Faculty Bibliography

BACKGROUND/UNASSIGNED:Substance use disorders (SUDs) are increasing in the obstetric population, vary with demographic characteristics, and are associated with adverse pregnancy outcomes. Cannabis use disorder and opioid use disorder are two of the most common SUDs during pregnancy. OBJECTIVE/UNASSIGNED:This study had two objectives. The first objective was to assess trends in any SUD diagnosis during delivery hospitalizations from 2000 to 2018 by maternal age, ZIP code income quartile, and hospital location and teaching status. The second objective was to determine risk for adverse pregnancy outcomes during delivery hospitalizations specifically in the presence of cannabis and opioid use disorder diagnoses. STUDY DESIGN/UNASSIGNED:We conducted a serial cross-sectional analysis of the 2000-2018 National Inpatient Sample. Delivery hospitalizations to women aged 15-54 years with substance use disorder diagnoses were identified. SUD included (i) cannabis use disorder; (ii) opioid use disorder; (iii) alcohol use disorder; and (iv) other drug use disorder. We used joinpoint regression to estimate the average annual percent change (AAPC) in any substance use disorder diagnoses with 95% confidence intervals (CIs) by (i) ZIP code income quartile, (ii) hospital location and teaching status, and (iii) maternal age. We used unadjusted and adjusted log-linear regression to evaluate the relationship between cannabis use disorder and opioid use disorder several adverse maternal outcomes. We report unadjusted and adjusted risk ratios (aRRs) as measures of effect. RESULTS/UNASSIGNED:From 2000 to 2018, trends analyses broadly demonstrated increasing risk for SUD across demographic categories. In trends analyses stratified by ZIP code-income quartile, the proportion of deliveries with any SUD diagnosis increased across each income quartile with significant increases in the lowest income quartile (AAPC 4.6%, 95% CI 0.4%, 8.9%), second lowest quartile (AAPC 6.3%, 95% CI 5.3%, 7.4%), second highest quartile (AAPC 5.4%, 95% CI 4.1%, 6.8%), and highest quartile (AAPC 4.4%, 95% CI 2.1%, 6.8%). A larger increasing AAPC for SUD was present for deliveries in rural hospitals (AAPC 12.3%, 95% CI 9.8%, 14.9%) as compared to teaching (AAPC 5.7%, 95% CI 5.2%, 6.3%) and non-teaching urban hospitals (AAPC 7.0%, 95% CI 5.9%, 8.1%). By maternal age group, there was a significant larger AAPC for SUD for women aged 15-19 years (AAPC 8.5%, 95% CI 6.6%, 10.4%), 20-24 years (AAPC 9.0%, 95% CI 6.9%, 11.1%) and 25-29 years (AAPC 9.8%, 95% CI 9.1%, 10.6%) than women ≥30 years of age. Cannabis use disorder was associated with increased adjusted risk for preterm delivery (aRR 1.44, 95% CI 1.43, 1.45) and abruption and antepartum hemorrhage (aRR 1.77, 95% CI 1.75, 1.80). Opioid use disorder was associated with risk for non-transfusion severe maternal morbidity (aRR 1.73, 95% CI 1.67, 1.79), preterm delivery (aRR 1.75, 95% CI 1.74, 1.77), and abruption and antepartum hemorrhage (aRR 2.15, 95% CI 2.11, 2.19). CONCLUSION/UNASSIGNED:While substance use disorders are increasing in pregnancy across rural and urban settings, age groups, and income quartiles, several populations are associated with higher increased risks and trends. These findings support that SUDs are likely to continue to be of public health significance in diverse geographic and demographic settings.

BACKGROUND/UNASSIGNED:Costs for obstetrical care may be increasing for both patients and insurers. OBJECTIVE/UNASSIGNED:To examine predictors of and trends in the cost of medical care during pregnancy. STUDY DESIGN/UNASSIGNED:We performed a study of pregnancies from 2009 to 2019 covered by commercial insurance resulting in term, singleton delivery hospitalizations and included in the MarketScan database. The analysis categorized pregnancies based on whether delivery occurred via cesarean versus vaginal delivery and whether pre-gestational diabetes or chronic hypertension was present. We estimated inflation-adjusted total medical costs from 273 days before through 42 days after delivery hospitalization discharge. The analysis evaluated costs for inpatient services, outpatient services, and outpatient drugs separately and trended these costs over the study period. The analysis dichotomized total medical costs into insurer liability versus out-of-pocket patient costs. The study used quantile regression models fit separately to evaluate costs for vaginal and cesarean delivery including demographic and medical characteristics. RESULTS/UNASSIGNED: < .01). In adjusted analyses, chronic hypertension, diabetes, and cesarean delivery were associated with increased median total costs. CONCLUSION/UNASSIGNED:Total and out-of-pocket medical costs for maternity care are increasing among commercially insured patients. Chronic hypertension, pregestational diabetes, and cesarean delivery are important predictors of costs.

