbilical cord blood collection increases operative time and postoperative BT in PCS. Patients should be appropriately counseled and selected for UCBC based on hemorrhage risk factors.
Induction Method Combination in Patients With Hypertensive Disorders of Pregnancy [ID 2683632]
Authors: Price Corley Rachelle , Luceno Lisvet , Givens Florence Osei , Vilchez Gustavo , Louis Judette Marie , Duncan Jose R.
Published: May 2024

INTRODUCTION:

We aim to evaluate cesarean birth (CB) rates according to induction method combinations in patients with hypertensive disorders of pregnancy (HDP).

METHODS:

We conducted a retrospective study including singleton pregnancies with HDP admitted to labor and delivery at a tertiary center from January 2018 to December 2019. Clinical and sociodemographic data were extracted from electronic medical records. Pregnancies with incomplete data and those who declined a trial of labor were excluded. Hypertensive disorder of pregnancy was defined according to the American College of Obstetricians and Gynecologists classification. Cesarean birth rates were compared among induction agent combinations using binary logistic regression. A value of P<.05 was considered significant.

RESULTS:

A total of 552 pregnancies met inclusion criteria. Of these, 113 were induced with oxytocin, 112 with mechanical agents and oxytocin, 58 with a mechanical method and prostaglandins, 31 received prostaglandins alone, 54 received oxytocin and prostaglandins, 80 received oxytocin, prostaglandins, and a mechanical agent, 35 were induced with mechanical methods, and 69 were in spontaneous labor. Demographic and baseline characteristics were not different by induction agent combination. After logistic regression, the combination of prostaglandins and mechanical agents was associated with a decreased CB rate; odds ratio, 0.4 (95% CI: 0.1–0.9), using those in spontaneous labor as reference. No other agent combination was associated with an increased or decreased in CB rate.

CONCLUSION:

Induction of labor with a combination of prostaglandins and mechanical agents may decrease CB rates compared with other combination methods for induction in pregnancies with HDP.
For Patients Undergoing an Induction of Labor, Does Increased Body Mass Index Necessitate Higher Doses of Misoprostol? [ID 2683640]
Authors: Mason-Otey Akailah T. , Lundsberg Lisbet S. , Culhane Jennifer F. , Merriam Audrey
Published: May 2024

INTRODUCTION:

Obesity is associated with prolonged induction of labor (IOL). This study aimed to investigate the association between body mass index (BMI) and number of misoprostol administrations in patients undergoing IOL.

METHODS:

This was a retrospective cohort analysis of patients undergoing IOL at a single institution from June 2012 to January 2023. Singleton, term patients receiving at least one dose of misoprostol were included (n=4,780). Body mass index at admission was defined as normal (18.5 to <25.0), overweight (25 to <30), Class I obesity (30 to <35), Class II obesity (35 to <40), and Class III (≥40). The primary outcome was the number of misoprostol doses. Demographics were compared by BMI category using chi-square and ANOVA. Crude and multiple linear regression was used to generate parameter estimates and 95% CIs.

RESULTS:

Among the cohort, 4.6%, 23.9%, 31.3%, 21.0%, and 19.2% were normal, overweight, Class I, Class II, and Class III, respectively. Public insurance, cHTN, HDP, and pre-gestational diabetes were positively associated with increasing BMI (P<.0001). Mean misoprostol doses significantly increased across BMI categories (from normal 3.3 [SD 2.4] to Class III 5.0 [SD 3.6]; P<.0001). Compared to normal BMI, model estimates increased for overweight, 0.75 (CI, 0.29–1.22); Class I, 1.03 (CI, 0.57–1.48); Class II, 1.40 (CI, 1.93–1.87); and Class III, 1.75 (CI, 1.28–2.22). After adjustment for aforementioned demographics, these estimates were attenuated but still significant.

