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Background: Two-thirds of pregnancy-related deaths occur from 1 day to 1 year after birth, and medical complications frequently occur after birth. Postpartum health concerns are often urgent, requiring timely medical care, which may contribute to a reliance on acute care. One approach to improving postpartum health is to investigate birthing parents' accounts of acute care use in the months after birth, which is what we did in this study., Methods: This mixed-methods study included questionnaire responses, semi-structured interviews, and chart review of 18 English-speaking individuals who used acute care in the 90 days after birth in the southeastern United States. Interviews were conducted remotely, recorded, and professionally transcribed. Qualitative data were inductively coded to iteratively develop categories and themes with respect to contributors and barriers to postpartum acute care use., Results: Birthing parents engaged in complex decision-making processes to decide where and when to seek postpartum acute care in response to their urgent health concerns. Many described fear and uncertainty about their postpartum health. Most participants contacted a healthcare practitioner before using acute care, followed their guidance, and were treated or otherwise reassured at the acute care visit., Discussion: These findings suggest multilevel opportunities for strengthening healthcare systems, including better-preparing individuals for the postpartum period and structuring care to accommodate birthing parents and include their support systems. The insights from this study can inform multilevel strategies for strengthening healthcare so that birthing parents are safe and well postpartum., (© 2024 Wiley Periodicals LLC.)

Objective: To describe the rate, timing, and primary diagnosis codes for emergency care visits up to 8 weeks (56 days) after live birth among Medicaid beneficiaries in North Carolina (NC). Materials and Methods: Using a linked dataset of Medicaid hospital claims and certificates of live birth, which included Medicaid beneficiaries who had a live-born infant in NC between January 1, 2013, and November 4, 2019, and met inclusion criteria ( n = 321,879), we estimated week-specific visit rates for emergency care visits that did not result in hospital admission (outpatient) and those that did (inpatient). We assessed the 10 leading diagnosis code categories for emergency care visits and described the characteristics of people with 0, 1, or ≥2 outpatient emergency care visits. Results: One in eight (12.4%) Medicaid beneficiaries had an emergency care visit that did not result in inpatient hospital admission during the first 8 weeks postpartum. Visit rates peaked in postpartum week 2. Diagnosis codes for nonspecific symptoms and substance use were the two leading diagnosis code categories for outpatient emergency care visits. Respiratory concerns and gastrointestinal concerns were the two leading diagnosis code categories for inpatient emergency care visits. Compared with those with zero outpatient emergency care visits, a greater proportion of people with ≥2 visits had less than a high school education, used tobacco during pregnancy, had Medicaid insurance outside of pregnancy, had mental health as a medical comorbidity, and/or had ≥2 medical comorbidities. Conclusions: These findings support scheduling health care visits early in the postpartum period, when emergency care visits are most frequent, and point to unmet needs for substance use support.

Introduction: Postpartum acute care utilization (PACU), including visits to an emergency department, obstetric triage, or urgent care ("outpatient"), and hospital readmissions, may indicate medical complications and signal unmet health needs. Methods: We estimated the incidence of PACU and examined patterns by sociodemographic factors, pregnancy and birth characteristics, time since discharge from the birth hospitalization, and medical indications. We constructed a retrospective cohort of people aged ≥18 years who delivered ≥1 liveborn infant >20 weeks of gestation from July 1, 2021, to December 31, 2022, using electronic health record data from a quaternary maternity hospital in the Southeastern United States PACU data throughout the health care system were collected through March 31, 2023. We excluded people with a hospital stay >6 days ( n = 29). Results: In this cohort of 6,041 birthing people, 11.3% had ≥1 outpatient encounters (range 0-6) and 3.2% had ≥1 hospital readmissions (range 0-4) within 12 weeks of discharge from the birth hospitalization. Median time to first outpatient PACU was 10 days post-discharge and 6 days for first hospital readmission. Among encounters for the top five medical indications, time to first postpartum acute care encounter varied by medical indication (log-rank test of equality over strata Chi-square = 69.93, degrees of freedom = 4, p < 0.0001). Complications specified during the puerperium ( n = 234) and hypertension and hypertensive-related conditions complicating the puerperium ( n = 87) were the two most frequent indications. Conclusion: These findings can inform efforts to direct health resources to improve postpartum health care and health outcomes.

Background: Hypertensive disorders of pregnancy (HDP) are associated with long-term maternal risks for cardiovascular disease for reasons that remain incompletely understood., Methods: The HCHS/SOL (Hispanic Community Health Study/Study of Latinos), a multi-center community-based cohort of Hispanic/Latino adults recruited 2008 to 2011, was used to evaluate the associations of history of de novo HDP (gestational hypertension, preeclampsia, eclampsia) with echocardiographic measures of cardiac structure and function in Hispanic/Latina women with ≥1 prior pregnancy and the proportion of association mediated by current hypertension (>140/90 mm Hg or antihypertensive therapy)., Results.: The study cohort included 5168 Hispanic/Latina women with an average age (SD) of 58.7 (9.7) years at time of echocardiogram. Prior de novo HDP was reported by 724 (14%) of the women studied and was associated with lower left ventricle (LV) ejection fraction -0.66 (95% confidence interval [CI], -1.21 to -0.11), higher LV relative wall thickness 0.09 (95% CI, 0-0.18), and 1.39 (95% CI, 1.02-1.89) higher risk of abnormal LV geometry after adjusting for blood pressure and other confounders. The proportion of the association mediated by current hypertension between HDP and LV ejection fraction was 0.09 (95% CI, 0.03-0.45), LV relative wall thickness was 0.28 (95% CI, 0.16-0.51), abnormal LV geometry was 0.14 (95% CI, 0.12-0.48), concentric left ventricular hypertrophy was 0.31 (95% CI, 0.19-0.86), and abnormal LV diastolic dysfunction was 0.58 (95% CI, 0.26-0.79)., Conclusions.: In a large cohort of Hispanic/Latina women those with history of de novo HDP had detectable and measurable subclinical alterations in cardiac structure and both systolic and diastolic dysfunction that were only partially mediated by current hypertension., Competing Interests: Disclosures None.

