bluuebunny/crossref_metadata_2025_split huggingface dataset:
Decentralized Clinical Trials: A Flexible and Efficient Adjunct to Accelerate Pregnancy Complication Research [ID: 1377487]
Authors: Cowan Alison , Brundage Tiffany , Greenberg Rebecca , MacDonald Reece , Moe Alison , Reddy Mitsu 
Published: May 2023

INTRODUCTION:
This study sought to determine whether a decentralized, mobile-friendly, virtual model could achieve appropriate enrollment for a pregnancy health study after COVID-19 closed most clinical research. Preterm birth continues to be a significant and growing issue with 2021 rates exceeding 10%. There is urgent need for new research and technology to improve the ability to predict, prevent, and personalize treatment for complications such as preterm birth, preeclampsia, and gestational diabetes.

METHODS:
This was a prospective, observational study of a cell-free RNA platform utilizing direct-to-participant recruitment via targeted social media from July 2020 to December 2021. The IRB-approved study was open to patients aged 18–45 with a singleton pregnancy in the United States. Participants signed informed consent, provided record release forms, completed a short questionnaire, and scheduled mobile phlebotomy via a web-based platform.

RESULTS:
One thousand eight hundred ninety-four participants submitted samples in less than 18 months. Because of delays in shipping, insufficient volume, temperature stability, and hemolysis, 63 samples (3.3%) were not useable. Medical records were received for over 85% of participants. The cohort is geographically and ethnically diverse representing 1,220 zip codes across 30 states.

CONCLUSION:
This work demonstrates a decentralized, mobile-friendly, virtual study is feasible, efficient, scalable, and flexible, enabling clinical research during a global pandemic. The rate of medical records receipt is likely affected by the large quantity of unique providers and hospitals. This is a rapid, patient-accepted way to conduct clinical research as a supplement to traditional enrollment models.
Race Differences in Transfusion Thresholds in Patients Undergoing Cesarean Delivery [ID: 1377655]
Authors: Phillips Jaclyn , Hacker Francis , Lemon Lara , Simhan Hyagriv , Simhan Jayanthi , Simhan Uma 
Published: May 2023

INTRODUCTION:
Transfusion is a major contributor to severe maternal morbidity (SMM) and is influenced by the presence of anemia on admission for delivery. As rates of SMM vary by race, we sought to describe transfusion thresholds by race and hemoglobin on admission for delivery.

METHODS:
This was an IRB-approved retrospective cohort analysis of deliveries in a single health care network from 2015 to 2020. Multivariable binomial regression models assessed the relationship between transfusion, hemoglobin on admission for delivery, and race. Patients with hemorrhage, abruption, or placenta abnormalities were excluded to control for events associated with transfusion. Models were adjusted for age, parity, insurance, marital status, and tobacco use and evaluated by mode of delivery. Anemia was defined as hemoglobin less than 11.0 mg/dL.

RESULTS:
Eighty-one thousand six hundred thirteen delivery admissions were included. People of Black race diagnosed with anemia had 1.4 times the odds of transfusion compared to White race (95% CI 1.1–1.8). In anemic patients undergoing cesarean, people of Black race had two times the odds of transfusion than people of White race (95% CI 1.4–2.7). For example, people of Black race undergoing cesarean with starting hemoglobin of 6.0 mg/dL had a 76% (95% CI 64–88%) predicted probability of transfusion compared to 27% (95% CI 17–37%) for people of White race at the same starting hemoglobin undergoing cesarean.

CONCLUSION:
Transfusion was more likely in people of Black race compared to White race regardless of starting hemoglobin value or underlying risk factors. This was most pronounced in patients undergoing cesarean. Exploration of specific factors contributing to this finding in the context of structural racism and inequitable care are warranted.
Main Street, USA Enrollment: Community Hospital Recruitment Strategies for Diverse and Equitable Selection of Pregnant Participants in a Prospective Cohort Study [ID: 1377833]
Authors: Sutton Elizabeth , Cowan Alison , Haverty Carrie , Jones Briasha , Moe Alison , Russell Donna 
Published: May 2023

INTRODUCTION:
The same factors contributing to disproportionately worse health outcomes are also barriers to inclusion in research for Black, Hispanic, and Indigenous patients. In this subanalysis of a large, multisite prospective cohort study of maternal plasma mRNA signatures and adverse pregnancy outcomes (APOs), we sought to determine whether equitable representation was aided by the inclusion of a large community hospital as an enrollment site.

