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Introduction Over 265 000 women are living with HIV in the USA, but limited research has investigated the physical, mental and behavioural health outcomes among women living with HIV of reproductive age. Health status during the reproductive years before, during and after pregnancy affects pregnancy outcomes and long-term health. Understanding health outcomes among women living with HIV of reproductive age is of substantial public health importance, regardless of whether they experience pregnancy. The Health Outcomes around Pregnancy and Exposure to HIV/Antiretrovirals (HOPE) study is a prospective observational cohort study designed to investigate physical and mental health outcomes of young women living with HIV as they age, including HIV disease course, engagement in care, reproductive health and choices and cardiometabolic health. We describe the HOPE study design, and characteristics of the first 437 participants enrolled as of 1 January 2024.Methods and analysis The HOPE study seeks to enrol and follow 1630 women living with HIV of reproductive age, including those with perinatally-acquired HIV, at 12 clinical sites across 9 US states and Puerto Rico. HOPE studies multilevel dynamic determinants influencing physical, mental and social well-being and behaviours of women living with HIV across the reproductive life course (preconception, pregnancy, post partum, not or never-pregnant), informed by the socioecological model. Key research areas include the clinical course of HIV, relationship of HIV and antiretroviral medications to reproductive health, pregnancy outcomes and comorbidities and the influence of racism and social determinants of health. HOPE began enrolling in April 2022.Ethics and dissemination The HOPE study received approval from the Harvard Longwood Campus Institutional Review Board, the single institutional review board of record for all HOPE sites. Results will be disseminated through conference presentations, peer-reviewed journals and lay summaries.

Abstract BackgroundThe COVID-19 pandemic accelerated telemedicine and mobile app use, potentially changing our historic model of maternity care. MyChart is a widely adopted mobile app used in health care settings specifically for its role in facilitating communication between health care providers and patients with its messaging function in a secure patient portal. However, previous studies analyzing portal use in obstetric populations have demonstrated significant sociodemographic disparities in portal enrollment and messaging, specifically showing that patients who have a low income and are non-Hispanic Black, Hispanic, and uninsured are less likely to use patient portals. ObjectiveThe study aimed to estimate changes in patient portal use and intensity in prenatal care before and during the pandemic period and to identify sociodemographic and clinical disparities that continued during the pandemic. MethodsThis retrospective cohort study used electronic medical record (EMR) and administrative data from our health system’s Enterprise Data Warehouse. Records were obtained for the first pregnancy episode of all patients who received antenatal care at 8 academically affiliated practices and delivered at a large urban academic medical center from January 1, 2018, to July 22, 2021, in Chicago, Illinois. All patients were aged 18 years or older and attended ≥3 clinical encounters during pregnancy at the practices that used the EMR portal. Patients were categorized by the number of secure messages sent during pregnancy as nonusers or as infrequent (≤5 messages), moderate (6-14 messages), or frequent (≥15 messages) users. Monthly portal use and intensity rates were computed over 43 months from 2018 to 2021 before, during, and after the COVID-19 pandemic shutdown. A logistic regression model was estimated to identify patient sociodemographic and clinical subgroups with the highest portal nonuse. ResultsAmong 12,380 patients, 2681 (21.7%) never used the portal, and 2680 (21.6%), 3754 (30.3%), and 3265 (26.4%) were infrequent, moderate, and frequent users, respectively. Portal use and intensity increased significantly over the study period, particularly after the pandemic. The number of nonusing patients decreased between 2018 and 2021, from 996 of 3522 (28.3%) in 2018 to only 227 of 1743 (13%) in the first 7 months of 2021. Conversely, the number of patients with 15 or more messages doubled, from 642 of 3522 (18.2%) in 2018 to 654 of 1743 (37.5%) in 2021. The youngest patients, non-Hispanic Black and Hispanic patients, and, particularly, non–English-speaking patients had significantly higher odds of continued nonuse. Patients with preexisting comorbidities, hypertensive disorders of pregnancy, diabetes, and a history of mental health conditions were all significantly associated with higher portal use and intensity. ConclusionsReducing disparities in messaging use will require outreach and assistance to low-use patient groups, including education addressing health literacy and encouraging appropriate and effective use of messaging.

