Background: Preterm birth (PTB; gestational age <37 weeks) is the leading cause of infant morbidity and mortality worldwide. Low and excessive gestational weight gain (GWG) has been previously cited as risk factors for PTB. This has not been explored in Puerto Rico, an area with high PTB rates.

Methods: We conducted a retrospective analysis using the birth certificate data files from 2005 to 2012 from the PR Department of Health in order to examine the relationship between GWG and PTB. GWG was categorized into low, adequate, or excessive based for each category of pre-pregnancy body mass index based on American College of Obstetricians and Gynecologists classifications. Logistic regression was used to determine the crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between GWG and PTB.

Results: There were 320,695 births included in this analysis; 33% with high GWG and 28% with low GWG. A greater percentage of women with low GWG were <20, had less than a high school education, and were underweight compared to women with adequate and excessive GWG. Women with low compared to adequate GWG had increased odds of PTB (OR=1.58, 95% CI=1.55-1.62). Excessive GWG was inversely associated with PTB (OR=0.76, 95% CI=0.74-0.78).

Conclusions: Low GWG represents a modifiable risk factor for PTB in PR. Future research should examine other factors that may contribute to GWG, such as dietary factors and explore pathways through which GWG may be contributing to PTB.

Background

Within medical and surgical specialties, hospital readmission rates not only serve as metrics for quality of care but also highlight risk factors and inform preventive efforts for such occurrences; within obstetrics, this practice is less common. Therefore, the present study investigates postpartum readmissions over five years within California.

Methods

Readmissions within the first 6 weeks after an in-hospital delivery that took place between 2010 and 2014 were identified from patient discharge data; these data included relevant maternal comorbidities and pregnancy and delivery complications (ICD-9 codes). Readmitted postpartum patients were compared to the non-readmitted birth population by demographic, pregnancy, and delivery characteristics, to identify factors associated with readmission.

Results

Among 1,919,118 delivery hospitalizations identified, 24,107 (1.3%) were readmitted within 42 days postpartum. Readmitted patients were more likely than were non-readmitted patients to have had a cesarean delivery (48.5% vs 32.8%, P<.0001); to have experienced preterm labor (12.3% vs 6.3%, P<.0001); to have had hemorrhage (12.1% vs 6.7%, P<.0001); to be publicly insured (49.8% vs 42.5%, P<.0001); and to be black (11.2% vs 5.7%, P<.0001). Moreover, for the readmitted patients, these comorbidities were more prevalent: pregnancy-related hypertensive disorder (14.9% vs 6.3%, P<.0001); obesity (13.2% vs 7.1%, P<.0001); diabetes (12.9% vs 9.3%, P<.0001); psychiatric disease (7.4% vs 4.3%, P<.0001); and substance abuse (3.9% vs 1.7%, P<.0001).

Conclusions

Cesarean delivery, preterm labor, hemorrhage, insurance, race/ethnicity, and maternal comorbidities are associated with increased risk of postpartum readmissions. Prior to and during delivery, preventive efforts should target these women at increased risk for readmission.

Context and motivation: United States maternal mortality rates (MMR) not only exceed those of other developed countries, but also exhibit considerable racial disparities. In 2015, the United States, along with other countries such as Jamaica, North Korea, Serbia, and South Africa, were among the 13 countries in the entire world where MMR were higher than it was back in 1990. In this study, by focusing on specific maternal and infant health related health spending, we show that public health activities play a significant role in mitigating maternal mortality and the racial disparity in outcomes. To our knowledge, this is the first large scale longitudinal study examining the impact of a public health package of pregnancy-related programs on maternal mortality rates.

Methods: We use administrative data on pregnancy-related public health expenditures, maternal mortality rates and demographics from all 67 Florida counties for 2001-2014. We estimate fixed-effects regression and Generalized Method of Moments (GMM) models. By addressing both potential endogeneity and serial correlation, GMM allows for the identification of causal relationships between public health expenditures and maternal mortality rates. We provide a series of robustness and falsification tests.

Findings: We find statistically significant improvements in outcomes, with a 10% increase in pregnancy-related public health spending leading to a 12.2% decline in maternal mortality rates among black mothers and a 20.8% reduction in the black-white maternal mortality gap.

Conclusions: Our analysis provides strong evidence of public health program effectiveness in reducing maternal mortality rates and racial disparities.

Background: Public health surveillance relying solely on death certificate data has been shown to misclassify obstetric causes of pregnancy-associated deaths (deaths while pregnant or within one year after pregnancy ended), but reporting of pregnancy-associated suicide has not been systematically examined, to date.

Methods: The California Department of Public Health Pregnancy-Associated Mortality Review (CA-PAMR) created a pregnancy-associated cohort through linkage of maternal death certificates, birth/fetal death certificates, and hospital discharge data. To identify potential misclassification, CA-PAMR screened all pregnancy-associated deaths, including drug overdose and accidental deaths, and included them for review based on: ICD-10 codes; manner of death; coroner mention of intentionality per family/friends; or mention of recent depression related to the pregnancy/postpartum period. Coroner and medical records were abstracted for all potential cases, and a committee of experts reviewed and classified each death as suicide, accidental or unable to determine.

Results: From 2002-2012, death certificates among a linked pregnancy-associated cohort identified 86 suicides, and CA-PAMR identified an additional 31 suspected cases. Among the 117 deaths, the committee confirmed all but one (85/86) of the originally-coded suicide cases and determined that 45% (14/31) accidental/other deaths were suicide (total n=99). Most of the misclassified deaths were due to drug overdose. As a result of the additional yield, suicide ratios post-CA-PAMR review were significantly higher than the ratios based on death certificates alone for any given 3-year moving average during the study.

Conclusions: CA-PAMR investigation and reports of pregnancy-associated deaths revealed a high degree of underreporting of one major cause of death, suicide.

Background: Intrauterine devices (IUD) and long acting reversible contraception methods (LARC) are considered highly effective contraception. We examined trends in utilization by type of contraception and specifically IUD/LARC utilization stratified by type of commercial insurance for a national single private payer.

Methods: We utilized administrative claims data (2010-2017) from Optum Clinformatics Data Mart to identify women aged 18-45. Using the Healthcare Effectiveness Data and Information Set definition, we identified type of contraception as well as any evidence of IUD/LARC. We examined use across four major payer subtypes, including HMOs, PPOs, EPOs, and POS. Age standardized utilization was calculated for all types of contraception amongst actively enrolled women on a plan and compared using linear regression. Baseline and final year-month utilization were calculated.

Results: We identified a monthly average of 2,388,585 women actively enrolled whose utilization of IUD/LARC increased from 28.3/10,000 women in January 2010 to 75.8/10,000 in December 2017 (p<0.001). Both vaginal rings (89.6/10,000 in January 2010 vs. 62.7/10,000 in December 2017, p<0.001) and oral contraceptives (1,166/10,000 in January 2010 vs. 838/10,000 in December 2017, p<0.001) decreased substantially. We also found EPO plans consistently have the highest utilization throughout the analysis timeframe (35.4/10,000 in January 2010 vs. 78.2/10,000 in December 2017, p<0.001), while HMOs had the lowest utilization (26.3/10,000 vs. 66.9/10,000, p<0.001).

Conclusion: Type of commercial insurance influences contraception utilization. Plan benefit design and patient cost sharing may be strong drivers of utilization of highly effective contraception as well as alternative methods.