Objective: To examine the association between unknown maternal Group B Streptococcal (GBS) colonization and the risk of severe neonatal morbidity among individuals undergoing planned cesarean delivery., Methods: We performed a secondary analysis of a multicenter, prospective observational study of individuals with singleton gestations and planned cesarean delivery ≥37 weeks gestation with cervical dilation ≤3 cm, intact membranes, and no evidence of labor or induction. GBS status was categorized as positive, negative, or unknown. The primary outcome was a composite of severe neonatal morbidity, including clinical or culture-proven sepsis, ventilator support in the first 24 h, respiratory distress syndrome, hypotension requiring treatment, intubation, necrotizing enterocolitis, hypoxic-ischemic encephalopathy, or death. We compared individuals with unknown GBS status to those with positive and negative GBS status., Results: In this cohort, 4,963 individuals met inclusion criteria; 72% had unknown GBS status, 25% were GBS negative and 3% were GBS positive. Among individuals with unknown GBS status, 208 (5.9%) had the primary composite neonatal outcome, compared with 75 (6%) of GBS negative individuals and 6 (4%) of GBS positive individuals. There was no difference in composite severe neonatal morbidity among GBS unknown, GBS negative, and GBS positive individuals (5.9% vs 6% vs 4%, p  = .61). After adjusting for male sex and intrapartum antibiotic exposure, unknown GBS status was not associated with severe neonatal morbidity (adjusted risk ratio, 0.95; 95% confidence interval, 0.73-1.22)., Conclusion: GBS status at time of planned cesarean delivery does not appear to be associated with composite severe neonatal morbidity. The cost effectiveness and clinical utility of GBS screening among individuals undergoing planned cesarean delivery requires further investigation.

Background: The COVID-19 pandemic started a period of rapid transition to telehealth in obstetrical care delivery to maintain social distancing and curb the spread of the virus. The use of telehealth, such as telephone and video visits, remote imaging interpretation, and provider-to-provider consultations, increased in the early months of the pandemic to maintain access to prenatal and postpartum care. Although there is considerable literature on the use of telehealth in obstetrical care, there are limited data on widespread telehealth use among different practice types and patient populations during the pandemic and whether these are preferred technologies., Objective: This study aimed to describe variations in telehealth use for obstetrical care among practices in North Carolina during the COVID-19 pandemic and to outline future preferences and needs for continued telehealth use. This study also aimed to delineate telehealth use among rural and micropolitan and metropolitan practices to better understand if telehealth use varied by practice location., Study Design: A web-based survey was distributed to practice managers of obstetrical practices in North Carolina from June 14, 2020 to September 14, 2020. Practice managers were contacted through assistance of the Community Care of North Carolina Pregnancy Medical Home program. Practice location was defined as rural, micropolitan, or metropolitan based on the county population. The survey assessed telehealth use before and during the COVID-19 pandemic, types of modalities used, and preferences for future use. Descriptive statistics were performed to describe survey responses and compare them by practice location., Results: A total of 295 practice managers were sent a web-based survey and 98 practice managers responded. Responding practices represented 66 of 100 counties in North Carolina with 50 practices from rural and micropolitan counties and 48 practices from metropolitan counties. The most common type of provider reported by practice managers were general obstetrician and gynecologists (85%), and the most common practice type was county health departments (38%). Overall, 9% of practices reported telehealth use before the pandemic and 60% reported telehealth use during the pandemic. The most common type of telehealth modality was telephone visits. There were no significant differences in the uptake of telehealth or in the modalities used by practice location. A total of 40% of practices endorsed a preference for continued telehealth use beyond the COVID-19 pandemic. The most commonly reported need for continuation of telehealth use was assistance with patient access to telehealth technologies (54%). There were no significant differences in the preferences for telehealth continuation or future needs by practice location., Conclusion: Telehealth use increased among a variety of practice types during the pandemic with no variation observed by practice location in terms of modalities used, future preferences, or needs. This study assessed statewide uptake of and differences in obstetrical telehealth use during the early COVID-19 pandemic. With telehealth becoming an integral part of obstetrical care delivery, this survey has implications for anticipating the needs of practices and designing innovative solutions for providers and pregnant people beyond the COVID-19 pandemic., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Although studies have demonstrated a J-shaped association between parity and cardiovascular disease (CVD), the association with arterial stiffness is not fully understood., Methods: We examined the association between parity and carotid-femoral pulse wave velocity (cfPWV), a measure of central arterial stiffness. We conducted a longitudinal analysis of 1220 women (mean age 73.7 years) who attended the Atherosclerosis Risk in Communities Study visit 5 (2011-2013). At visit 2 (1990-1992), women self-reported parity (number of prior live births), which we categorized as: 0 (never pregnant or pregnant with no live births); 1-2 (referent); 3-4; and 5+ live births. Technicians measured cfPWV at visit 5 (2011-2013) and visit 6 or 7 (2016-2019). Multivariable linear regression modeled the associations of parity with visit 5 cfPWV and cfPWV change between visit 5 and 6/7 adjusted for demographics and potential confounding factors., Results: Participants reported 0 (7.7%), 1-2 (38.7%), 3-4 (40.0%), or 5+ (13.6%) prior live births. In adjusted analyses, women with 5+ live births had a higher visit 5 cfPWV ( β =50.6 cm/s, 95% confidence interval: 3.6, 97.7 cm/s) than those with 1-2 live births. No statistically significant associations were observed for other parity groups with visit 5 cfPWV or with cfPWV change., Discussion: In later life, women with 5+ live births had higher arterial stiffness than those with 1-2 live births, but cfPWV change did not differ by parity, suggesting women with 5+ live births should be targeted for early primary prevention of CVD given their higher arterial stiffness at later-life., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Bonner, Jayawickreme, Malek, Vladutiu, Oliver-Williams, Cortés, Tanaka and Meyer.)

