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Background: The incidence of hypertensive disorders of pregnancy (HDP) are on the rise in the United States, especially in the South, which has a heavy chronic disease burden and large number of Medicaid nonexpansion states. Sizeable disparities in HDP outcomes exist by race/ethnicity, geography, and health insurance coverage. Our objective is to explore HDP in the Alabama Medicaid maternity population, and the association of maternal sociodemographic, clinical, and care utilization characteristics with HDP diagnosis. Materials and Methods: Data were from Alabama Medicaid delivery claims in 2017. Bivariate analyses were used to examine maternal characteristics by HDP diagnosis. Hierarchical generalized linear models, with observations nested at the county level, were used to assess multivariable relationships between maternal characteristics and HDP diagnosis. Results: Among women with HDP diagnosis, a higher proportion were older, Black, had other comorbidities, and had more perinatal hospitalizations or emergency visits compared with those without HDP diagnosis. There were increased odds of an HDP diagnosis for older women and those with comorbidities. Black women (adjusted odds ratio [aOR] = 1.24, 95% confidence interval [CI]: 1.16–1.33), women insured only during pregnancy by Sixth Omnibus Reconciliation Act Medicaid (aOR = 1.08, 95% CI: 1.02–1.15), and women entering prenatal care (PNC) in the second trimester (aOR = 1.10, 95% CI: 1.03–1.18) had elevated odds of HDP diagnosis compared with their counterparts. Conclusions: Beyond traditional demographic and clinical risk factors, not having preconception insurance coverage or first trimester PNC entry were associated with higher odds of HDP diagnosis. Improving the provision and timing of maternity coverage among Medicaid recipients, particularly in nonexpansion states, may help identify and treat women at risk of HDP and associated adverse perinatal outcomes.

Health inequities are not caused by personal failings or shortcomings within disadvantaged groups, which can be erased with behavioral interventions. The scope of the problem is much greater and will only fully be addressed with the examination of the systems, structures, and policies that perpetuate racism, classism, and an economic, class, race, or gender divide between patients and the people who care for them. Solution-oriented strategies to achieve health equity will remain elusive if researchers continue to focus on behavior modification in patients while failing to do harder work that includes focusing on the institutions, community, and societal contexts in which pregnant women are living; addressing social determinants of health; considering racism in study design, analysis, and reporting; valuing the voices of patients, practitioners, and researchers from historically disadvantaged groups; disseminating research findings back to the community; and developing policy and reimbursement structures to support care delivery change that advances equitable outcomes. A case study shows us how group prenatal care may be one viable vehicle through which to affect this change. Group prenatal care is one of the few interventions shown to improve pregnancy outcomes for black women. Studies of group prenatal care have predominantly focused on the patient, but here we propose that the intervention may exert its greatest impact on clinicians and the systems in which they work. The underlying mechanism through which group prenatal care works may be through increased quantity and quality of patient and practitioner time together and communication. We hypothesize that this, in turn, fosters greater opportunity for cross-cultural exposure and decreases clinician implicit bias, explicit bias, and racism, thus increasing the likelihood that practitioners advocate for systems-level changes that directly benefit patients and improve perinatal outcomes.

Objective This study aimed to determine the feasibility and effectiveness of Diabetes Group Prenatal Care to increase patient engagement in diabetes self-care activities. Study Design A pilot randomized controlled trial was conducted at two sites. Inclusion criteria were English or Spanish speaking, type 2 or gestational diabetes, 22 to 34 weeks of gestational age at first study visit, ability to attend group care at specified times, and willingness to be randomized. Exclusion criteria included type 1 diabetes, multiple gestation, major fetal anomaly, serious medical comorbidity, and serious psychiatric illness. Women were randomized to Diabetes Group Prenatal Care or individual prenatal care. The primary outcome was completion of diabetes self-care activities, including diet, exercise, blood sugar testing, and medication adherence. Secondary outcomes included antenatal care characteristics, and maternal, neonatal, and diabetes management outcomes. Analysis followed the intention-to-treat principle. Results Of 159 eligible women, 84 (53%) consented to participate in the study and were randomized to group (n = 42) or individual (n = 42) prenatal care. Demographic characteristics were similar between study arms. Completion of diabetes self-care activities was similar overall, but women in group care ate the recommended amount of fruits and vegetables on more days per week (5.1 days/week ± 2.0 standard deviation [SD] in group care vs. 3.4 days ± 2.6 SD in individual care; p Conclusion Diabetes group care is feasible and shows promise for decreasing gestational weight gain, improving diet, and increasing postpartum diabetes testing among women with pregnancies complicated by diabetes. Key Points