CONCLUSION:

Increasing BMI is associated with increased average dose of misoprostol during IOL. This highlights the need to investigate safety of increased misoprostol dosing for IOL among obese patients.
Antepartum and Intrapartum Characteristics Associated With Neonatal Encephalopathy [ID 2683510]
Authors: Denisova Elizabeth , Gurram PadmaLatha , Khan Sameer A. , Livatova Katherine , White Abbigail , Reynolds Katherine
Published: May 2024

INTRODUCTION:

We aim to identify antepartum and intrapartum characteristics associated with neonatal encephalopathy (NE).

METHODS:

This is a retrospective cohort study from 2013 to 2023. Neonates greater than 34–35 weeks of gestation with NE were identified based on ICD-9/ICD-10 codes. Each case was matched to three controls. Neonates (>34–35 weeks of gestation, cord pH >7, no NE) next to index case were identified as controls. Congenital anomalies, chromosomal abnormalities, and less than 34 weeks were excluded. The outcome measures are incidence and trends of NE in last 10 years and antepartum and intrapartum risk factors associated with NE. This study was IRB approved.

RESULTS:

Twenty cases were included and matched with 60 controls. The number of cases increased since 2013. 1 in 6,000 neonates delivered was identified as NE in 2014, versus 4 of the 5,700 births in 2016, versus 3 of the 2,114 neonates delivered in 2023. Mean maternal age, race/ethnicity/insurance are similar between groups. Cases are more likely to have obesity class 3 (P=.05) and nulliparous (P=.01), class A2 gestational diabetes mellitus (GDMA2) (P=.05), preterm prelabor rupture of membranes (PPROM) (P=.0.01), and tobacco use (P=.00). There is statistically significant difference in Category 3 fetal heart tracing (P=.00), meconium (P=.03), placental abruption (P=.00), and general anesthesia (P=.00) between groups. Mode of delivery, breech, shoulder dystocia cord prolapse, chorioamnionitis, uterine rupture, amniotic fluid embolism, and maternal cardiovascular collapse were similar between groups. Gestational age at delivery, birth weight, and gender were similar between groups.

CONCLUSION:

The risk factors associated with NE in our study are obesity class 3, nulliparity, tobacco use, GDMA2, PPROM, Category 3 tracing, meconium, and placental abruption.
Effects of COVID-19 Vaccination on Nebraska Maternal Health Outcomes [ID 2683619]
Authors: Wells Brittney , Walsh Marissa , Soares Lauren , Borland Ashley , Becker Ashley , Zeineddine Sami
Published: May 2024

INTRODUCTION:

When the COVID-19 vaccine was developed, there were many concerns about the risk–benefit profile, especially in pregnancy. The purpose of this study was to elucidate the effect of COVID-19 vaccination on maternal health outcomes.

METHODS:

An IRB-approved, retrospective analysis was performed using data from CHI Nebraska's 2021 EPIC health records to determine whether maternal COVID-19 vaccination prior to delivery in previously healthy, primigravid women aged 18–35 affected maternal health outcomes. The outcomes studied included preterm delivery, eclampsia, gestational diabetes, preeclampsia, placental abruption, placenta previa, and postpartum hemorrhage.

RESULTS:

Of the 7,997 patients analyzed, 1,220 were vaccinated for COVID-19 prior to their delivery date. Compared to patients that were not vaccinated, vaccinated patients had statistically significant increased rates of gestational diabetes and preeclampsia (odds ratio [OR] 1.31; P=.02103; OR 1.47, P=.00589). Vaccinated patients were also found to have increased rates of eclampsia, placenta previa, preterm delivery, and postpartum hemorrhage, but these were not statistically significant. Clinically, these differences between vaccinated and nonvaccinated patients were small for all outcomes tested, all being less than 2%.