OBJECTIVE/UNASSIGNED:To determine which antiepileptic drugs pregnant women receive by trimester. METHODS/UNASSIGNED:This retrospective cohort study using the IBM Watson Health MarketScan Research Databases evaluated which antiepileptic drugs pregnant women with epilepsy received by trimester. Women with aged 15-54 years with a history of seizure disorder who underwent a delivery hospitalization between 2008 and 2017 were included in the analysis. Descriptive statistics were performed. RESULTS/UNASSIGNED:Of 34,144 women with a seizure disorder diagnosis and a delivery hospitalization, 10,289 (30.1%) received an anti-epileptic medication during pregnancy of which more than half received lamotrigine or levetiracetam. Other antiepileptic medications used by >5% of the population during any one trimester in the study period included carbamazepine, clonazepam, and topiramate. In evaluating medication use in the 1st trimester versus the 2nd trimester, clonazepam use decreased 32.0% (95% CI 60.0%, 77.0%) from 5.6% to 3.8% of patients receiving antiepileptics from the 1st to the 2nd trimester, gabapentin deceased 22.1% (95% CI 0.68%, 0.90%) from 4.1% to 3.2%, and topiramate decreased 30.0% (95% CI 62.8%, 77.9%) from 7.2% to 5.1%. In comparison, levetiracetam increased from 22.5% to 33.3% between the 1st and 3rd trimester and lamotrigine 22.2% to 27.5% between the 1st and 3rd trimester, 48.3% and 24.0% increases respectively. CONCLUSION/UNASSIGNED:Antiepileptic drugs with less favorable fetal risk profiles such as topiramate decreased by trimester while medications with more favorable fetal risk profiles such as lamotrigine and levetiracetam increased. These findings broadly support that there are opportunities to improve pre-conceptional counseling of women with epilepsy.

OBJECTIVE/UNASSIGNED:To determine whether infertility diagnoses differ between Black ethnic subgroups. DESIGN/UNASSIGNED:Retrospective review. SETTING/UNASSIGNED:an urban safety-net hospital. PATIENTS/UNASSIGNED:Women seeking infertility care between 2005 and 2015. INTERVENTIONS/UNASSIGNED:diagnoses) were reviewed to confirm diagnoses. Data were stratified by race and subsequently by ethnicity to evaluate the differences in infertility diagnoses between Black American, Black Haitian, and Black African women. White American women were used as the comparison group. MAIN OUTCOME MEASURES/UNASSIGNED:Infertility diagnoses between Black ethnic subgroups and White women. RESULTS/UNASSIGNED:A total of 358 women met the inclusion criteria, including 99 Black American, 110 Black Haitian, 61 Black African, and 88 White American women. Anovulation/polycystic ovary syndrome was the most common diagnosis in each ethnic group, accounting for 40% of infertility among White American, 57% among Black American, 25% among Black Haitian, and 21% among Black African women. There were no significant differences in the individual infertility diagnoses between Black and White women. Between ethnic subgroups, multivariate analysis showed significantly higher odds of infertility because of anovulation/polycystic ovary syndrome in Black American women compared with Black African women (odds ratio [OR], 4.9; 95% confidence interval [CI], 1.4-17.0). Compared with Black African women, higher odds of tubal factor infertility were observed in Black American (OR, 4.7; 95% CI, 1.16-18.7) and Black Haitian women (OR, 4.0; 95% CI, 1.1-14.0). CONCLUSIONS/UNASSIGNED:Infertility diagnoses were not homogeneous across Black ethnic groups. Studies examining infertility should specify the ethnic subgroups within a race because this may affect results.