Background: Associations between preconception cardiometabolic markers and birth outcomes have been noted, but data are scarce for Hispanics/Latinos. We examined the association between preconception cardiometabolic markers, birthweight and preterm birth among U.S. Hispanic/Latina women. Materials and Methods: The Hispanic Community Health Study/Study of Latinos is a cohort study of U.S. adults 18-74 years of age, including 3,798 women of reproductive age (18-44 years) from four field centers representing Hispanic/Latino backgrounds of Cuban, Dominican, Mexican, Puerto Rican, Central American, and South American. A baseline clinic examination (2008-2011) and a second clinic examination (2014-2017), including ascertainment of birth outcomes, allowed for identification of 517 singleton live births between the exams. Preconception cardiometabolic markers included abdominal obesity (waist circumference ≥88 cm), body mass index >30 kg/m 2 , high blood pressure (systolic ≥120 mmHg and diastolic ≥80 mmHg), elevated triglycerides (≥150 mg/dL), low high-density lipoprotein cholesterol (<50 mg/dL), elevated fasting glucose (≥100 mg/dL), and insulin. Complex survey linear regression modeled the association between cardiometabolic markers and birthweight-for-gestational age z -score; complex survey logistic regression modeled the association with preterm birth. Analyses adjusted for Hispanic/Latina background, field center, years between baseline and birth, age, and nulliparity. Results: In adjusted linear regression models, elevated fasting glucose was associated with higher birthweight z -scores (β = 0.56, 95% confidence interval [95% CI] 0.14 to 0.99), even after further adjustment for maternal percent body fat (β = 0.53, 95% CI 0.10 to 0.95). In adjusted logistic regression models, high blood pressure (odds ratio [OR] = 2.57, 95% CI 1.13 to 5.88) and increased insulin (OR = 1.50, 95% CI 1.06 to 2.14, for a 10 mU/L increase) were associated with higher odds for preterm birth. Conclusions: Infant birthweight and preterm birth may be influenced by selected cardiometabolic risk factors before pregnancy among Hispanic/Latina women.