To assess whether outpatient cervical ripening with a transcervical Foley catheter in parous women undergoing elective induction of labor shortens the total duration of time from admission to the labor ward until delivery.We performed an open-label randomized controlled trial at a single academic center in parous women at 39 weeks of gestation or greater with a cervix 3 cm or less dilated, or, if 2-3 cm dilated, less than 80% effaced and reassuring fetal heart rate monitoring (defined as moderate variability with a normal baseline and absence of decelerations). Exclusions were obstetric and neonatal conditions deemed unsuitable for outpatient cervical ripening, contraindications to vaginal delivery, or conditions that required immediate hospitalization. Women were randomized in the ambulatory setting to either an outpatient transcervical catheter (with immediate placement) or inpatient transcervical catheter placement and concomitant oxytocin infusion on the labor ward. Women in the outpatient group were instructed to return to the hospital the next day or sooner if labor occurred. Induction of labor was managed per institutional protocol, and once participants were admitted, oxytocin was initiated. The primary outcome was the duration of time from labor ward admission until delivery. Based on a prior study in our institution, a total of 128 women were needed for 80% power to detect a 12-hour difference in total duration spent from labor ward admission until delivery with a two-sided α of 0.05.Of 743 women screened, 129 provided consent and were randomized from May 2016 to October 2017. Baseline characteristics were balanced between groups. Outpatient cervical ripening did not significantly shorten the time from labor ward admission until delivery (12.4±7.4 vs 13.5±7.0 hours, P=.38).Outpatient cervical ripening in parous women does not shorten the time from labor ward admission until delivery if oxytocin is initiated simultaneously with inpatient transcervical catheter placement.ClinicalTrials.gov, NCT02756689.

Objective Perinatal Mood and Anxiety Disorders (PMADs) are one of the most common complications of the perinatal period.1 ACOG recommends screening for both depressive and anxiety symptoms at least once during the perinatal period using a standardized, validated tool.2 The Edinburgh Postnatal Depression Screen (EPDS) is the most commonly used tool to screen for depression, and while it contains anxiety-related questions, it has not been validated to screen for anxiety. In fact, the ideal tool to screen for perinatal anxiety remains a matter of debate.3-5 The aim of our study was to evaluate the ability of the EPDS to also screen for anxiety related symptoms as compared to the gold-standard of the Generalized Anxiety Disorder-7 (GAD-7). Study Design Women receiving obstetric care at three of the University of Alabama at Birmingham obstetric clinics were screened simultaneously using the EPDS and GAD-7 from 10/1/17 to 5/31/18. The screened population included English and Spanish-speaking women from public and private offices at varied gestational ages and postpartum. Only the first screen was included if a woman was screened more than once. The total score on both the EDPS and GAD-7, as well as the score on three anxiety-specific EPDS questions (#4, 5 and 6) were collected. Demographic data were collected from the electronic medical record. A positive score was set at 10 for both the GAD-7 and EPDS. The data were then analyzed using standard statistical modeling including logistic regression and Pearson correlation coefficients. Results 407 women were screened and included in the study: 102 (25%) were postpartum, otherwise average gestational age was 22.4 weeks; 178 (44%) self-identified as African American and 24 (6%) as Hispanic; 203 (49%) received care in the public office (predominantly Medicaid-insured). Only 13 (3%) of screens were completed in Spanish. The prevalence of a positive GAD-7 was 17% and a positive EPDS was 11%. The correlation between a positive EPDS and GAD-7 screen was 0.83 (p Conclusion PMADs are common in our obstetric population. A positive EPDS alone was correlated with a positive GAD-7. In the presence of a negative EPDS screen, using a score of 5 or greater on the three anxiety-specific EPDS questions may be helpful in identifying women who could benefit from further anxiety screening and treatment.

To investigate the relationships between psychological and physiologic measures of stress, mood, and gestational age at delivery and preterm birth.This prospective cohort study recruited healthy women in the early second trimester who were 18-45 years of age. Validated psychological measures of perceived stress, depressive symptoms, and anxiety were completed at 16, 22, 28, 34, and 40 weeks of gestation. Cortisol concentration was measured in maternal hair at 16, 28, and 40 weeks of gestation to approximate first-, second-, and third-trimester levels of physiologic stress. Statistical methods included: analyses of variance, t tests, χ, Pearson correlations, regression modeling, and mediation analysis as appropriate. Hair cortisol concentrations were natural log-transformed to normalize values.Eleven (12%) of the 90 included women had a spontaneous preterm birth or preterm premature rupture of membranes. Perceived stress at 16 weeks of gestation correlated with both second-trimester cortisol concentration (r=0.28, P=.007) and earlier gestational age at delivery (r=-0.30, P.01). Gestational age at delivery was also negatively correlated with cortisol concentration in the second trimester (r=-0.25, P=.02) and second-trimester cortisol concentration was higher in preterm- (2.7 ± 0.4 log-transformed pg/mg) compared with term- (2.0 ± 0.7 log-transformed pg/mg, P.001) delivered women. Using mediation statistics, the association between the psychological measure, the physiologic measure, and gestational age at delivery was mainly driven by increased physiologic stress (hair cortisol concentration) in the second trimester (difference in coefficients [standard error]=-0.05 [0.02]).Higher perceived stress in the second trimester is associated with both elevated second-trimester hair cortisol concentration and gestational age at delivery. Physiologic measure of stress in the second trimester appears most strongly associated with preterm birth. Identification and amelioration of early pregnancy stressors may attenuate physiologic stress and ultimately affect preterm birth.

