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Objective This study aimed to elucidate factors contributing to uptake of highly effective contraception, including permanent contraception, and no contraceptive plan among postpartum people with HIV (PWHIV). Study Design A retrospective cohort analysis was conducted to correlate postpartum birth control (PPBC) with sociodemographic and biomedical variables among postpartum PWHIV who received care at The Ruth M. Rothstein CORE Center and delivered at John H. Stroger, Jr. Hospital of Cook County in Chicago, from 2012 to 2020. Results Earlier gestational age (GA) at initiation of prenatal care, having insurance, and increased parity are associated with uptake of highly effective contraception. Meanwhile, later GA at presentation increased odds of having no PPBC plan. Conclusion Early prenatal care, adequate insurance coverage, and thorough PPBC counseling are important for pregnant PWHIV. Key Points Contraceptive use among PWHIV is poorly understood. Having insurance and increased parity are associated with long-acting reversible contraception use. Earlier GA at first prenatal care visit is associated with increased PPBC uptake. [ABSTRACT FROM AUTHOR]

Introduction: Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated with worse perinatal outcomes. Reasons for discharges AMA are not well understood. The objective of this study is to identify the obstacles that prevent obstetric patients from accepting recommended care and highlight the structural reasons behind AMA discharges. Methods: Electronic health records of patients admitted to antepartum, peripartum, or postpartum services between 2008 and 2018 who left "AMA" were reviewed. Progress notes from clinicians and social workers were extracted and analyzed. Reasons behind discharge were categorized using qualitative thematic analysis. Results: Fifty-seven (0.12%) obstetric patients were discharged AMA. Reasons for discharge were organized into two overarching themes: extrinsic (50.9%) and intrinsic (40.4%) obstacles to accepting care. Eleven participants (19.3%) had no reason documented for their discharge. Extrinsic obstacles included childcare, familial responsibilities, and other obligations. Intrinsic obstacles included disagreement with provider regarding medical condition or plan, emotional distress, mistrust or discontent with care team, and substance use. Discussion: The term "AMA" casts blame on individual patients and fails to represent the systemic barriers to staying in care. Obstetric patients were found to encounter both extrinsic and intrinsic obstacles that led them to leave AMA. Healthcare providers and institutions can implement strategies that ameliorate structural barriers. Partnering with patients to prevent discharges AMA would improve maternal and infant health and progress towards reproductive justice. Significance: What is Already Known on this Subject?: Obstetric patients who leave "against medical advice (AMA)" have worse perinatal outcomes and often are from marginalized communities. The term, AMA, is also stigmatizing, placing blame on individual decision making rather than systemic barriers to access. Reasons for leaving AMA are not well understood in the obstetric population. What does this Study add?: We reframe the discussion around leaving AMA by describing obstacles in accepting care. Patients experienced both extrinsic and intrinsic obstacles to accepting medical care, from childcare issues to disagreement with treatment plan. Partnering with patients to overcome these obstacles would improve maternal and infant health and increase equity and reproductive justice. [ABSTRACT FROM AUTHOR]