BackgroundYouTube is an increasingly common source of health information; however, the reliability and quality of the information are inadequately understood. Several studies have evaluated YouTube as a resource during pregnancy and found the available information to be of poor quality. Given the increasing attention to postpartum health and the importance of promoting safe opioid use after birth, YouTube may be a source of information for birthing individuals. However, little is known about the available information on YouTube regarding postpartum pain. ObjectiveThe purpose of this study is to systematically evaluate the quality of YouTube videos as an educational resource for postpartum cesarean pain management. MethodsA systematic search of YouTube videos was conducted on June 25, 2021, using 36 postpartum cesarean pain management–related keywords, which were identified by clinical experts. The search replicated a default YouTube search via a public account. The first 60 results from each keyword search were reviewed, and unique videos were analyzed. An overall content score was developed based on prior literature and expert opinion to evaluate the video’s relevance and comprehensiveness. The DISCERN instrument, a validated metric to assess consumer health information, was used to evaluate the reliability of video information. Videos with an overall content score of ≥5 and a DISCERN score of ≥39 were classified as high-quality health education resources. Descriptive analysis and intergroup comparisons by video source and quality were conducted. ResultsOf 73 unique videos, video sources included medical videos (n=36, 49%), followed by personal video blogs (vlogs; n=32, 44%), advertisements (n=3, 4%), and media (n=2, 3%). The average overall content score was 3.6 (SD 2.0) out of 9, and the average DISCERN score was 39.2 (SD 8.1) out of 75, indicating low comprehensiveness and fair information reliability, respectively. High-quality videos (n=22, 30%) most frequently addressed overall content regarding pain duration (22/22, 100%), pain types (20/22, 91%), return-to-activity instructions (19/22, 86%), and nonpharmacologic methods for pain control (19/22, 86%). There were differences in the overall content score (P=.02) by video source but not DISCERN score (P=.45). Personal vlogs had the highest overall content score at 4.0 (SD 2.1), followed by medical videos at 3.3 (SD 2.0). Longer video duration and a greater number of comments and likes were significantly correlated with the overall content score, whereas the number of video comments was inversely correlated with the DISCERN score. ConclusionsIndividuals seeking information from YouTube regarding postpartum cesarean pain management are likely to encounter videos that lack adequate comprehensiveness and reliability. Clinicians should counsel patients to exercise caution when using YouTube as a health information resource.

ImportancePregnancy induces unique physiologic changes to the immune response and hormonal changes leading to plausible differences in the risk of developing post-acute sequelae of SARS-CoV-2 (PASC), or Long COVID. Exposure to SARS-CoV-2 during pregnancy may also have long-term ramifications for exposed offspring, and it is critical to evaluate the health outcomes of exposed children. The National Institutes of Health (NIH) Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC aims to evaluate the long-term sequelae of SARS-CoV-2 infection in various populations. RECOVER-Pregnancy was designed specifically to address long-term outcomes in maternal-child dyads.MethodsRECOVER-Pregnancy cohort is a combined prospective and retrospective cohort that proposes to enroll 2,300 individuals with a pregnancy during the COVID-19 pandemic and their offspring exposed and unexposed in utero, including single and multiple gestations. Enrollment will occur both in person at 27 sites through the Eunice Kennedy Shriver National Institutes of Health Maternal-Fetal Medicine Units Network and remotely through national recruitment by the study team at the University of California San Francisco (UCSF). Adults with and without SARS-CoV-2 infection during pregnancy are eligible for enrollment in the pregnancy cohort and will follow the protocol for RECOVER-Adult including validated screening tools, laboratory analyses and symptom questionnaires followed by more in-depth phenotyping of PASC on a subset of the overall cohort. Offspring exposed and unexposed in utero to SARS-CoV-2 maternal infection will undergo screening tests for neurodevelopment and other health outcomes at 12, 18, 24, 36 and 48 months of age. Blood specimens will be collected at 24 months of age for SARS-CoV-2 antibody testing, storage and anticipated later analyses proposed by RECOVER and other investigators.DiscussionRECOVER-Pregnancy will address whether having SARS-CoV-2 during pregnancy modifies the risk factors, prevalence, and phenotype of PASC. The pregnancy cohort will also establish whether there are increased risks of adverse long-term outcomes among children exposed in utero.Clinical trials.gov identifierClinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT05172011.

ImportanceSARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis.MethodsRECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms.DiscussionRECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options.RegistrationNCT05172024.

BackgroundPatient navigation, a patient-centered intervention to promote comprehensive health care, is an emerging innovation in obstetrics to optimize postpartum care. We aimed to evaluate the implementation of a novel postpartum patient navigation program at an urban academic medical center.MethodsThis mixed-methods study analyzed the implementation of a postpartum patient navigation program within an ongoing randomized control trial. This study analyzed three navigators' logs of interactions with 50 patients, care team members, and community organizations throughout patients' first year postpartum. We categorized and quantified interactions by topic addressed, care team member interacted with, and communication mode used. We also conducted semi-structured interviews with each navigator every three months (5 interviews per navigator), emphasizing navigation experiences, relationships with patients and care teams, integration in the care team, and healthcare system gaps. Interview data were analyzed using the constant comparative method to identify themes using the constructs of the Consolidated Framework for Implementation Research (CFIR).ResultsAnalysis of navigator logs revealed a high patient need level, especially in the first 3 months postpartum. CFIR-guided analysis of intervention characteristics revealed positive perceptions of navigation's utility due to its adaptability. Navigation's complexity, however, posed an early obstacle to implementation that diminished over time. Outer setting analysis indicated navigators addressed patient needs through interactions with multiple systems. Despite clinicians' initial unfamiliarity with navigation, inner setting analysis suggested ongoing communication and electronic medical record use facilitated integration into the care team. Regarding individual and process characteristics, findings emphasized how navigator self-efficacy and confidence increased with experience (individual) and was facilitated by comprehensive training and reflection (process). Overall, barriers to implementation included unfamiliarity, varied patient engagement, and innovation complexity. Facilitators included high patient need, communication with outside organizations, medical record usage, navigator characteristics (self-efficacy, communication skills, and personal growth), a comprehensive training period, consistent reflection, high relative advantage, and high adaptability to patient need.ConclusionPatient navigation is a promising innovation to improve postpartum care coordination and support care team efforts. The successful implementation of navigation in this study indicates that, if shown to improve patient outcomes, obstetric navigation could be a component of patient-centered postpartum care.