Purpose: This study examined the association between household food insufficiency and flourishing among young children (6 months-5 years) in the U.S. and assessed whether sleep adequacy modifies this association., Methods: We used data from the 2018-2020 National Surveys of Children's Health. Adjusted prevalence differences and 95% confidence intervals (CI) for the association between household food insufficiency and flourishing were modeled using average marginal predictions from logistic regression models. Sleep adequacy was assessed as an effect measure modifier on the additive scale., Results: Evidence supports additive scale effect measure modification of the food insufficiency-flourishing association by sleep adequacy (Likelihood Ratio Test statistic = 12.4, degrees of freedom = 2, P < .05). Adjusted for potential confounders, the prevalence of flourishing was 13.2 percentage points lower (95% CI: -22.6, -3.7) for children in households with insufficient food and inadequate sleep compared to those with sufficient food and adequate sleep., Conclusions: Our findings suggest that having enough food and enough sleep are associated with greater wellbeing. These modifiable factors should be targeted by public health interventions to facilitate flourishing among young children in the U.S., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Cerclage is used for the prevention of spontaneous preterm birth; however, many patients at high risk of spontaneous preterm birth who have a cerclage in place eventually deliver before term. Although inflammation, measured by biomarkers (eg, cytokines), is a known risk factor for preterm delivery, evaluation of inflammation to determine pregnancy outcomes among patients with cerclage is poorly understood., Objective: We sought to examine levels of maternal plasma inflammatory cytokines in the midtrimester among asymptomatic patients with a cervical cerclage (placed for any indication, including history, ultrasound, and examination indications) to evaluate the association between cytokine levels and preterm birth., Study Design: This was a prospective cohort study of singleton, nonanomalous pregnancies who had a cerclage placed at <24 weeks of gestation from 2015 to 2018 at a single tertiary institution. Maternal plasma was collected perioperatively whenever possible. A custom magnetic bead Luminex cytokine assay was used to measure plasma inflammatory cytokine levels from these stored samples. The primary outcome was preterm birth at <37 weeks of gestation. A statistical cut point was calculated for each cytokine level to assess its optimal sensitivity and specificity for spontaneous preterm birth prediction. Patients were classified as having a "high" or "low" result for each cytokine based on this cut point. Receiver operating characteristic curve analysis was performed to estimate sensitivity, specificity, and positive and negative predictive values for spontaneous preterm birth prediction. Cox proportional-hazards regression modeled the association between the number of "high" inflammatory cytokines and gestational age at delivery, adjusting for confounders. Additional analyses were performed on the subgroup of patients with history-indicated cerclage and those with an ultrasound- or examination-indicated cerclage., Results: A total of 43 patients participated in this study: 20 (46.5%) had spontaneous preterm birth (median, 30.9 weeks of gestation; interquartile range, 28.4-35.0). Plasma samples were collected at a median of 0 (interquartile range, -2 to 17) days concerning cerclage placement and a median of 18 (interquartile range, 13-21) weeks of gestation. Based on the statistical cut point for each cytokine level, 7% of patients had zero, 20.9% had 1, 18.6% had 2, 20.9% had 3, and 32.6% had ≥4 "high" cytokine results. Each additional "high" cytokine level was associated with earlier delivery (hazard ratio, 1.51; 95% confidence interval, 1.25-1.81) even after controlling for ultrasound- or examination-indication for cerclage (hazard ratio, 1.73; 95% confidence interval, 0.95-3.15). The presence of ≥4 "high" cytokine levels was 70% sensitive and 74% specific for predicting spontaneous preterm birth (area under the curve, 0.846; 95% confidence interval, 0.728-0.964; positive predictive value, 70%; negative predictive value, 73.9%)., Conclusion: Among patients with a cervical cerclage, elevated midtrimester maternal plasma cytokine profiles were associated with subsequent preterm birth and can estimate the probability of preterm birth. Confirmation and refinement of this noninvasive panel may provide insight into improved selection of individuals who may benefit from cerclage placement and investigation of therapeutic strategies to mitigate midpregnancy inflammation., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Importance: Surveillance of severe maternal morbidity (SMM) is critical for monitoring maternal health and evaluating clinical quality improvement efforts., Objective: To evaluate national and state trends in SMM rates from 2012 to 2019 and potential disruptions associated with the transition to International Classification of Diseases, 10th Revision, Clinical Modification and Procedure Coding System (ICD-10-CM/PCS) in October 2015., Design, Setting, and Participants: This repeated cross-sectional analysis examined delivery hospitalizations from 2012 through 2019 in the Healthcare Cost and Utilization Project's National Inpatient Sample and State Inpatient Databases, an all-payer compendium of hospital discharge records from community, nonrehabilitation hospitals. Trends were evaluated using segmented linear binomial regression models that allowed for discontinuities across the ICD-10-CM/PCS transition. Analyses were completed from April 2021 through March 2022., Exposures: Time, ICD-10-CM/PCS coding system, and state., Main Outcomes and Measures: SMM rates, excluding blood transfusion, per 10 000 delivery hospitalizations, overall and by indicator., Results: From 2012 to 2019, there were 5 964 315 delivery hospitalizations in the national sample representing a weighted total of 29.8 million deliveries with a mean (SD) maternal age of 28.6 (5.9) years. SMM rates increased from 69.5 per 10 000 in 2012 to 79.7 per 10 000 in 2019 (rate difference [RD], 10.2; 95% CI, 5.8 to 14.6) without a significant change across the ICD-10-CM/PCS transition (RD, -3.2; 95% CI, -6.9 to 0.6). Of 20 SMM indicators, rates for 10 indicators significantly increased while 3 significantly decreased; 5 of these changes were associated with ICD-10-CM/PCS transition. Acute kidney failure had the largest increase, from 6.4 to 15.3 per 10 000 delivery hospitalizations (RD, 8.9; 95% CI, 7.5 to 10.3) with no change associated with ICD transition (RD, -0.1; 95% CI, -1.2 to 1.1). Disseminated intravascular coagulation had the largest decrease from 31.3 to 21.2 per 10 000 (RD, 10.2; 95% CI, -12.8 to -7.5), with a significant drop associated with ICD transition (RD, -7.9; 95% CI, -10.2 to -5.6). State SMM rates significantly decreased for 1 state and significantly increased for 21 states from 2012 to 2019 and associations with ICD transition varied., Conclusions and Relevance: In this cross-sectional study, overall US SMM rates increased from 2012 to 2019, which was not associated with the ICD-10-CM/PCS transition. However, data for certain indicators and states may not be comparable across coding systems; efforts are needed to understand SMM increases and state variation.

Aim: This study aimed to examine the association between lifecourse factors and flourishing among children ages 1-5 years., Study Design: Using data from the combined 2016 and 2017 National Survey of Children's Health (N = 18 007 children aged 1-5 years), flourishing was defined as parent-reported child's affection, resilience, curiosity about learning, and affect. Multivariable logistic regression modelled the associations between lifecourse factors and flourishing. These factors were identified according to the lifecourse health development model., Results: Approximately 63% of children aged 1-5 years were flourishing. Children who were female (vs. male, adjusted prevalence ratio [APR]: 1.06, 95% confidence interval [CI]: 1.00-1.11), White, non-Hispanic (vs. Black, non-Hispanic, APR: 1.13, 95% CI: 1.01-1.26), not having a special health care need (vs. special health care need, APR: 1.15, 95% CI: 1.03-1.26), not having an emotional, developmental or behavioural disorder (EBD) (vs., Ebd, Apr: 1.66, 95% CI:1.23-2.10), spoke English at home (vs. other language, APR: 1.30, 95% CI: 1.06-1.54), parents received emotional social support (vs. no emotional social support, APR: 1.11, 95% CI: 1.01-1.21) and who lived in a supportive neighbourhood (vs. not in supportive neighbourhood, APR: 1.12, 95% CI:1.05-1.18) were more likely to flourish. Children from households within 0%-99% of the federal poverty level (APR: 0.89, 95% CI: 0.79-0.98) were less likely to be flourishing compared with their counterparts from households within 400% of the federal poverty level., Conclusions: Findings indicate that several lifecourse factors are associated with young children's flourishing, including being female, White, non-Hispanic, not having a special health care need or EBD, English as a primary language, parents receiving emotional social support, having neighbourhood support and a lower household income. Our findings promote the continuation of programmes supporting diverse and low-income children's families and communities such as home visiting and Head Start, which provide avenues for bolstering children's health and development across the lifespan., (© 2021 John Wiley & Sons Ltd. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Previous literature has highlighted that women who have a pregnancy affected by gestational hypertension or preeclampsia are at higher risk of cardiovascular disease (CVD) in later life. However, CVD is a composite of multiple outcomes, including coronary heart disease, heart failure, and stroke, and the risk of both CVD and hypertensive disorders of pregnancy varies by the population studied. We conducted a narrative review of the risk of cardiovascular outcomes for women with prior gestational hypertension and pre-eclampsia. Previous literature is summarized by country and ethnicity, with a higher risk of CVD and coronary heart disease observed after gestational hypertension and a higher risk of CVD, coronary heart disease and heart failure observed after pre-eclampsia in most of the populations studied. Only one study was identified in a low- or middle-income country, and the majority of studies were conducted in white or mixed ethnicity populations. We discuss potential interventions to mitigate cardiovascular risk for these women in different settings and highlight the need for a greater understanding of the epidemiology of CVD risk after gestational hypertension and pre-eclampsia outside of high-income, white populations., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (Copyright © 2021 The Author(s).)