CONCLUSION:

Although our research was restricted by accessibility of the vaccine in early 2021, it illustrated that vaccinated individuals did not experience any significant increase in eclampsia, placenta previa, postpartum hemorrhage, or preterm delivery compared to the unvaccinated. We found that history of COVID-19 vaccination correlated with a small, yet significant increased rate of gestational diabetes and preeclampsia. Further research should be done to further elucidate how the vaccination affects health outcomes as they pertain to pregnancy.
Correlation of Peripartum Acute Kidney Injury Severity With Obstetric Comorbidity Index Scores and Maternal Morbidity [ID 2683636]
Authors: Kishkovich Thomas , Kempf Abigail M. , Pelletier Andrea , Patton Nicole , Farber Michaela K. , Smith Nicole A.
Published: May 2024

INTRODUCTION:

Risk stratification systems are increasingly used to predict obstetric complications. The Obstetric Comorbidity Index (OB-CMI) is one validated prediction tool, applying weighted scores to maternal and obstetric conditions. Although acute kidney injury (AKI) is a severe maternal morbidity, there is limited information on predicting AKI severity. We aimed to investigate the utility of OB-CMI scores and its specific comorbidities in predicting obstetric AKI severity, and the relationship of AKI severity and other maternal morbidity outcomes.

METHODS:

This was an IRB-exempt, retrospective cohort study of AKI cases (ICD-10 code N17.0-17.9) between January 2018 and December 2022 at a single academic institution with ∼6,000 births annually. Information was extracted via chart review. Cases were stratified by those meeting American College of Obstetricians and Gynecologists (ACOG)/Society for Maternal-Fetal Medicine (SMFM) criteria for severe renal injury. Those with unknown baseline Cr were assigned 0.7 (the 95th percentile Cr value at 39–40 weeks). Groups were compared based on admission OB-CMI scores and comorbidities, and maternal morbidity events using independent t-tests, χ2, and Fisher's exact as appropriate.

RESULTS:

Two hundred thirty cases were reviewed: 8.3% (19 cases) met ACOG/SMFM AKI criteria. There was no significant difference in mean OB-CMI scores (mean 3.8 versus 4.1; P=.782) or incidence of individual comorbidities between groups. Regarding other maternal morbidity events, ACOG/SMFM criteria AKI was significantly associated with other severe morbidity events (47.4% versus 12.3%; P<.001), including transfusion, disseminated intravascular coagulation, intubation, and intensive care unit admission.

CONCLUSION:

The OB-CMI score was poorly predictive of AKI severity; however, the occurrence of severe AKI by ACOG/SMFM criteria was associated with a 4-fold increased rate of co-occurring maternal morbidity events and a 2.5-fold increased rate of blood transfusion.
Patient Needs and Perceptions of Doula Care: A Survey Study [ID 2683478]
Authors: Marudo Catherine P. , Nicotra Caroline , Chou Brandon , Fletcher Michelle M. , Amani Jamarah , Antoine Rebekah
Published: May 2024

INTRODUCTION:

Doulas improve birth outcomes, and doulas that provide culturally congruent care are needed in historically marginalized communities who experience stark disparities in maternal mortality and morbidity. This study characterizes the needs and perceptions of doula care among patients from the same health care system.

METHODS:

This IRB-approved, cross-sectional study, in collaboration with community-based midwives and doulas, administered de-identified surveys in two obstetrics/gynecology clinics in South Florida. Surveys characterized 1) patient demographics, along with 2) patient understanding of, and 3) patient need for doula care.

RESULTS:

One-hundred seventy-six patients were surveyed and an alpha level of 0.05 was utilized for all statistical tests. Multivariate analysis showed that patients with an annual household income between $25,000 and $50,000 (OR = 4.87; 95% CI, [1.02–23.36]) were almost five times more likely than those with an annual household income below $25,000 to have an interest in doula care. Chi-squared analysis found no statistically significant relationship between race and interest in doula care, X2 (4, N = 176) = 2.80, P=.591. Among patients who expressed interest for doula care, χ2 analysis found a statistically significant relationship where Black and/or African American patients were less likely than White/Caucasian patients to be able to pay for doula care, X2 (8, N = 148) = 19.25, P=.014.