Objective Our objective was to examine the biomedical and sociodemographic factors associated with the prescription of naloxone among pregnant people with opioid-use disorder (OUD) who were admitted for initiation of medications for OUD (i.e., buprenorphine-containing medications or methadone) following the implementation of a statewide initiative focused on reducing adverse perinatal health outcomes. Study Design This is a single-site, retrospective cohort study of pregnant people admitted for the management of OUD at an urban, tertiary care center between 2013 and 2020. The primary outcome is evidence of a prescription of naloxone, ascertained from the electronic medical record. Bivariate and multivariable logistic regression modeling was performed to evaluate biomedical and sociodemographic variables associated with a prescription for naloxone. Covariates for inclusion in the multivariate logistic regression model were selected based on a p < 0.05 on bivariate analysis. Statistical significance was set at p < 0.05. Results One hundred and thirty-nine participants met the inclusion criteria. On bivariate analysis, people who received naloxone were more likely to be admitted after the initiation of a statewide initiative focused on reducing adverse perinatal outcomes associated with perinatal OUD. Those individuals reporting intravenous drug use (IVDU) were less likely to receive naloxone. On multivariate logistic regression, after controlling for IVDU and epoch of admission, both IVDU (adjusted odds ratio [aOR]: 0.27, 95% confidence interval [CI]: 0.11–0.70) and epoch of admission (aOR: 3.48, 95% CI: 1.28–9.50) were independently associated with receipt of prescription of take-home naloxone. Conclusion Naloxone prescription was independently associated with the epoch of admission and route of drug administration. These data can be useful in the evaluation and development of clinical practices to increase rates of naloxone prescription in pregnant people with OUD admitted for inpatient management. Key Points Thirty four percent of individuals with perinatal OUD were prescribed take-home naloxone (THN). Epoch of admission and route of drug administration were independently associated with THN. These data can be used to guide public health and clinical programming for pregnant people. [ABSTRACT FROM AUTHOR]

Objective  The aim of this study was to assess whether social vulnerability among foreign-born pregnant women living with HIV is associated with maternal viremia during pregnancy. Study Design  This retrospective cohort study included all foreign-born pregnant women living with HIV who received prenatal care in a multidisciplinary prenatal clinic between 2009 and 2018. A licensed clinical social worker evaluated all women and kept detailed clinical records on immigration status and social support. Social vulnerability was defined as both living in the United States for less than 5 years and reporting no family or friends for support. The primary outcome was evidence of viral non-suppression after achievement of initial suppression. Secondary outcomes were the proportion of women who required > 12 weeks after starting antiretroviral therapy to achieve viral suppression, median time to first viral suppression (in weeks) after initiation of antiretroviral therapy, and the proportion who missed ≥ 5 doses of antiretroviral therapy. Bivariable analyses were performed. Results  A total of 111 foreign-born women were eligible for analysis, of whom 25 (23%) were classified as socially vulnerable. Social and clinical characteristics of women diverged by social vulnerability categorization but no differences reached statistical significance. On bivariable analysis, socially-vulnerable women were at increased risk for needing > 12 weeks to achieve viral suppression (relative risk: 1.78, 95% confidence interval: 1.18–2.67), though there was no association with missing ≥ 5 doses of antiretroviral therapy or median time to viral suppression after initiation of antiretroviral therapy. Conclusion  Among foreign-born, pregnant women living with HIV, markers of virologic control during pregnancy were noted to be worse among socially-vulnerable women. Insofar as maternal viremia is the predominant driver of perinatal transmission, closer clinical surveillance and support may be indicated in this population. Key Points 23% of foreign-born pregnant women living with HIV were identified as socially vulnerable. Socially-vulnerable women were at higher risk for re-emergent viremia (24 vs. 7%, RR 3.44). Socially-vulnerable women were at higher risk for needing >12 weeks to become aviremic (64 vs. 36%, RR: 1.7). [ABSTRACT FROM AUTHOR]