METHODS:
Pregnant persons between 18 and 45 year old with a singleton pregnancy eligible to enroll in this IRB-approved prospective cohort study at Woman’s Hospital (Baton Rouge, Louisiana). A hybrid of indirect and direct recruitment strategies, bolstered by text message communication and gift card compensation, were deployed to facilitate enrollment that mirrored the community’s diversity.

RESULTS:
Two thousand five hundred twenty-two participants have been enrolled over 22 months (18% of the hospital’s eligible patient population): 41% of participants are Black, 9% are of Hispanic origin, 50% are White, and 9% Other race. This identically mirrors the demographics of the hospital obstetric patient population (38% Black, 7% Hispanic, 49% White, and 13% Other).

CONCLUSION:
Participants overall mirrored the diverse population served. Inclusion of study sites outside of the traditional academic setting is an effective strategy for promoting equitable access to clinical research, combating barriers to inclusion in research faced by the populations that are disproportionately affected by APOs.
Racial Differences in Severe Maternal Morbidity Exist for Tricare Beneficiaries [ID: 1377133]
Authors: Lyon Emily , Gonzalez-Brown Veronica , Keyser Erin , Porter Katherine , Tindal Rachel 
Published: May 2023

INTRODUCTION:
Maternal morbidity and mortality rates in the United States have increased in the last two decades with a disproportionate effect on women of color. Military Tricare coverage models universal health care access; however, in studies looking at births in military treatment facilities, disparities still exist for women of color. This study analyzes maternal delivery outcomes for all women with Tricare coverage including deliveries in the civilian sector.

METHODS:
Data from 6.2 million births in the Centers for Disease Control and Prevention WONDER Linked Birth/Infant Death Records for 2017–2019 were analyzed for all-cause morbidity (transfusions, perineal lacerations, uterine rupture, unplanned hysterectomy, and intensive care unit admissions), severe maternal morbidity (SMM) (excludes lacerations), and SMM excluding transfusion. Risk ratios were calculated comparing overall maternal morbidity rates between Tricare, Medicaid, self-pay, and private insurance. In addition, risk ratios were calculated between insurance types stratified by race.

RESULTS:
Compared to private insurance, Tricare insurance had significantly reduced risk of all-cause maternal morbidity. Compared to White women, Black women with Tricare and all other insurances had a decreased risk of all-cause morbidity, but a significantly increased risk of SMM and SMM without transfusion. Asian women had significant increased risk of all-cause, SMM and SMM without transfusion. There was no significant difference in the risk of morbidity for women of color with Tricare insurance compared to women of color with Medicaid, private, or self-pay insurance.

CONCLUSION:
The risk of severe maternal morbidity remains elevated for women of color despite access to Tricare health insurance.
Quantitative Fetal Fibronectin to Predict Prolonged Induction of Labor [ID: 1371638]
Authors: Novack Mallory , Herring Amy , Roloff Kristina , Ruma Michael , Valenzuela Guillermo , Varberg Nathan 
Published: May 2023

INTRODUCTION:
Prolonged induction of labor is problematic for patients and providers alike, but we lack clinical tools to help predict time to delivery. We hypothesize quantitative fetal fibronectin may function as a tool to predict prolonged induction.

METHODS:
We performed a prospective observational study of low-risk patients undergoing induction of labor at 39 0/7 to 41 0/7 weeks. Prior to induction, fetal fibronectin (fFN) sampling (off-label use) and transvaginal cervix length were completed. Median fFN values were compared to time-to-delivery using 12-, 24-, and 36-hour thresholds. Delivery within these thresholds was modeled using logistic regression after controlling for parity, Bishop score, cervical length, and gestational age. Continuous log time-to-delivery was modeled using linear regression. Arrowhead Regional Medical Center IRB granted approval Protocol #21–29.

RESULTS:
Of 95 patients enrolled, 35 (37%), 70 (74%), and 80 (84%) patients delivered within 12, 24, and 36 hours. Unadjusted tests for differences in median fFN in these groups were nonsignificant. Cervical length and gestational age were removed from adjusted models because of nonsignificance. Regression models showed a significant relationship between fFN and delivery time within 24 hours, but not within 12 or 36 hours. Each 50 ng/mL increase in fFN was associated with 25% higher odds of delivering within 24 hours (adjusted odds ratio [aOR] 1.25, 95% CI 1.01–1.54, P=.04) with a 3.7% decrease in labor time (53-minute reduction in a 24-hour labor) (aOR 0.963, 95% CI 0.929–0.097, P=.04).