CONCLUSION:

Results illustrate an increased need for doula access among patients in a large academic, safety-net hospital, especially those from historically marginalized groups. This study encourages other health care systems to assess the need for increased doula support within their communities.
Single-Dose Azithromycin Prophylaxis in Planned Vaginal Delivery for Sepsis Prevention: A Systematic Review and Meta-analysis of Randomized Controlled Trials [ID 2683483]
Authors: Philip Chris E. , Crosara Laura F. , Orsini Pedro V. B. , Eskandar Karine , Khalil Samira M.
Published: May 2024

INTRODUCTION:

The use of oral azithromycin as a preventive measure against postpartum infections of planned vaginal births has been the subject of many randomized controlled trials. However, the results from these trials have not been consistent. Therefore, performed a systematic review and meta-analysis to determine whether the use of a single-dose of oral azithromycin is clinically significant.

METHODS:

We systematically searched PubMed, Embase and Cochrane Central for RCTs from May to June 2023, comparing a single dose of oral azithromycin to placebo in patients undergoing planned vaginal delivery at minimum 28 weeks of gestational age. The main outcomes were puerperal and neonatal sepsis. Statistical analyses were performed using Review Manager 5.4.1 (Cochrane Collaboration). Heterogeneity was assessed with I2 statistics.

RESULTS:

Four randomized controlled trials were included (mothers, n= 42,235; newborns n= 42,492). Approximately 49.8% of mothers received a single dose of oral azithromycin for sepsis prophylaxis. Azithromycin significantly reduced the incidence of puerperal sepsis (risk ratio [RR] 0.65; 95% CI; P<.001), mastitis or breast abscess (RR 0.58; 95% CI; P<.001), endometritis (RR 0.65; 95% CI; P<.001), wound infection (RR 0.81; 95% CI; P=.013), infection rate (RR 0.62; 95% CI; P<.001) and fever (RR 0.50; 95% CI, 0.28–0.89; P=.018) in mothers compared to placebo.

CONCLUSION:

Azithromycin shows to be an effective preventive measure against many postpartum infections in mothers but a substantial effect on neonatal outcomes has not yet been conclusively observed.
A Retrospective Look at Clusters of Maternal Mortality [ID 2683584]
Authors: Solomon Lindsey , DeCesare Ana , Amin Raid W. , Taylor Sarah A. , Decesare Julie
Published: May 2024

INTRODUCTION:

The objective of this study was to identify clusters in the United States with the highest and lowest rates of maternal mortality, to pinpoint changes in maternal mortality rates, and to forecast maternal deaths by demographic variables.

METHODS:

A retrospective cohort study was used to report maternal deaths in the United States. The maternal mortality counts (as defined by ICD-10 codes) from 2010 to 2020 at the county level for the 48 contiguous states were obtained from the Centers for Disease Control and Prevention (CDC) via their Wonder application. Variables such as population density, environmental conditions, race, ethnicity, and physical and mental health conditions for each county were identified. A regression analysis and spatial cluster analysis of these variables generated a heat map to identify areas in the United States with high and low rates of maternal mortality.

RESULTS:

Spatial clusters in the 48 contiguous states averaged across all years were identified. There are discrete areas with higher maternal mortality, some broad, such as the Southeast region, and some specified to cities, such as New York. A regression model used multiple factors to predict maternal deaths from demographic variables. The four best predictors were high population density, air pollution, and Hispanic and African American ethnicities. Clusters were also identified with the lowest maternal mortality.

CONCLUSION:

The United States has the highest maternal mortality rate (MMR) among all high-income countries. Historically, MMR has steadily increased since 2016. This study found that the best predictors for maternal mortality were high population density, air pollution, and Hispanic and African American subpopulations. Such a study can be used by health agencies and beyond to delve into possible causes of elevated maternal mortality in certain geographic regions of the United States. More studies are indicated to determine causality and unearth strategies to improve maternal outcomes.
The Effect of Preeclampsia on Adverse Maternal Outcomes in Women With Placental Abruption at a Large Urban Hospital in Tennessee From 2019 to 2022 [ID 2683655]
Authors: Swayze Emma J. , Swailes Alexa L. , Weber Caiden
Published: May 2024

INTRODUCTION:

Placental abruption is associated with increased pregnancy-related morbidity and mortality. Few studies have explored the effect of individual risk factors for placental abruption on outcomes. Our study evaluates the association of preeclampsia and maternal morbidity in patients with placental abruption.