Introduction: Community Healthy Start program evaluations are often limited by a lack of robust data and rigorous study designs. This study describes an enhanced methodological approach using local program data linked with existing population-level datasets for external comparison to evaluate the Enterprise Community Healthy Start (ECHS) program in two rural Georgia counties and presents results from the evaluation., Methods: ECHS program data were linked to birth records and the Pregnancy Risk Assessment Monitoring System (PRAMS) for 869 women who delivered a live birth in Burke and McDuffie counties from 2010 to 2011. Multivariate logistic regressions with and without propensity score methods modeled the association between ECHS participation and maternal health indicators and pregnancy outcomes., Results: 107 ECHS participants and 726 non-participants responded to PRAMS and met eligibility criteria. Compared with non-participants, ECHS participants were younger, completed fewer years of education, and were more likely to be non-Hispanic Black, unmarried, insured with Medicaid, participating in WIC, and having an unintended pregnancy. Models with and without propensity score weighting derived similar results: there was a positive association between ECHS participation and receiving adequate or adequate plus prenatal care (p < 0.05); no statistically significant associations were observed between ECHS participation and any other health behaviors, health care access and utilization measures or pregnancy outcomes., Discussion: Rigorous evaluation of a local Healthy Start program using linked PRAMS and birth records with a population-based external comparison group and propensity score methods is an enhanced and feasible approach that can be applied in other local and state jurisdictions., (© 2021. This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply.)

Objective: This study aimed to assess whether colonization with group B streptococcus (GBS) is associated with maternal peripartum infection in an era of routine prophylaxis., Study Design: This study presented a secondary analysis of women delivering ≥37 weeks who underwent a trial of labor from the U.S. Consortium on Safe Labor (CSL) study. The exposure was maternal GBS colonization and the outcome was a diagnosis of chorioamnionitis, and secondarily, analyses were restricted to deliveries not admitted in labor and measures of postpartum infection (postpartum fever, endometritis, and surgical site infection). Logistic regression with generalized estimating equations was used accounting for within-woman correlations. Models adjusted for maternal age, parity, race, prepregnancy body mass index, pregestational diabetes, insurance status, study site/region, year of delivery, number of vaginal exams from admission to delivery, and time (in hours) from admission to delivery., Results: Among 170,804 assessed women, 33,877 (19.8%) were colonized with GBS and 5,172 (3.0%) were diagnosed with chorioamnionitis. While the frequency of GBS colonization did not vary by chorioamnionitis status (3.0% in both groups), in multivariable analyses, GBS colonization was associated with slightly lower odds of chorioamnionitis (adjusted odds ratio [AOR]: 0.89; 95% confidence interval [CI]: 0.83-0.96). In secondary analyses, this association held regardless of spontaneous labor on admission; and the odds of postpartum infectious outcomes were not higher with GBS colonization., Conclusion: In contrast to historical data, GBS colonization was associated with lower odds of chorioamnionitis in an era of routine GBS screening and prophylaxis., Key Points: · Data in an era prior to routine group B streptococcus (GBS) screening and prophylaxis showed that maternal GBS colonization was associated with a higher frequency of maternal peripartum infection.. · In the current study, GBS colonization was associated with lower odds of chorioamnionitis in an era of routine GBS screening and prophylaxis.. · The results highlight potential benefits of GBS screening and intrapartum antibiotic prophylaxis beyond neonatal disease prevention, including mitigating the risk of maternal infectious morbidity.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: The purpose of this study was to identify child, family/household, organization (provider), and neighborhood/community factors associated with parental concern about weight among children with overweight/obesity in order to inform effective interventions for improving health in this pediatric population., Methods: Prevalence of parental concern about child weight was estimated and factors identified within an adapted family ecological framework. Using cross-sectional data from the 2018 National Survey of Children's Health, we conducted bivariate and multivariable analyses of 10 to 17-year olds (N = 15,427) for whom height and weight information was reported by parents or primary caregivers., Results: There were 4287 children, aged 10 to 17 years, with overweight/obesity (31%). Approximately 34% of parents of children with overweight/obesity reported being concerned about their child's weight, with the remainder being not concerned. In adjusted analyses, 23% of children with overweight and 45% of children with obesity had parents who reported being concerned. Factors associated with parental concern among children with overweight/obesity included child weight status, female gender, peer social difficulties, the extent of the child's daily activities affected by health conditions, poorer parental coping, and having been told the child was overweight by a provider., Conclusions: Only one in three parents of children with overweight/obesity reported being concerned about their child's weight, although parental concern was more common among children affected by obesity more so than overweight. A combination of child, family, and organization (provider) factors were associated with parental concern. Provider feedback about child overweight may improve parental awareness of a weight-related health issue., (Published by Elsevier Inc.)