BackgroundPeople with gestational diabetes have enhanced learning requirements during pregnancy, and management of their disease often requires the translation of health information into new health behavior changes. Seeking information from the internet to augment learning from health professionals is becoming more common during pregnancy. YouTube is a popular free and accessible web-based resource, which may be particularly useful for individuals with low health literacy or other barriers to receiving high-quality health care; however, the quality and content of YouTube videos varies, and little is known about those covering gestational diabetes. ObjectiveWe aimed to systematically evaluate the quality, content, and reliability of YouTube videos about gestational diabetes. MethodsA systematic search of YouTube videos was conducted over the course of 1 week in April 2020 using the following keywords: “gestational diabetes,” “gestational diabetes management,” “gestational diabetes treatment,” and “pregnancy and diabetes.” The search results were displayed by relevance, replicating a default YouTube search attempt. The first 60 results from each keyword were reviewed (n=240). Exclusion criteria were videos unrelated to gestational diabetes, videos not in English, and those for which the full video was not available at the time of review. For each unique video, a gestational diabetes content score was used to rate video comprehensiveness and accuracy, and the DISCERN instrument, a validated metric to assess consumer health information, was used to evaluate the reliability of information presented. Videos were further categorized by quality: videos with DISCERN scores lower than 3 (out of 5) or a content score less than 4 (out of 7) were categorized as low quality, and all others were designated high quality. We performed descriptive analysis and compared video characteristics by source and quality rating. ResultsFor 115 unique videos, the mean content score (out of 7) was 3.5 (SD 2.0) , and the mean DISCERN score (out of 5) was 2.7 (SD 0.7), representing low to moderate information comprehensiveness and reliability respectively. Video sources were categorized as personal vlog (12/115, 10.4%), web-based education (37/115, 32.2%), medical (52/115, 45.2%), business or company (13/115, 11.3%), and media clip (1/115, 0.9%). DISCERN and content scores trended higher among medical and web-based education videos. The majority of videos (n=88) were categorized as low quality, while 27 videos were categorized as high quality. Video duration was longer for high-quality videos (P

BackgroundThe rising prevalence of hepatitis C virus (HCV) infection and the availability of direct acting antivirals for HCV treatment has prompted a public health goal of HCV eradication. Despite the availability of treatment for HCV, treatment programs have generally excluded pregnant individuals. Our objective was to query patients and clinicians to identify barriers to including pregnant individuals in HCV treatment programs.Methods and findingsThis qualitative investigation included obstetricians and previously/currently pregnant individuals with HCV. Participants completed interviews regarding knowledge of and attitudes towards HCV treatment and perceived barriers to treatment during pregnancy. Data were analyzed using the constant comparative method. Obstetricians (N = 18) and patients (N = 21) described concerns about equity, access, and cost. Both expressed uncertainty about safety and confirmed a need for clinician education. Obstetricians emphasized the lack of professional guidelines. Although some clinicians expressed concern about patient adherence and engagement, patients were largely desirous of treatment; both groups identified potential benefits of antenatal treatment.ConclusionsBoth patients and obstetricians were generally receptive to HCV treatment in pregnancy and recognized pregnancy as an important window of opportunity for treatment. Our findings suggest the need for further research on maternal-fetal safety of HCV treatment as well as on interventions to ensure fair and appropriate access to HCV treatment for pregnant individuals.

BackgroundChanges to the healthcare system due to COVID-19 have altered care delivery during birth and the postpartum period, a transitional time that requires intensive healthcare support and that is complicated by well-established health disparities. Our objective was to identify additional challenges to healthcare interactions that emerged for low-income postpartum individuals during the pandemic.MethodsThis is a qualitative investigation of low-income postpartum individuals enrolled in a trial of postpartum care, who gave birth in the United States in the first three months of the COVID-19 pandemic. Participants completed in-depth semi-structured interviews that addressed healthcare experiences during and after birth, both for in-person and telemedicine encounters. Transcripts were analyzed using the constant comparative method.ResultsOf 46 eligible individuals, 87% (N = 40) completed an interview, with 50% identifying as non-Hispanic Black and 38% as Hispanic. Challenges were organized into three domains: unanticipated changes in the birth experience, delayed care, and perceived disadvantages of telemedicine. Changes in the birth experience addressed uncertainty about COVID-19 status, COVID-19 testing, separation from newborn, and visitor restrictions. Delayed care themes addressed logistical challenges, postpartum care, health maintenance, and pediatric care. Participants reported multiple telemedicine-related challenges, including difficulty establishing rapport with providers.ConclusionsUnderstanding the challenges experienced by low-income peripartum individuals as the COVID-19 pandemic evolves is critical to informing guidelines and diminishing inequities in healthcare delivery. Potential solutions that may mitigate limitations to care in the pandemic include emphasizing shared decision-making in care processes and developing communication strategies to improve telemedicine rapport.