METHODS:

We conducted a retrospective case–control study to evaluate the association of preeclampsia with adverse maternal outcomes in the setting of placental abruption. Univariate analyses were used to determine the relationship between preeclampsia and known adverse maternal outcomes of placental abruption. Multivariate logistic regression was then used to evaluate the relationship between preeclampsia and each significantly associated outcome, adjusting for factors including body mass index, gestational age, mode of delivery, race, trauma, diabetes, placental location, cocaine and tobacco use, prior cesarean sections, year of delivery, and parity. Significance was assessed at an alpha of 0.05.

RESULTS:

Of 147 singleton pregnancies complicated by placental abruption from 2019 to 2022, 37 (25.2%) were complicated by preeclampsia. No significant differences were found between groups in incidence of acute kidney injury, disseminated intracellular coagulation, cesarean delivery, fetal demise, preterm birth, or low birth weight. On adjusted multivariable regression, we found preeclampsia increased the odds of maternal transfusion requirement (adjusted odds ratio [aOR] 3.55; 95% CI: 1.2, 10.4) and postoperative hospital stay greater than 2 days (aOR 4.05; 95% CI: 1.5, 11.2).

CONCLUSION:

Preeclampsia was an independent predictor of need for blood transfusion and increased duration of hospital stay in patients with placental abruption. Recognition of preeclampsia as an independent risk factor for these outcomes may allow medical optimization, increased preparedness, and lead to decreased pregnancy-related morbidity.
Multidisciplinary Simulation Improves Resident Comfort With Perinatal Bereavement Care [ID 2683378]
Authors: Santos Roca Antonio J. , Rodriguez Normaliz , Poehacker Stefanie , Hays Jacinda , Chase Tess
Published: May 2024

INTRODUCTION:

Physicians have difficulty delivering bad news because of discomfort and lack of appropriate education. We introduce an initiative to enhance trainee comfort in delivering the diagnosis of intrauterine fetal demise (IUFD) through multidisciplinary simulation training.

METHODS:

Twelve obstetrics and gynecology residents participated in perinatal bereavement training with a palliative care specialist utilizing the SPIKES framework, followed by an immersive simulation of an IUFD case and debrief with multidisciplinary physicians. Pre- and post-training surveys were administered. This study was approved by the IRB.

RESULTS:

Participants were equally distributed in training year (58% female, 33% male). 92% had previously delivered the diagnosis of IUFD, yet 50% had no previous bereavement training, and of those with training, most (84%) had less than 2 hours. Wilcoxon signed-ranks tests showed statistically significant increase in comfort level of delivering bad news (Z=66; P=.003), delivering a diagnosis of fetal demise (Z=64; P=.005), and having the skills and foundation to deliver the news of a fetal demise (Z=28; P=.017). Qualitative responses identified acquisition of verbal and nonverbal skills such as direct patient communication, using the word death, and sitting down at the patient’s eye level prior to delivering the news. Most described the experience as real, immersive, and a safe learning environment. One hundred percent would recommend the course to others.

CONCLUSION:

Perinatal bereavement education in obstetrics and gynecology residency training is lacking. Multidisciplinary, immersive simulation training significantly increased residents’ comfort and perceived preparedness in delivering the diagnosis of fetal demise.
The Necessity of Type and Screen Result Prior to Proceeding to Operating Room for Scheduled Cesarean Delivery in a Low Hemorrhage Risk Population [ID 2683392]
Authors: Hoffmann Eva , Druyan Brian Z. , Fletcher Michelle M. , Ridore Michelande , Paidas Michael J. , Toledo Paloma
Published: May 2024

INTRODUCTION:

Delays in the operating room (OR) on labor and delivery are common. This leads to inefficiency, patient, and physician dissatisfaction and financial ramifications. One root cause of OR delays involves waiting for type and screen results prior to wheels into the OR. Our objective was to determine whether a type and screen result is necessary prior to wheeling into the OR.