Background: Folate depletion in the postpartum period may increase the risk of adverse pregnancy outcomes for women with a short interpregnancy interval following a live birth. We sought to examine folate levels by time since last live birth among U.S. women. Materials and Methods: Data were from 4,809 U.S. women, 20-44 years of age, participating in the National Health and Nutrition Examination Survey, 2007-2016. Red blood cell (RBC) folate was measured using microbiological assay on whole blood samples. Dietary folate intake and folic acid supplementation were measured during a 24-hour dietary recall. Prevalence of supplementation by time since last live birth was estimated from logistic regression models; mean levels of RBC folate and mean intake of dietary folate equivalent were estimated from linear regression models. Models were adjusted for maternal sociodemographic characteristics. Results: In adjusted models, supplementation (±standard error) was highest among women in the first year postpartum (31.7% ± 3.2) compared with nulliparous women (23.7% ± 1.9) and those 2-3 years (15.6% ± 1.9) and ≥3 years (18.4% ± 1.6) after last live birth. Mean RBC folate was highest among women in the first year postpartum, regardless of supplementation, with overall mean levels of 606 ± 15 ng/mL, compared with 484 ± 9, 477 ± 11, and 474 ± 7 among women in the aforementioned groups, respectively. Mean dietary folate intake was also highest among postpartum women: 542 ± 23 mcg/day, compared with 474 ± 12, 486 ± 21, and 467 ± 12. Conclusions: Folate levels are highest in the first year postpartum compared with other time periods within a woman's reproductive lifespan. These findings do not support the idea that postpartum U.S. women are depleted in folate, on average.

Background: Non-Hispanic black maternal race is a known risk factor for preterm birth. However, the contribution of paternal race is not as well established., Objective: We sought to evaluate the risk of preterm birth among non-Hispanic black, non-Hispanic white, and mixed non-Hispanic black and non-Hispanic white dyads., Study Design: This was a population-based cohort study of all live births in the United States from 2015 to 2017, using live birth records from the National Vital Statistics System. Singleton, nonanomalous infants whose live birth record included maternal and paternal self-reported race as either non-Hispanic white or non-Hispanic black were included. The primary outcome was preterm birth at <37 weeks' gestation; secondary outcomes included preterm birth at <34 and <28 weeks' gestation and delivery gestational age (as a continuous variable). Data were analyzed using chi-square, t test, analysis of variance, and logistic regression. A Kaplan-Meier survival curve was also generated., Results: There were 11,809,599 live births during the study period; 4,008,622 births met the inclusion criteria. Of included births, 291,647 (7.3%) occurred at <37 weeks' gestation. Using the convention of maternal race first followed by paternal race, preterm birth at <37 weeks' gestation was most common among non-Hispanic black and non-Hispanic black dyads (n=70,987 [10.8%]), followed by non-Hispanic black and non-Hispanic white (n=3137 [9.5%]), non-Hispanic white and non-Hispanic black (n=9136 [8.3%]), and non-Hispanic white and non-Hispanic white dyads (n=209,387 [6.5%]; P<.001 for trend). Births at <34 weeks' (n=74,474) and <28 weeks' gestation (n=18,474) were also more common among non-Hispanic black and non-Hispanic black dyads. Specifically, 24,351 (3.7%) non-Hispanic black and non-Hispanic black, 1017 (3.1%) non-Hispanic black and non-Hispanic white, 2408 (2.2%) non-Hispanic white and non-Hispanic black, and 46,698 non-Hispanic white and non-Hispanic white dyads delivered at <34 weeks' gestation, and 7988 non-Hispanic black and non-Hispanic black (1.2%), 313 (1.0%) non-Hispanic black and non-Hispanic white, 584 (0.5%) non-Hispanic white and non-Hispanic black, and 9589 (0.3%) non-Hispanic white and non-Hispanic white dyads delivered at <28 weeks' gestation. Non-Hispanic white and non-Hispanic white dyads delivered at a mean 38.8± standard deviation of 1.7 weeks' gestation, although non-Hispanic white and non-Hispanic black, non-Hispanic black and non-Hispanic white, and non-Hispanic black and non-Hispanic black dyads delivered at 38.6±2.0, 38.5±2.3, and 38.3±2.4 weeks' gestation, respectively (P<.001). Adjusted odds ratios for the association between maternal or paternal race and preterm birth were highest for non-Hispanic black and non-Hispanic black dyads at each gestational age cutoff: adjusted odds ratio, 1.60 (95% confidence interval, 1.11-1.19) (<37 weeks' gestation); adjusted odds ratio, 2.47 (95% confidence interval, 2.41-2.53) (<34 weeks' gestation); and adjusted odds ratio, 4.22 (95% confidence interval, 4.04-4.41) (<28 weeks' gestation) compared with the non-Hispanic white referent group. Models adjusted for insurance status, chronic hypertension, tobacco use during pregnancy, history of previous preterm birth, and male fetus. In the Kaplan-Meier survival analysis, non-Hispanic black and non-Hispanic black dyads delivered the earliest across the range of delivery gestational ages compared with all other combinations of dyads., Conclusion: Non-Hispanic black paternal race is a risk factor for preterm birth and should be considered when evaluating maternal a priori risk of prematurity. Future research should investigate the mechanisms behind this finding, including determining the contribution of factors, such as racism, maternal and paternal genetics, and epigenetics to an individual's risk of preterm birth., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To identify risk factors associated with neonatal intermediate or intensive care unit (NICU) stay ≥3 days among women with threatened late preterm birth (PTB)., Study Design: Secondary analysis of women with nonanomalous, singleton gestations enrolled in multicenter trial of betamethasone versus placebo for late PTB. Maternal and obstetric characteristics at time of presentation with threatened PTB were compared between those with and without NICU stay ≥3 days. Multivariable logistic regression identified risk factors for NICU stay ≥3 days., Result: Of 2795 eligible mother-neonate dyads, 962 (34%) had NICU stay ≥3 days. Gestational age and fetal growth restriction as the reason for threatened PTB had the strongest association with NICU stay ≥3 days in the final model (AUC 0.76)., Conclusion: Maternal and obstetric characteristics at the time of admission for threatened late PTB should be considered when counseling patients about the probability of NICU stay ≥3 days.