CONCLUSION:
Our findings suggest fFN maybe a useful tool to identify patients who will deliver within 24 hours of induction initiation.
Outpatient Cervical Ripening: A Multicentered Retrospective Cohort Study [ID: 1377444]
Authors: Alavifard Sepand , Ashraf Rizwana , Chamy Caroline , Dong Zi Yang (Susan) , D’Souza Rohan , Roberts Surain 
Published: May 2023

INTRODUCTION:
This study aims to compare safety and effectiveness between different outpatient cervical ripening (CR) methods.

METHODS:
Seven community and academic hospitals in the Greater Toronto Area that performed outpatient CR participated. We reviewed eligible charts over 12–24 months based on predetermined criteria. Multivariable analyses were performed; covariates included nulliparity, cervical unfavourability, and maternal and gestational age. Binary outcomes were modeled using logistic regression, presented as adjusted odds ratio (OR) with 95% CI. Time-to-event outcomes were described using unadjusted Kaplan-Meier curves. Multivariable time-to-event analyses were performed using accelerated failure time models with effects presented as time ratios (TRs) with 95% CI.

RESULTS:
We identified 1,910 pregnancies that underwent outpatient CR using balloon catheters in 881 (46%), dinoprostone vaginal inserts (DVIs) in 553 (29%), and dinoprostone vaginal gel/tablets (DG/T) in 476 (25%) pregnancies. The choice of agent varied considerably per site; one site used balloon catheters in 95%, another used DG/T in 95%, and three sites used DVI in more than 74% of cases. There were no differences in cesarean deliveries or adverse events related to CR. Compared to balloon catheters, patients with pharmacological ripening more often needed a subsequent ripening agent (DVI adjusted odds ratio 2.32 [1.62, 2.81], DG/T 3.26 [2.44, 4.36]). CR-to-delivery time did not differ, but compared to balloon catheters, DG/T had a shorter admission-to-delivery (aTR 0.71 [0.59, 0.86]) interval.

CONCLUSION:
Balloon catheters, DVI, and DG/T for outpatient CR are comparable in terms of safety and effectiveness. When choosing between agents, consideration should be given to clinical findings, patient preference, and resource availability.
Outcomes in Low-Risk Patients Before and After an Institutional Policy Offering 39-Week Elective Inductions [ID: 1379269]
Authors: Cozzi Gabriella , Battarbee Ashley , Blanchard Christina , Oben Ayamo , Sinkey Rachel , Subramaniam Akila 
Published: May 2023

INTRODUCTION:
We aimed to pragmatically analyze the effect of offering elective induction of labor (eIOL) in low-risk patients on perinatal outcomes.

METHODS:
This was a retrospective cohort study of low-risk nulliparous or multiparous patients delivering live, nonanomalous singletons at a single center at greater than or equal to 39 0/7 weeks’ gestational age (GA). Those with prior or planned cesarean delivery (CD), ruptured membranes, medical comorbidities, or contraindications to vaginal delivery were excluded. Patients were categorized as before (pre-eIOL; January 2012 to March 2014) or after (post-eIOL; March 2019 to December 2021) an institution-wide policy offering eIOL at 39 0/7 weeks. Births from April 2014 to December 2018 were considered to be during-eIOL given increased exposure to eIOL during the period of the ARRIVE trial at our center. The primary outcome was CD. Characteristics and outcomes were compared between the pre- and during-eIOL, and pre- and post-eIOL groups, and adjusted OR (aOR) (95% CI) was calculated using multivariable regression. Subgroup analysis by parity was planned.

RESULTS:
Of 10,966 patients analyzed, 2,611 (23.8%) were pre-eIOL, 5,486 (50.0%) during-eIOL, and 2,869 (26.2%) post-eIOL. Groups differed with respect to labor type, age, race and ethnicity, marital and payor status, and GA at care entry. Post-eIOL was associated with lower odds of CD compared to pre-eIOL (aOR 0.75 [95% CI 0.66–0.87]), which was consistent for both nulliparas (aOR 0.71 [0.59–0.85]) and multiparas (aOR 0.64 [0.52–0.79]). During-eIOL was also associated with lower odds of CD compared to pre-eIOL (aOR 0.73 [0.65–0.82]). Both during- and post-eIOL groups were associated with higher odds of chorioamnionitis, operative delivery, and hemorrhage compared to pre-eIOL. However, only among post-eIOL were there fewer neonatal birth weights greater than 4,000 g, large-for-GA infants, and hypoglycemia compared to pre-IOL.