Introduction To assess the relationship between periconception glycemic control and congenital anomalies in a contemporary, diverse population of women with pregestational diabetes.Research design and methods This is a retrospective cohort study of all pregnant women with pregestational diabetes at a single institution (2003–2017) in the USA. The primary outcome was frequency of major or minor congenital anomalies. Glycemic control was assessed by periconception glycosylated hemoglobin (HbA1c). The association of periconception HbA1c with pregnancy outcomes was assessed using bivariable and multivariable analyses.Results Our sample included 351 women, of which 63.8% had type 2 diabetes. Our study cohort is racially and ethnically diverse, with approximately equal numbers of women identifying as white non-Hispanic, black non-Hispanic and Hispanic, with 3.4% identifying as Asian. Of these 351 women, 52 (14.8%) had a fetus with a congenital anomaly, of whom the majority (n=43) had a major anomaly. Over half (51.1%) of all major anomalies were cardiovascular. Compared with the group with the best glycemic control (HbA1c ≤7.4%), which had an anomaly frequency of 10.2%, the frequency of congenital anomalies increased significantly with each category of worsening glycemic control (HbA1c 7.5%–9.4%: 20.6%, adjusted OR (aOR) 2.35, 95% confidence interval (CI) 1.08 to 5.13; HbA1c 9.5% to 11.4%: 25.8%, aOR 2.86, 95% CI 1.08 to 7.59; HbA1c ≥11.5%: 37.5%, aOR 7.66, 95% CI 2.27 to 25.9).Conclusion In a diverse cohort of women with pregestational diabetes, higher periconception HbA1c, especially HbA1c >9.5, was significantly associated with major congenital fetal anomalies. Our study sample is reflective of the current population of pregnant women with diabetes, including women with type 2 diabetes and from racial and ethnic minorities.

ObjectiveIn 2012, recommendations for universal tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination during pregnancy were released. Our objective was to determine if Tdap, influenza, and pneumococcal vaccine uptake during pregnancy changed after the release of the guidelines, and identify factors associated with receiving the Tdap and influenza vaccine after 2012.MethodsWe conducted a retrospective cohort study on pregnant individuals who initiated prenatal care before 20 weeks' gestation between 11/2011-11/2012 ("pre-guideline") and 12/2012-12/2015 ("post-guideline"). Vaccine uptake dates were abstracted from medical records. The pre and post-guideline cohorts were compared to determine if Tdap vaccine uptake and timing improved after the new Tdap guidelines. We additionally examined influenza and pneumococcal vaccine uptake before and after guidelines. Factors associated with receipt of the Tdap and influenza vaccine during pregnancy in the post-guideline cohort were evaluated using multivariable logistic regression models.ResultsOf 2,294 eligible individuals, 1,610 (70.2%) received care in the post-guideline cohort. Among the pre-guideline cohort, 47.4% received Tdap, whereas Tdap uptake increased to 86.1% after the guidelines (pConclusionsReceipt and timing of Tdap vaccine improved after implementation of the 2012 ACIP guidelines. Receipt of influenza vaccine uptake also improved during the study period, while uptake of the pneumococcal vaccine remained low. Significant racial disparities exist in receipt of Tdap and influenza vaccine during pregnancy.