Background: The nutritional status of women in the preconception period is of paramount importance due to its role in reproduction., Objective: Our aim was to assess overall diet quality during the preconception period and its association with infant birth weight adjusted for gestational age (GA)., Design: This is an observational longitudinal cohort of Hispanic people living in the United States., Participants/setting: Data are from the Hispanic Community Health Study/Study of Latinos baseline (2008-2011) and second clinic examinations (2014-2017). Included are the first 497 singleton live-born infants among the 2,556 women (younger than 45 years) who attended the second visit. Field sites were located in Miami, FL; Bronx, NY; Chicago, IL; and San Diego, CA, and represent individuals with heritage from Cuba, Dominican Republic, Mexico, Puerto Rico, and Central and South America., Main Exposure: Diet assessment included two 24-hour recalls from baseline. The 2010 Healthy Eating Index (HEI-2010) was used to measure diet quality, with higher scores indicating better quality., Statistical Analyses Performed: Complex survey linear regression estimated the association between HEI-2010 scores (continuous variable and categorized into tertiles) and birth-weight z score and birth weight for GA percentile., Results: Mean (standard deviation) age of women was 25.8 (5.2) years and 36.4% were classified as underweight or normal weight, 30.0% were overweight, and 33.6% had obesity at baseline. Mean (standard deviation) HEI-2010 score was 56.5 (13.4), and by weight classifications was 54.4 (14.1) for underweight or normal weight and 57.7 (12.8) for overweight or obesity. Median (interquartile range) birth-weight z score was 0.5 (interquartile range [IQR], -0.2 to 1.3) overall and 0.2 (IQR, -0.5 to 1.0), 0.6 (IQR, -0.2 to 1.3), and 0.5 (IQR, -0.2 to 1.4) for the first, second, and third HEI-2010 tertile, respectively. Median birth weight for GA percentile was 68.2 (IQR, 40.2 to 89.7) overall, and 56.8 (IQR, 29.6 to 85.0), 71.5 (IQR, 42.8 to 90.0), and 70.1 (IQR, 42.9 to 91.2) by HEI-2010 tertile. In adjusted models, the highest tertile of the HEI-2010 score was associated with a higher birth-weight z score and birth weight for GA percentile, and the continuous HEI-2010 score was only associated with birth weight for GA percentile. Preconception body mass index (calculated as kg/m 2 ) did not modify these associations., Conclusions: Overall diet quality, as measured by the HEI-2010, in the preconception period is associated with infant birth weight adjusted for GA among US Hispanic and Latina women., (Copyright © 2021 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Maternal mortality and severe maternal morbidity are critical health issues in the United States, with unacceptably high rates and racial, ethnic, and geographic disparities. Various factors contribute to these adverse maternal health outcomes, ranging from patient-level to health system-level factors. Furthermore, a majority of pregnancy-related deaths are preventable. This review briefly describes the epidemiology of maternal mortality and severe maternal morbidity in the United States and discusses selected initiatives to reduce maternal mortality and severe maternal morbidity in the areas of data and surveillance; clinical workforce training and patient education; telehealth; comprehensive models and strategies; and clinical guidelines, protocols, and bundles. Related Health Resources and Services Administration initiatives are also described.

Background: Screening for diabetes in early pregnancy is recommended for high-risk women, however, the optimal test for the diagnosis of early gestational diabetes mellitus (GDM) is unknown. Thus, the objective of this study was to evaluate hemoglobin A 1c (HbA 1c ) as a diagnostic test for early GDM compared with two-step testing. Materials and Methods: Retrospective cohort of women with prior GDM or obesity who had HbA 1c and two-step testing <21 weeks' gestation. Early GDM was diagnosed by 1 hour, 50 g oral glucose challenge test (GCT) ≥135 mg/dL and ≥2 abnormal values on 3 hour, 100 g oral glucose tolerance test or GCT >200 mg/dL. The area under the receiver operating characteristic curve (AUC) evaluated HbA 1c for diagnosis of early GDM. Results: Of 243 women, 14 (5.8%) had early GDM by two-step testing. Median HbA 1c levels were higher among women with GDM versus those without GDM (5.8% vs. 5.3%, p  < 0.001). The AUC for HbA 1c compared with two-step testing was 0.80 (95% CI 0.69-0.91). The optimal HbA 1c threshold was 5.6% (64% sensitivity, 84% specificity). Conclusions: HbA 1c is moderately predictive of early GDM compared with two-step testing, and a threshold lower than that used for diabetes diagnosis among nonpregnant adults is justified.