CONCLUSION:
Institutional policy offering eIOL at 39 0/7 to low-risk patients was associated with a lower CD rate and lower birth weights, and an increased risk of chorioamnionitis and hemorrhage.
Variation in Severe Maternal Morbidity Among Black and White Medicaid Enrollees in 27 States [ID: 1368013]
Authors: Admon Lindsay , Auty Samantha , Daw Jamie , Declercq Eugene , Gordon Sarah , Kozhimannil Katy 
Published: May 2023

INTRODUCTION:
Interventions designed to address high rates of severe maternal morbidity (SMM) and improve maternal health equity often lack comprehensive data on the relative burden of specific SMM indicators across populations. This study examines variation in indicators of delivery-related SMM among non-Hispanic Black compared with non-Hispanic White Medicaid beneficiaries in 27 states.

METHODS:
We conducted a pool, cross-sectional analysis of the 2016–2018 Transformed Medicaid Statistical Information System. Unadjusted estimates of indicator frequency were generated for 27 states with adequate quality data on non-Hispanic Black and non-Hispanic White race and ethnicity. We estimated rates for each indicator for each racial group overall and within each state. This study was approved by the IRB at Boston University.

RESULTS:
Among deliveries to the non-Hispanic Black population (n=629,774), six indicators occurred at overall rates greater than 25 per 10,000 deliveries: eclampsia (leading indicator in 15 states), pulmonary edema/heart failure (3 states), renal failure (1 state), adult respiratory distress syndrome (3 states), sepsis (2 states), and disseminated intravascular coagulation (2 states). Among deliveries to the non-Hispanic White population (n=1,051,459), indicators occurred in different rank-order and at rates typically less than half of those identified among the non-Hispanic Black population. Morbidity indicators among the non-Hispanic White population were distributed differently across states.

CONCLUSION:
These findings provide opportunities for interventions designed to reduce SMM and improve maternal health equity in Medicaid to be tailored to the leading causes of SMM, which differ among non-Hispanic Black and White populations across and within states.
Age-Related Disparities in National Maternal Mortality Trends in the United States From 2000 to 2019 [ID: 1376567]
Authors: Huang Ryan , Abenhaim Haim Arie 
Published: May 2023

INTRODUCTION:
Over the past two decades, there has been a trend toward increasing maternal age in the United States. The study objective was to examine the association of maternal age with maternal mortality in the United States and examine temporal trends in mortality by maternal age.

METHODS:
A nationwide population-based cross-sectional study in the United States between 2000 and 2019 was conducted using data from the Centers for Disease Control and Prevention’s “Birth Data” and “Mortality Multiple Cause” data files. Annual incidence and period trends in maternal deaths were calculated using the annual maternal deaths over annual live births across age groups. Multivariate logistic regression models were used to estimate the association between maternal age and risk of maternal mortality and calculate temporal changes in risk of mortality over the study period.

RESULTS:
Between 2000 and 2019, 21,241 deaths were observed in women during pregnancy and childbirth for an average incidence of 26.3 maternal deaths/100,000 births (95% CI 21.8–31.2). Of all deaths, 6,870 (32.3%) were in women 35 years or older, while only 15.1% of live births were attributed to women 35 years or older. Compared with women 25–29 years of age, there was a significantly greater risk of maternal mortality among women 35–39 (odds ratio 1.60, 95% CI 1.53–1.67), 40–44 (3.78, 3.60–3.99), 45–49 (28.49, 26.49–30.65), and 50–54 (343.50, 319.44–369.37). Risk of mortality increased over time, with the greatest rise in women 35 years or older.

CONCLUSION:
In the United States, maternal mortality increased during the past two decades, especially in women 35 years or older. Given these findings, targeted strategies to reduce the increasing maternal mortality should become a priority.
A Systematic Review Investigating Disparities in Maternal Mortality in Latin American Countries [ID: 1376589]
Authors: Ernst Rebecka , Acoff Eboni , Hsu Albert 
Published: May 2023

INTRODUCTION:
The goal of this review is to investigate maternal mortality rates (MMRs) in Latin American countries. While there are clear disparities in maternal mortality rates in Black versus non-Hispanic White women, the rate of maternal mortality rates in Hispanic women has not been well characterized. This study specifically addresses disparities in maternal mortality rates in Latin American countries. It also explores factors contributing to high MMR including socioeconomic status, age, comorbidities, ethnicity, and access to health care.