METHODS:

This was an IRB-approved retrospective cohort study conducted at a single state sponsored academic institution. Chart review was performed identifying all patients who had a scheduled cesarean delivery (CD) from August 1, 2022, through September 31, 2022. We identified all patients who received a blood transfusion intra-op or postoperatively. We excluded all patients who had a medium-risk hemorrhage score or greater. We then calculated timing of blood transfusion from wheels into the OR.

RESULTS:

We identified a total of 85 patients scheduled for CD. Of these, 7 patients required a blood transfusion, and 4/7 patients received a blood transfusion within 60 minutes of wheels into the OR. There were no patients with a low-risk hemorrhage score on admission who received a blood transfusion within 60 minutes of wheels into the OR.

CONCLUSION:

There were no patients with a low-risk hemorrhage score scheduled for CD required a blood transfusion within 60 minutes of wheels into the OR. This supports elimination of mandatory type and screen result prior to wheels in for patient scheduled for CD with a low-risk hemorrhage score.
Intimate Partner Violence Screening in a Pregnant Military Population: Implementation of the E-HITS Protocol [ID 2683442]
Authors: Gregg Rebecca W. , Teneyuque Nicholas , Griffis Jeffrey
Published: May 2024

INTRODUCTION:

The military population has higher rates of intimate partner violence (IPV) compared to the civilian population. This is further exacerbated in obstetrics patients, with an estimated rate of 4–29% of pregnant women affected. The American College of Obstetricians and Gynecologists and 2018 Department of Defense Clinical Practice Guidelines for Management of Pregnancy recommend routine screening for IPV at obstetric visits, although a preferred screening modality has not been identified.

METHODS:

The prevalence of IPV in pregnancy before and after implementation of the validated Extended-Hurt, Insult, Threaten, Scream (E-HITS) questionnaire at a single military treatment facility was compared. Retrospective chart review was conducted between January and December 2019 of patients who had been screened using a single question (“Do you feel safe at home?”). E-HITS was implemented in the obstetrics clinic in February 2022, and data were collected prospectively for 12 months. The difference between the two IPV screening modalities was analyzed using Fisher’s exact test.

RESULTS:

A total of 1,627 IPV screenings were reviewed. Of the 783 IPV screenings using the single question, there were 2 positive screens (0.26%). Using greater than 7 as the positive screening cutoff, there were 24 positives (2.84%) out of the 844 E-HITS screenings. Using greater than 6 as the cutoff for E-HITS, there were 54 positive screens (6.4%). There was a statistically significant difference in the detection rate between the two modalities at both cutoff levels (P<.0001).

CONCLUSION:

E-HITS is a more sensitive screening tool for IPV in this population, more closely mirroring previously published rates.
Discharges Against Medical Advice in Pregnant Patients at a Canadian Tertiary Care Center: Does Lack of Access to Childcare Play a Role? [ID 2683591]
Authors: Litalien Ariane , Aubrey Christa L. , Merali Sabrina
Published: May 2024

INTRODUCTION:

Discharges against medical advice (AMA) during pregnancy have been associated with poor maternal and fetal outcomes. Moreover, one of the documented reasons why female patients might leave the hospital AMA is lack of access to childcare. In recent years, lack of access to childcare has been identified as a potential risk factor for discharge AMA and maternal mortality at a tertiary care center in Edmonton, Alberta, Canada. The goal of this chart review project is to study the characteristics of pregnant women who leave AMA from this center, and to determine what proportion of these discharges is due to difficulties securing childcare.

METHODS:

Ethics approval was obtained through the University of Alberta’s Health Research Ethics Board. All patients who were discharged AMA from the triage and antepartum units at the study site between May 28, 2021, and May 27, 2022, were identified. Patients were included in the chart review as long as they remained undelivered at the time of discharge. Reasons for admission and discharge AMA were extracted from each patient’s chart whenever available. Patients' age, gravidity, parity, and gestational age at the time of discharge were also collected.