Abstract Background One approach for improving breastfeeding support and alleviating breastfeeding disparities is the implementation of a clinic-based peer counselor. Our objective was to assess the “real life” effects of an autonomous peer counselor who provides tailored support to low-income, minority women based on individual needs rather than a pre-determined research protocol. Methods This is a secondary analysis of a prospective cohort study of women receiving publicly funded prenatal care during the 6 months before and after introduction of a peer counselor in a single prenatal clinic. The peer counselor provided one-on-one antenatal and postpartum lactation support. Electronic medical record and survey data were collected. The primary outcome was breastfeeding continuation at 6 weeks postpartum. Secondary outcomes included breastfeeding comfort, confidence, and training satisfaction, any breastfeeding, and total breastfeeding duration. Bivariable and multivariable analyses were performed. Results Peer counselor exposure was not associated with the primary outcome of continued breastfeeding at 6 weeks (55.6% with peer counselor versus 49.1% without; aOR 1.26, 95% CI 0.69–2.31). However, women with peer counselor exposure were more likely to be satisfied with breastfeeding training at the time of delivery (98.2% vs. 83.6%, p = 0.006) and were more likely to have performed any breastfeeding (89.8% vs. 78.9%, p = 0.04), which remained significant on multivariable analysis (aOR 2.85, 95% CI 1.11–7.32). Conclusions Peer counselor interventions are a promising approach to increase breastfeeding initiation. Further research is required to inform the most efficacious approach while also allowing peer counselors to operate independently and in line with the specific needs of their clients.

Objective This study aimed to evaluate postpartum weight retention (PPWR) among women who participated in a postpartum patient navigation (PN) program. Study Design English-speaking pregnant or postpartum women receiving publicly-funded prenatal care at a hospital-based clinic were invited to receive PN services through 12 weeks postpartum. Women were eligible for this analysis if height and weight values were available. Weights at 4 to 12 weeks and up to 12 months postpartum were compared in PN and non-PN historical-control groups and analyzed as mean PPWR (difference from prepregnancy weight) and categorically as PPWR > 5kg. Results Among the 311 women, 152 participated in the PN program and 159 were historical controls. There were no differences in age, race and ethnicity, prepregnancy body mass index (BMI), nulliparity, and preterm birth between the groups (p > 0.05). At 4 to 12 weeks postpartum, mean PPWR (4.0 ± 6.7 vs. 2.7 ± 6.3 kg, p = 0.06) and PPWR > 5 kg (61/144 [42%] vs. 50/145 [34%], p = 0.15) did not differ between groups. Similarly, up to 12 months postpartum, mean PPWR (4.5 ± 7.1 vs. 5.0 ± 7.5 kg, p = 0.59) and PPWR > 5 kg (22/50 [44%] vs. 30/57 [53%], p = 0.55) did not differ between groups. Conclusion Although PN is a promising intervention to improve women's health care utilization and other associated health outcomes, in this particular navigation program, participation was not associated with PPWR at 4 to 12 weeks and up to 12 months postpartum.

Perinatal loss, including fetal and infant death, is a devastating experience for parents, resulting in long-term adverse physical and psychosocial outcomes. However, little is known about what services might best support grieving parents. We aimed to understand the role of professional bereavement photography in assisting the grieving process of parents who have lost a fetus or infant, by examining the perspectives of bereaved parents, professional photographers, and health care professionals. Twenty semistructured interviews were conducted, and interview transcripts were analyzed using modified grounded theory. Twenty-three individuals participated, including 6 bereaved parents, 8 photographers, and 9 health care professionals. Analyses generated 5 major themes describing ways in which the photographs were valuable to parents: validation of the experience, permission to share, creation of a permanent and tangible legacy, creation of positive memories, and moving forward after the loss. Hospitals should consider incorporation of professional bereavement photography services into palliative care and bereavement programs.

Abstract Objective This study was aimed to examine the association between having an ultrasound estimate of fetal weight (US-EFW) and mode of delivery among obese women. Study Design A retrospective cohort study of nulliparous women with a body mass index of ≥ 35 kg/m2 who delivered term singleton gestations. We examined whether having had an US-EFW within 35 days of delivery, or an US-EFW ≥ 90th percentile for gestational age, was associated with intrapartum cesarean delivery. Results Of 2,826 women, 22.5% (n = 636) had an US-EFW within 35 days of delivery. Having an US-EFW was associated with increased frequency of cesarean (43.1% for those with an US-EFW versus 30.0% for those without, p