BACKGROUND:Racial and ethnic diversification of the physician and nurse workforce is recommended as a leverage point to address the impact of structural racism in maternal care, but empirical evidence supporting this recommendation is currently lacking. OBJECTIVE:This study aimed to assess the association between state-level registered nurse workforce racial and ethnic diversity and severe adverse maternal outcomes during childbirth. STUDY DESIGN:This population-based cross-sectional study analyzed 2017 US birth certificate data. Severe adverse maternal outcomes included eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Proportions of minoritized racial and ethnic registered nurses in each state were abstracted from the American Community Survey (5-year estimate, 2013-2017). This proportion was categorized into 3 terciles, with the first tercile corresponding to the lowest proportion and the third tercile corresponding to the highest proportion. Crude and adjusted odds ratios and 95% confidence intervals of severe adverse maternal outcomes associated with terciles of the state proportion of minoritized racial and ethnic nurses were estimated using logistic regression models. RESULTS:Of the 3,668,813 birth certificates studied, 29,174 recorded severe adverse maternal outcomes (79.5 per 10,000; 95% confidence interval, 78.6-80.4). The mean state proportion of minoritized racial and ethnic nurses was 22.1%, ranging from 3.3% in Maine to 68.2% in Hawaii. For White mothers, the incidence of severe adverse outcomes was 85.3 per 10,000 for those who gave births in states in the first tercile of the proportion of minoritized racial and ethnic nurses and 53.9 per 10,000 for those who gave birth in states in the third tercile (risk difference, -31.4 per 10,000; 95% confidence interval, -34.4 to -28.5). It corresponds to a 37% decreased risk of severe adverse maternal outcomes associated with giving birth in a state in the third tercile (crude odds ratio, 0.63; 95% confidence interval, 0.60-0.66). A decreased risk of severe adverse maternal outcomes was observed for Black mothers (crude odds ratio, 0.65; 95% confidence interval, 0.61-0.70), Hispanic mothers (crude odds ratio, 0.51; 95% confidence interval, 0.48-0.54), and Asian and Pacific Islander mothers (crude odds ratio, 0.65; 95% confidence interval, 0.58-0.72) but not for Native American mothers (crude odds ratio, 0.89; 95% confidence interval, 0.72-1.09) or mothers with >1 race (crude odds ratio, 1.44; 95% confidence interval, 0.72-1.09). After adjustment for patients and hospital characteristics, giving birth in states in the third tercile was associated with a reduced risk of severe adverse outcomes as follows: 32% for White mothers (adjusted odds ratio, 0.68; 95% confidence interval, 0.59-0.77), 20% for Black mothers (adjusted odds ratio, 0.80; 95% confidence interval, 0.65-0.99), 31% for Hispanic mothers (adjusted odds ratio, 0.69; 95% confidence interval, 0.58-0.82), and 50% for Asian and Pacific Islander mothers (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.65). The associations of the proportion of minoritized racial and ethnic nurses with the risk of severe adverse maternal outcomes were not statistically significant for Native American mothers and more than 1 race mothers. Results were similar when blood transfusion was excluded from the outcome measure. CONCLUSION:A diverse state registered nurse workforce was associated with a reduced risk of severe adverse maternal outcomes during childbirth.

OBJECTIVE:To characterize delivery hospitalization trends of patients aged 11-19 years and associated comorbidities and outcomes. METHODS:For this repeated cross-sectional analysis, deliveries to patients aged 11-54 years were identified in the 2000-2018 National Inpatient Sample. Temporal trends in deliveries to patients aged 11-14 years and 15-19 years were analyzed using joinpoint regression to estimate average annual percent change with 95% CIs. The association of deliveries among patients aged 11-19 years with other comorbid conditions was analyzed. The relationship between delivery among patients aged 11-19 years and adverse maternal outcomes was analyzed with unadjusted and adjusted logistic regression models, with unadjusted and adjusted odds ratios (aORs) as measures of effect. RESULTS:An estimated 73,198,153 delivery hospitalizations from 2000 to 2018 were included, of which 88,363 were to patients aged 11-14 years and 6,359,331 were to patients aged 15-19 years. The proportion of delivery hospitalizations among patients aged 11-14 years decreased from 2.1 to 0.4 per 1,000 from 2000 to 2018 (average annual percent change -7.8%, 95% CI -8.5% to -7.2%). Deliveries to patients aged 15-19 years decreased from 2000 to 2018, from 11.5% to 4.8% of all deliveries (average annual percent change -4.9%, 95% CI -5.6% to -4.3%). For deliveries among patients aged 11-19 years, rates of obesity, mental health conditions, substance use disorder, asthma, and pregestational and gestational diabetes all significantly increased over the study period. From 2000 to 2018, rates of severe maternal morbidity (average annual percent change 2.4%, 95% CI 1.6-3.1%), postpartum hemorrhage (average annual percent change 2.4%, 95% CI 1.4-3.4%), cesarean delivery (average annual percent change 1.3%, 95% CI 0.9-1.7%), and hypertensive disorders of pregnancy (average annual percent change 3.3%, 95% CI 2.8-3.8%) all increased significantly among deliveries to patients aged 11-19 years. Compared with deliveries to patients aged 20-54 years, deliveries to patients aged 11-14 years were associated with increased risk for severe maternal morbidity (aOR 1.73, 95% CI 1.49-2.00), hypertensive disorders of pregnancy (aOR 1.79, 95% CI 1.71-1.88), and postpartum hemorrhage (aOR 1.37, 95% CI 1.27-1.49). CONCLUSION:Deliveries among patients aged 11-19 years have decreased, but both comorbidity and risk for adverse outcomes increased among this age group.