RESULTS:

During the study period, approximately 9.3% of recorded discharges from the triage and antepartum units were for patients who left AMA. In total, we included 89 individual patient visits that ended with a discharge AMA. For these patients, the most frequent reason for admission was threatened preterm labor (including short cervix). Although the reason motivating discharges AMA was not documented in the majority of charts reviewed (49/89), lack of access to childcare was the most frequently documented reason provided by patients for leaving AMA (15/40).

CONCLUSION:

Improving access to childcare for pregnant patients who are admitted to the study site might help to decrease discharges AMA, and therefore help reduce perinatal complications.
Reduction of the NTSV (Nulliparous, Term, Singleton, Vertex) Cesarean Section Rate and Evaluation of Balancing Measures [ID 2683626]
Authors: Counts Rachael
Published: May 2024

INTRODUCTION:

To decrease the nulliparous, term, singleton, vertex (NTSV) cesarean section (CS) rate at a single tertiary care center. We hypothesized the NTSV CS rate due to labor dystocia would decrease after the intervention.

METHODS:

Quality improvement interventions were instituted over 7 months, including education on labor dystocia, recognition of NTSV patients, implementation of necessary skills, guidelines to support labor progression, and improvements in team communication. A retrospective chart review was performed over the 6 months prior and 6 months after intervention period. Primary outcomes included NTSV CS rates and indication for CS. Secondary outcomes included adverse maternal and neonatal outcomes.

RESULTS:

There were 1,079 NTSV patients during the pre-intervention (n=421) and post-intervention (n=658) timeframes. The NTSV CS rate downtrended but was not statistically different between the pre- and post-intervention timeframes. The NTSV CS rate due to labor dystocia down-trended but was not statistically different. There were no differences in the neonatal adverse outcomes pre- and post-intervention. Rates of chorioamnionitis/endometritis (4.1% pre- versus 9.9% post-intervention; P=<.01) and hospital readmission rates (0.3% pre- versus 2.7% post-intervention; P=.01) were both significantly increased in the vaginal delivery cohort after the intervention. Differences in other maternal adverse outcomes pre- and post-intervention were not statistically different in the vaginal delivery nor CS cohort.

CONCLUSION:

Despite not being statistically significant, there was a notable clinical difference in the NTSV CS rate following this quality improvement initiative. However, the potential associated increases in chorioamnionitis/endometritis and postpartum readmission rates should be considered.
Obstetric Anal Sphincter Injury Management at a Tertiary Academic Birthing Center: A Quality Improvement Initiative [ID 2683441]
Authors: Zdroik Anna , Greene Andrew , VanderMeersch Courtney M. , Stamilio David M. , Matthews Catherine A.
Published: May 2024

INTRODUCTION:

As a quality improvement project, we implemented an evidence-based management protocol to optimize outcomes after obstetric anal sphincter injuries (OASIS). The aim was to evaluate compliance with practice guidelines for antibiotic use, standardized surgical technique and documentation, utilization of a bowel regimen, and short-term outpatient follow-up after a resident educational OASIS program.

METHODS:

An OASIS practice guideline was implemented via a curriculum utilizing didactics and simulation with porcine sphincter models to demonstrate primary prevention, proper diagnosis, repair technique, documentation, and post-procedure OASIS management. Pre (August 2018 to July 2022) and post-intervention (August 2022 to July 2023) cohorts were compared for characteristics and provider adherence to guidelines. We used control charts, chi-squared, and Student's t-tests to estimate the effect of the intervention.

RESULTS:

Among 226 OASIS cases, 168 were pre-intervention and 58 were post-intervention. Proper documentation of OASIS repair increased from 13 (7.7%) pre-intervention to 24 (41.4%) post-intervention (risk ratio [RR] 7.57; 95% CI, 4.3–13.1); proper antibiotic use increased from 79 (47.0%) pre-intervention to 39 (67.2%) post-intervention (RR 1.42; CI, 1.12–1.18); and utilization of bowel regimen increased from 147 (87.5%) to 56 (96.6%) post-intervention (RR 1.1; CI, 1.02–1.18). There was no change in close follow-up appointment attendance (81.0% for both groups; P=.98). Control charts showed a process change in bowel regimen use and OASIS documentation, but no significant change in antibiotic use or close follow-up appointments.