Objective: To evaluate gestational latency in individuals who did and did not receive perioperative cefazolin and indomethacin after physical examination-indicated cerclage.Methods: This is a retrospective cohort study of all pregnant women with a singleton gestation who underwent physical examination-indicated cerclage placement and delivered at Northwestern Memorial Hospital from 2009 to 2018. Physical examination-indicated cerclage was performed in the setting of painless cervical dilation of at least 1 cm between 16 0/7 and 23 6/7 weeks of gestation. After 2014, our practice universally implemented perioperative prophylaxis of cefazolin and indomethacin. Individuals were categorized based on exposure to perioperative prophylaxis. The primary outcome was pregnancy latency at least 28 days after cerclage placement. Secondary outcomes included median latency; median gestational age at delivery; preterm birth before 28 weeks of gestation; preterm prelabor rupture of membranes; chorioamnionitis; and median birth weight. Multivariable analyses were performed, as well as a sensitivity analysis using propensity score matching.Results: Cerclages were placed in 142 people: 72 (50.7%) received perioperative prophylaxis. Baseline demographics were not significantly different between groups. On multivariable analyses, individuals who received perioperative prophylaxis had a higher incidence of achieving a pregnancy latency at 28 days or more (adjusted relative risk [aRR] 1.21, 95% CI 1.05-1.40). Individuals who received perioperative prophylaxis had a significant improvement in gestational latency (+17.8 days, 95% CI 1.4-34.2 days) and birth weight (+489.8 g, 95% CI 64.6-915.0 g), with no differences in other outcomes. On sensitivity analysis, individuals receiving perioperative prophylaxis had a higher incidence of achieving a pregnancy latency at 28 days or more, (aRR 1.17, 95% CI 1.01-1.36) with no differences in other outcomes.Conclusion: Perioperative use of cefazolin and indomethacin prophylaxis during physical examination-indicated cerclage placement is associated with a significant prolongation in gestational latency without an increase in incidence of chorioamnionitis. [ABSTRACT FROM AUTHOR]

Background: In both the biomedical and public health literature, the risk for preterm birth has been linked to maternal racial/ethnic background, in particular African-American heritage. Despite this well-documented health disparity, the relationship of comorbid conditions, such as chronic hypertension, to maternal race/ethnicity and preterm birth has received relatively limited attention in the literature.Objective: The objective of the study was to evaluate the interaction between chronic hypertension and maternal racial/ethnic background on preterm birth.Study Design: This is a retrospective cohort study of singleton pregnancies among women who delivered between 2002 and 2015 at the University of California, San Francisco. The associations of chronic hypertension with both spontaneous and medically indicated preterm birth were examined by univariate and multivariate logistical regression, adjusting for confounders including for maternal age, history of preterm birth, maternal body mass index, insurance type (public vs private), smoking, substance abuse, history of pregestational diabetes mellitus, and use of assisted reproductive technologies. The interaction effect of chronic hypertension and racial/ethnicity was also evaluated. All values are reported as odds ratios, with 95% confidence intervals and significance set at P = .05.Results: In this cohort of 23,425 singleton pregnancies, 8.8% had preterm deliveries (3% were medically indicated preterm birth, whereas 5.5% were spontaneous preterm births), and 3.8% of women carried the diagnosis of chronic hypertension. Chronic hypertension was significantly associated with preterm birth in general (adjusted odds ratio, 2.74, P < .001) and medically indicated preterm birth specifically (adjusted odds ratio, 5.25, P < .001). When evaluating the effect of chronic hypertension within racial/ethnic groups, there was an increased odds of a preterm birth among hypertensive, African-American women (adjusted odds ratio, 3.91, P < .001) and hypertensive, Asian-American/Pacific Islander women (adjusted odds ratio, 3.51, P < .001) when compared with their nonhypertensive counterparts within the same racial/ethnic group. These significant effects were also noted with regard to medically indicated preterm birth for hypertensive African-American women (adjusted odds ratio, 6.85, P < .001) and Asian-American/Pacific Islander women (adjusted odds ratio, 9.87, P < .001). There was no significant association of chronic hypertension with spontaneous preterm birth (adjusted odds ratio, 0.87, P = .4).Conclusion: The effect of chronic hypertension on overall preterm birth and medically indicated preterm birth differs by racial/ethnic group. The larger effect of chronic hypertension among African-American and Asian/Pacific Islander women on medically indicated and total preterm birth rates raises the possibility of an independent variable that is not captured in the data analysis, although data regarding the indication for medically indicated preterm delivery was limited in this data set. Further investigation into both social-structural and biological predispositions to preterm birth should accompany research focusing on the effect of chronic hypertension on birth outcomes. [ABSTRACT FROM AUTHOR]