METHODS:
Four bibliographic databases were searched for keywords, including “maternal mortality,” “ethnic groups,” and “racial disparities.” Inclusion criteria were manuscripts that discussed Latin American countries; exclusion criteria included “wrong outcome” and studies only discussing maternal morbidity. Quality assessments for each study were completed.

RESULTS:
Bolivia (650/100,000), Mexico (413.5/100,000), and Ecuador (321.1/100,000) have the highest average MMR. Caribbean countries tend to have the lowest recorded MMR, whereas countries in Central and South America have the highest MMRs in Latin America. The most common factor associated with mortality was hypertensive disorders. Low socioeconomic status (SES) and extremes of maternal age were correlated with higher mortality rates.

CONCLUSION:
Many comorbidities contribute to mortality among pregnant women throughout Latin America, including human immunodeficiency virus, SES, extremes of maternal age, and access to care. This study shows a need for further research to help identify disparities in MMR across different Latin American countries.
Effect of Insurance Status on the Length of Time to Readmission for Postpartum Preeclampsia [ID: 1377910]
Authors: Jiang Judy , Benito Carlos , Casademont Catherine , Sigdel Manisha 
Published: May 2023

INTRODUCTION:
Maternal statistics show us that the majority of maternal morbidity and mortality occur postpartum, with a higher rate of morbidity and mortality in those without private insurance. Hypertensive disorders of pregnancy remain a significant cause of pregnancy-related death, and preeclampsia was found to account for 82% of the readmissions at our community-based hospital. Timely diagnosis of preeclampsia can prevent further morbidity and mortality. A retrospective cohort study was conducted to determine whether insurance status has an effect on length of time until diagnosis of preeclampsia requiring postpartum readmission.

METHODS:
All patients with deliveries and postpartum readmissions from January 1, 2018 to December 31, 2020, were included in the study at Saint Peters University Hospital in New Brunswick, New Jersey, with IRB approval. Data were obtained from the Paragon Electronic Medical Record, including the patient insurance status (private or service-Medicaid, Medicaid HMO, self-pay), race, ethnicity, age, length of admission and readmission, as well as length of time between the delivery admission to readmission. Institutional board review committee approval was obtained for this study.

RESULTS:
A total of 15,509 patients were delivered between 2018 and 2020 with 149 (0.96%; 149/15,509) patients readmitted for hypertensive disorders of pregnancy. The study showed that patients with private insurance were readmitted on average in 4.54+3.42 days after their delivery admission, whereas those without private insurance were admitted on average 6.30+4.91 days after delivery admission (P=.010).

CONCLUSION:
In this community-based hospital, patients with private insurance who were readmitted for preeclampsia were diagnosed and readmitted for treatment in a shorter period of time than those without private insurance.
Implementation of a Severe Maternal Morbidity Quality Review Process at a Level IV Public Hospital [ID: 1377992]
Authors: Stanteen Samantha Mendoza , Fomina Yevgenia , Gilbert Juanmekia , Nelson David , Pruszynski Jessica , Spong Catherine 
Published: May 2023

INTRODUCTION:
Severe maternal morbidity (SMM) is tracked by national organizations offering opportunities to evaluate, monitor, and address in near real time. Using a multidisciplinary case review committee to analyze all cases of SMM at a level IV inner-city hospital, we hypothesized that case reviews will identify opportunities for improvement in obstetric practices.

METHODS:
A case review was triggered for any delivery with an SMM ICD-10 code, transfusion of greater than 4 units, readmission within 48 hours of discharge, a patient safety concern by staff, or a severe adverse neonatal outcome. This cohort study included all of the case reviews of cases between 2019 and 2022. Severe maternal morbidity outcomes, demographics, and obstetric practices were analyzed.

RESULTS:
Of 36,671 deliveries, 296 (0.8%) met criteria and were reviewed. Of these, 80 (27%) had two or more concurrent SMM events. Postpartum hemorrhage was the most common (37%), followed by intensive care unit admission (13%) and hysterectomy (12%). After review, practices done well included interdisciplinary communication and prompt decision-making. Opportunities for improvement included inadequate access to peripartum care due to socioeconomic barriers, communication, and lack of role clarity.

CONCLUSION:
Social barriers, inadequate communication, and lack of role clarity were identified as the most common areas of improvement in SMM cases. These findings led to the development of an escalation of care pathway for massive transfusion protocol and vital signs thresholds at which to contact anesthesia. The implementation of a standardized SMM surveillance system results in systematic improvements in obstetric practices.