Search

Objective: Independent and joint impacts of maternal race/ethnicity and obesity on adverse birth outcomes, including pre-eclampsia, low birth weight, and macrosomia, were characterized., Methods: Retrospective cohort study of all 2007 California births was conducted using vital records and claims data. Maternal race/ethnicity and maternal body mass index (BMI) were the key exposures; their independent and joint impact on outcomes using regression models was analyzed., Results: Racial/ethnic minority women of normal weight generally had higher risk as compared with white women of normal weight (e.g., African-American women, pre-eclampsia adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI]: 1.48-1.74 vs. white women). However, elevated BMI did not usually confer additional risk (e.g., pre-eclampsia aOR comparing African-American women with excess weight with white women with excess weight, 1.17, 95% CI: 0.89-1.54). Obesity was a risk factor for low birth weight only among white women (excess weight aOR, 1.24, 95% CI: 1.04-1.49 vs. white women of normal weight) and not among racial/ethnic minority women (e.g., African-American women, 0.95, 95% CI: 0.83-1.08)., Conclusions: These findings add nuance to our understanding of the interplay between maternal race/ethnicity, BMI, and perinatal outcomes. While the BMI/adverse outcome gradient appears weaker in racial/ethnic minority women, this reflects the overall risk increase in racial/ethnic minority women of all body sizes., (© 2016 The Obesity Society.)

Objective: To assess trends over time of operative vaginal delivery and compare delivery-related morbidity between vacuum delivery, forceps delivery, or combined use of both in California., Methods: California ICD-9 discharge data from 2001 to 2007 were used to identify cases of forceps and vacuum delivery., Results: There was a decline in all operative delivery types (9.0% in 2001 to 7.6% in 2007), with the decline in the use of forceps most pronounced (7.26/1000 deliveries in 2001 to 3.85/1000 in 2007). Higher rates of third/fourth degree lacerations, postpartum hemorrhage, manual extraction of placenta, pelvic hematoma requiring evacuation, cervical laceration repair, and thromboembolic events were noted in forceps compared to vacuum deliveries. When both instruments were used, rates of third/fourth degree lacerations and postpartum hemorrhage were increased. Operative delivery failure was highest in combined use compared to forceps or vacuum alone., Conclusion: The incidence of operative vaginal delivery in California is declining, with decreasing use of forceps most notable. Several maternal morbidities are increased in forceps and combined deliveries compared to vacuum deliveries. There is a significantly higher risk of failure when two operative delivery methods are employed. These findings may be contributing to the declining willingness of providers to perform operative vaginal delivery.

Objective: To examine the association of antenatal weight gain above and below the 2009 Institute of Medicine (IOM) guidelines in the super-obese population (body mass index [BMI] of 50 or higher) on the maternal and neonatal morbidities of gestational hypertension or preeclampsia (pregnancy-induced hypertension), gestational diabetes mellitus, cesarean delivery, birth weight more than 4,000 g and more than 4,500 g, low birth weight, and preterm birth., Methods: The effect of gestational weight gain was assessed in this retrospective cohort study using California birth certificate and patient discharge diagnosis data. Unconditional logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (CIs) as a function of antenatal weight gain. Weight gain within 2009 IOM guidelines (11-20 pounds) served as the reference group., Results: The study population consisted of 1,034 women. Women gaining below, within, and above IOM guidelines accounted for 38.3, 23.5, and 38.2%, respectively. Weight gain below IOM guidelines was not associated with a statistically increased odds of preterm birth (OR 1.82, 95% CI 0.60-5.59) or low birth weight (OR 1.20, 95% CI 0.57-2.49); however, birth weight more than 4,000 g was significantly reduced (OR 0.50, 95% CI 0.32-0.77). Excessive weight gain statistically increased the odds of pregnancy-induced hypertension (OR 1.96, 95% CI 1.26-3.03) and cesarean delivery (OR 1.40, 95% CI 1.00-1.97) while not appearing to protect against the delivery of low-birth-weight neonates (OR 0.84, 95% CI 0.40-1.78)., Conclusion: Weight gain below the current guidelines in the super-obese cohort is not associated with an increase in maternal or neonatal risk while decreasing the odds of delivering a macrosomic neonate. Women with BMIs of 50 or higher may warrant separate gestational weight gain recommendations.

Objective: To evaluate the association between pre-pregnancy body mass index (BMI) and adverse pregnancy outcomes using a large administrative database., Methods: Retrospective cohort study of California women delivering singletons in 2007. The association between pre-pregnancy BMI category and adverse outcomes were evaluated using multivariate logistic regression., Results: Among 436,414 women, increasing BMI was associated with increasing odds of adverse outcomes. Obese women (BMI=30-39.9) were nearly 3 x more likely to have gestational diabetes (OR=2.83, 95% CI=2.74-2.92) and gestational hypertension/preeclampsia (2.68, 2.59-2.77) and nearly twice as likely to undergo cesarean (1.82, 1.78-1.87), when compared to normal BMI women (BMI=18.5-24.9). Morbidly obese women (BMI ≥ 40) were 4x more likely to have gestational diabetes (4.72, 4.46-4.99) and gestational hypertension/preeclampsia (4.22, 3.97-4.49) and nearly 3 x as likely to undergo cesarean (2.60, 2.46-2.74)., Conclusion: There is a strong association between increasing maternal BMI and adverse pregnancy outcomes. This information is important for counseling women regarding the risks of obesity in pregnancy.

Objective: The objective of this study was to examine the effect of hospital-level factors on mortality of very low birth weight infants using multilevel modeling., Study Design: This is a secondary data analysis of California maternal-infant hospital discharge data from 1997 to 2002. The study population was limited to singleton, non-anomalous, very low birth weight infants, who delivered in hospitals providing neonatal intensive care services (level-2 and higher). Hierarchical generalized linear modeling, also known as multilevel modeling, was used to adjust for individual-level confounders., Result: In a multilevel model, increasing hospital volume of very low birth weight deliveries was associated with lower odds of very low birth weight mortality. Characteristics of a particular hospital's obstetrical and neonatal services (the presence of residency and fellowship training programs and the availability of perinatal and neonatal services) had no independent effect., Conclusion: Using multilevel modeling, hospital volume of very low birth weight deliveries appears to be the primary driver of reduced mortality among very low birth weight infants.

Objective: To determine the adjusted effect of hospital level of care and volume on mortality of very low birth weight (VLBW) infants in the state of California, where deregionalization of perinatal care has occurred., Research Design: Secondary data analysis of California maternal-infant hospital discharge data from 1997 to 2002 was performed. Logistic regression was used to evaluate the odds of mortality among VLBW infants by hospital level of neonatal intensive care and volume of VLBW deliveries, in the context of differences in antenatal and delivery factors by hospital site of delivery., Results: Both maternal and fetal antenatal risk profiles and delivery characteristics vary by hospital site of delivery. After risk adjustment, lower-level, lower-volume units were associated with a higher odds of mortality. The highest odds of mortality occurred in level-1 units with < or =10 VLBW deliveries per year (odds ratio, 1.69; 95% confidence interval, 1.43-1.99). In isolation, hospital volume, rather than level of care, had the greater effect., Conclusions: Although deregionalization of perinatal services may increase access to care for high-risk mothers and newborns, its impact on hospital volume may outweigh its potential benefit.