CONCLUSION:

Implementation of an evidence-based management guideline was associated with increased compliance with evidence-based practices. Future improvement cycles are necessary to optimize outpatient follow-up after OASIS.
Patient and Provider Perspectives on Postpartum Pain Management in Individuals With Opioid Use Disorder and Chronic Pain [ID 2683542]
Authors: Azar Michelle , Sharif Limi , Moniz Michelle H. , Low Lisa Kane , Peahl Alex
Published: May 2024

INTRODUCTION:

Birthing people with opioid use disorder (OUD) and chronic pain (CP) face significant barriers to effective postpartum pain management including medical complexity of analgesic decisions as well as stigma and bias towards individuals with these diagnoses. To date, clinical practice guidelines (CPGs) for patients with OUD and CP have lacked patients’ perspectives. We sought to capture voices of patients and their medical providers to inform effective, equitable pain management CPGs for birthing people with OUD and CP.

METHODS:

We performed a subgroup analysis of 31 patient and 22 provider interviews conducted to develop CPGs. Institional review board approval was obtained along with participant consent, and data were de-identified. We isolated quotes pertaining to OUD and CP from participants with and providers caring for individuals with these conditions. We then used inductive thematic analysis, allowing insights to emerge from the data.

RESULTS:

In total, 266 quotes were identified relating to OUD and CP. Five key themes emerged from the data: 1) the need to mitigate health care team bias to improve pain management access and experience; 2) the need for standardized sets of pain management options for all patients; 3) the importance of tailoring pain management plans to individuals’ unique needs; 4) the need to partner with patients in creating pain management plans to promote trust and autonomy; and 5) the importance of interprofessional teams in treating postpartum pain for individuals with OUD and CP.

CONCLUSION:

Interviews with patients and the people who care for them reveal important considerations for CPGs that improve rather than exacerbate existing disparities for birthing people with OUD and CP. Implementation of CPGs informed by patients’ lived experiences is a crucial step in ensuring equitable options for postpartum pain management in patients who face significant biases and barriers to effective care.
Factors Associated With Postpartum Readmission for Hypertension in Women With Hypertensive Disorders of Pregnancy [ID 2683562]
Authors: Chen Grace , Jones Jody , Mowers Erika
Published: May 2024

INTRODUCTION:

Hypertensive disorders of pregnancy (HDP) are a common indication for postpartum readmissions. Our study aims to identify demographic and clinical variables associated with hypertension-related postpartum readmissions in patients with known HDP.

METHODS:

We conducted a retrospective cohort study at a single institution of patients who delivered between March 1, 2020, and March 31, 2022. We included patients with a HDP during their delivery admission but excluded those with chronic hypertension. Bivariate analysis was performed to identify if readmission rates were associated with maternal age, race, ethnicity, delivery route, severe disease, blood pressure before discharge, discharge timing, antihypertensive regimen inpatient and at discharge, or attendance at an outpatient blood pressure check. These variables were further stratified by race.

RESULTS:

Of 1,744 included patients, 68 (3.9%) were readmitted for hypertension. Odds of readmission increased if patients were greater than 35 years old (odds ratio [OR] 1.96; 95% CI, 1.13–3.41), had average blood pressure within 12 hours of discharge 140–149/90–99 (OR 1.95; 95% CI, 1.06–3.58), or if last blood pressure before discharge was 140–149/90–99 (OR 2.14; 95% CI, 1.22–3.74), and decreased if patients had severe disease (OR 0.41; 95% CI, 0.20–0.83) or received magnesium sulfate (OR 0.36; 95% CI, 0.18–0.71) during their delivery admission. Stratification by race did not elucidate any differences in risk factors.

CONCLUSION:

Blood pressure range in 140s/90s compared with normotension prior to discharge and advanced maternal age was associated with increased odds of postpartum readmission for hypertension. Future research and quality improvement interventions are needed regarding ideal blood pressure range prior to discharge.