OBJECTIVE:To characterize current trends and outcomes in pregnancies complicated by cystic fibrosis (CF) that resulted in delivery. METHODS:This repeated cross-sectional study used the U.S. National Inpatient Sample to identify delivery hospitalizations of patients with CF between 2000 and 2019. Trends in delivery hospitalizations of patients with CF were assessed using joinpoint regression to determine the average annual percent change (AAPC). The risk of adverse maternal and obstetric outcomes was compared between patients with and without CF using adjusted logistic regression models accounting for demographic, clinical, and hospital characteristics, with adjusted odds ratios (aORs) with 95% CIs as measures of association. The proportion of patients with CF and other chronic conditions such as pregestational diabetes was analyzed over time. RESULTS:From 2000 to 2019, the prevalence of CF at delivery increased from 2.1 to 10.4 per 100,000 deliveries (AAPC 6.7%, 95% CI 5.7-8.2%). The proportion of patients with CF and other chronic conditions increased from 18.0% to 37.3% (AAPC 3.1%, 95% CI 1.0-5.3%). Patients with CF were more likely to experience severe maternal morbidity (aOR 2.61, 95% CI 1.71-3.97), respiratory complications (aOR 17.45, 95% CI 11.85-25.68), venous thromboembolism (aOR 3.59, 95% CI 1.33-9.69), preterm delivery (aOR 2.15, 95% CI 1.79-2.59), abruption and antepartum hemorrhage (aOR 1.63, 95% CI 1.10-2.41), and gestational diabetes (aOR 2.47, 95% CI 2.47-3.70). CONCLUSION:Although still infrequent (approximately 1 in 10,000), deliveries complicated by CF increased approximately fivefold over the study period. The proportion of patients with CF and other chronic conditions is increasing. Patients with CF are at increased risk for a broad range of adverse outcomes.

BACKGROUND:Mental health conditions during delivery hospitalizations are not well characterized. OBJECTIVE:This study aimed to characterize the prevalence of maternal mental health condition diagnoses and associated risk during delivery hospitalizations in the United States. STUDY DESIGN:The 2000 to 2018 National Inpatient Sample was used for this repeated cross-sectional analysis. Delivery hospitalizations of women aged 15 to 54 years with and without mental health condition diagnoses, including depressive disorder, anxiety disorder, bipolar spectrum disorder, and schizophrenia spectrum disorder, were identified. Temporal trends in mental health condition diagnoses during delivery hospitalizations were determined using the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% confidence intervals. The trends in chronic conditions associated with mental health condition diagnoses, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, were analyzed. The association between mental health conditions and the following adverse outcomes was determined: (1) severe maternal morbidity, (2) preeclampsia or gestational hypertension, (3) preterm delivery, (4) postpartum hemorrhage, (5) cesarean delivery, and (6) maternal mortality. Regression models for each outcome were performed with unadjusted and adjusted risk ratios as measures of effects. RESULTS:Of 73,109,791 delivery hospitalizations, 2,316,963 (3.2%) had ≥1 associated mental health condition diagnosis. The proportion of delivery hospitalizations with a mental health condition increased from 0.6% in 2000 to 7.3% in 2018 (average annual percent change, 11.4%; 95% confidence interval, 10.3%-12.6%). Among deliveries in women with a mental health condition diagnosis, chronic health conditions, including asthma, pregestational diabetes mellitus, chronic hypertension, obesity, and substance use, increased from 14.9% in 2000 to 38.5% in 2018. Deliveries to women with a mental health condition diagnosis were associated with severe maternal morbidity (risk ratio, 1.88; 95% confidence interval, 1.86-1.90), preeclampsia and gestational hypertension (risk ratio, 1.59; 95% confidence interval, 1.58-1.60), preterm delivery (risk ratio, 1.35; 95% confidence interval, 1.35-1.36), postpartum hemorrhage (risk ratio, 1.37; 95% confidence interval, 1.36-1.38), cesarean delivery (risk ratio, 1.20; 95% confidence interval, 1.20-1.20), and maternal death (risk ratio, 1.31; 95% confidence interval, 1.12-1.56). The increased risk was retained in adjusted models. CONCLUSION:The proportion of delivery hospitalizations with mental health condition diagnoses increased significantly throughout the study period. Mental health condition diagnoses were associated with other underlying chronic health conditions and a modestly increased risk of a range of adverse outcomes. The findings suggested that mental health conditions are an important risk factor in adverse maternal outcomes.