Infants infected with Bordatella pertussis experience high morbidity and significant mortality. Vaccinating pregnant mothers with the tetanus-diphtheria-acellular pertussis (Tdap) vaccine is a recommended strategy for preventing infant pertussis. This is especially important for mothers living in poverty and from racial and ethnic minority populations as these groups are at increased risk of having a pertussis-affected infant. Using the Health Belief Model as a framework, we surveyed a convenience sample of pregnant mothers representing these high-risk populations to understand factors associated with Tdap vaccine uptake during their pregnancy. Among the 316 mothers surveyed, 82% had gotten or planned to get Tdap that same day even though 63% of the sample had concerns about the safety of the vaccine during pregnancy. Perceived benefits and norms were the Health Belief Model constructs most consistently associated with Tdap vaccination. Although 32% of women reported prior Tdap vaccine receipt, this factor was not associated with Tdap vaccination during the current pregnancy, contrasting studies of vaccination done in non-pregnant populations. Important variations in attitudes were apparent, with Spanish-speaking women significantly more likely to have concerns about the vaccine's safety and efficacy than English-speaking women. This study indicates that among this high-risk population acceptance of Tdap vaccine during pregnancy is high. However, our results suggest that it may be important to modify information conveyed about the safety and importance of Tdap during pregnancy based on individual level factors such as language or acculturation.

There is increasing attention on immunizations by obstetrician-gynecologists and a need to improve vaccination rates for all women.To evaluate the effect of a multimodal intervention on rates of immunization with tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); and influenza in outpatient obstetrics and gynecology clinics.Immunization rates at 2 clinics were compared pre- and post-implementation of multiple interventions at a public integrated health-care system. Study interventions began on June 6, 2012 and concluded on May 31, 2014; the preimplementation time period used was June 6, 2010 to June 5, 2012. Interventions included stocking of immunizations in clinics, revision and expansion of standing orders, creation of a reminder/recall program, identification of an immunization champion to give direct provider feedback, expansion of a payment assistance program, and staff education. All women aged 15 and older who made a clinic visit during influenza season were included in the influenza cohort; women who delivered an infant during the study time period and had at least 1 prenatal visit within 9 months preceding delivery were included in the Tdap cohort; each clinic visit by a nonpregnant woman aged 15-26 years was assessed and included in the HPV analysis as an eligible visit if the patient was lacking any of the 3 HPV vaccines in the series. The primary outcome was receipt of influenza and Tdap vaccine per current American College of Obstetricians and Gynecologists guidelines and receipt of HPV vaccine during eligible visits. Influenza and Tdap were assessed with overall coverage rates at the institutional level, and HPV was assessed at the visit level by captured opportunities. All analyses included generalized estimating equations and the primary outcome was assessed with time as a covariate in all models.A total of 19,409 observations were included in the influenza cohort (10,231 pre- and 9178 post-intervention), 2741 in the Tdap cohort (1248 pre- and 1493 post-intervention), and 12,443 in the HPV cohort (7966 pre- and 4477 post-intervention). Our population was largely Hispanic, English-speaking, and publicly insured. The rate of influenza vaccination increased from 35.4% pre-intervention to 46.0% post-intervention (P.001). The overall rate for Tdap vaccination increased from 87.6% pre-intervention to 94.5% post-intervention until the recommendation to vaccinate during each pregnancy was implemented (z = 4.58, P.0001). The average Tdap up-to-date rate after that recommendation was 75.0% (z = -5.77, P.0001). The overall rate of HPV vaccination with an eligible visit increased from 7.1% before to 23.7% after the intervention.Using evidence-based practices largely established in other settings, our intervention was associated with increased rates of influenza, Tdap, and HPV vaccination in outpatient underserved obstetrics and gynecology clinics. Integrating such evidence-based practices into routine obstetrics and gynecology care could positively impact preventive health for many women.