Objective: To investigate the association between maternal obesity as measured by prepregnancy body mass index (BMI) and group B streptococcus (GBS) colonization. Methods: We conducted a secondary analysis from the Consortium on Safe Labor Study (CSL) in the United States cohort study (2002-2008). Pregnant women with deliveries at ≥37 weeks of gestation who attempted labor were included (115,070 assessed deliveries). The association between maternal prepregnancy BMI, categorized as normal weight or below (<25 kg/m 2 ), overweight (25 to <30 kg/m 2 ), class I obesity (30 to <35 kg/m 2 ), class II obesity (35 to <40 kg/m 2 ), and class III obesity (≥40 kg/m 2 ), and GBS colonization was modeled using logistic regression with generalized estimating equations. Models adjusted for maternal age, parity, race, pregestational diabetes, insurance status, study site/region, and year of delivery. Results: The overall prevalence of GBS colonization was 20.5% (23,625/115,070), which increased with rising maternal BMI, normal weight 19.3% (13,543/70,098), overweight 20.8% (5,353/25,733), class I obesity 23.0% (2,596/11,275), class II obesity 26.1% (1,270/4,850), and class III obesity 27.7% (863/3,114). In multivariable analysis, increasing maternal obesity severity was associated with higher odds of GBS colonization, namely overweight (adjusted odds ratio [AOR]: 1.09, 95% confidence interval [CI]: 1.05-1.13), class I obesity (AOR: 1.20, 95% CI: 1.15-1.26), class II obesity (AOR: 1.42, 95% CI: 1.33-1.51), and class III obesity (AOR: 1.50; 95% CI: 1.38-1.62) compared with normal weight. In secondary analyses, these associations persisted when stratified by maternal race. Conclusions: In a national U.S. sample, increasing maternal obesity severity as assessed by prepregnancy BMI was associated with a higher likelihood of maternal GBS colonization during pregnancy.

Objectives: Despite persistent racial disparities in preterm birth (PTB) in the US among non-Hispanic (NH) black women compared to NH white women, it remains controversial whether sociodemographic factors can explain these differences. We sought to evaluate whether disparities in PTB persist among NH black women with high socioeconomic status (SES)., Study Design: We conducted a population-based cohort study of all live births in the US from 2015-2017 using birth certificate data from the National Vital Statistics System. We included singleton, non-anomalous live births among women who were of high SES (defined as having ≥ 16 years of education, private insurance, and not receiving Women, Infants and Children [WIC] benefits) and who identified as NH white, NH black, or 'mixed' NH black and white race. The primary outcome was PTB <37 weeks; secondary outcomes included PTB <34 and <28 weeks. In addition, analyses were repeated considering birthweight <2500g as a surrogate for preterm birth <37 weeks, birthweight <1500g as a surrogate for preterm birth <34 weeks, and birthweight <750g as a surrogate for preterm birth <28 weeks' gestation. Data were analyzed with chi-square, t-test, and logistic regression., Results: 2,170,686 live births met inclusion criteria, with 92.9% NH white, 6.7% NH black, and 0.4% both NH white and black race. Overall, 5.9% delivered <37, 1.3% <34, and 0.3 % <28 weeks. In unadjusted analyses of women with high SES, the PTB rate at each gestational age cutoff was higher for women of 'mixed' NH white and black race, and highest for women who were NH black only compared to women who were NH white only. In regression models we further adjusted for women with insurance and prenatal care their entire pregnancy, maternal race was associated with higher odds of PTB at each GA cutoff, with the highest odds observed at <28 weeks. Finally, in further adjustement analysis including only the 1,934,912 women who received prenatal care in the first trimester, findings were similar. Rates of preterm birth at each gestational age cutoff remained highest for women who identified as non-Hispanic black, intermediate for women identifying as both non-Hispanic black and white race, and lowest for non-Hispanic white women at <37 weeks (9.9% vs. 6.1% vs. 5.5%, respectively; p<0.001), <34 weeks (3.5% vs. 1.5% vs. 1.1%, respectively; p<0.001), and <28 weeks' gestation (1.2% vs. 0.4% vs. 0.2%, respectively, p<0.001)., Conclusions: Even among college-educated women with private insurance who are not receiving WIC, racial disparities in prematurity persist. These national findings are consistent with prior studies that suggest factors other than socio-demographics are important in the underlying pathogenesis of PTB., Competing Interests: The authors report no conflicts of interest or financial disclosures.

Background Inconsistent findings have been found among studies evaluating the risk of cardiovascular disease for women who have had pregnancies complicated by gestational hypertension (the new onset of high blood pressure without proteinuria during pregnancy). We provide a comprehensive review of studies to quantify the association between gestational hypertension and cardiovascular events in women. Methods and Results We conducted a systematic search of PubMed, Embase, and Web of Science in March 2019 for studies examining the association between gestational hypertension and any cardiovascular event. Two reviewers independently assessed the abstracts and full-text articles. Study characteristics and the relative risk (RR) of cardiovascular events associated with gestational hypertension were extracted from the eligible studies. Where appropriate, the estimates were pooled with inverse variance weighted random-effects meta-analysis. A total of 21 studies involving 3 60 1192 women (127 913 with gestational hypertension) were identified. Gestational hypertension in the first pregnancy was associated with a greater risk of overall cardiovascular disease (RR, 1.45; 95% CI, 1.17-1.80) and coronary heart disease (RR, 1.46; 95% CI, 1.23-1.73), but not stroke (RR, 1.26; 95% CI, 0.96-1.65) or thromboembolic events (RR, 0.88; 95% CI, 0.73-1.07). Women with 1 or more pregnancies affected by gestational hypertension were at greater risk of cardiovascular disease (RR, 1.81; 95% CI, 1.42-2.31), coronary heart disease (RR, 1.83; 95% CI, 1.33-2.51), and heart failure (RR, 1.77; 95% CI, 1.47-2.13), but not stroke (RR, 1.50; 95% CI, 0.75-2.99). Conclusions Gestational hypertension is associated with a greater risk of overall cardiovascular disease, coronary heart disease, and heart failure. More research is needed to assess the presence of a dose-response relationship between gestational hypertension and subsequent cardiovascular disease. Registration URL: https://www.crd.york.ac.uk/prosp​ero/; Unique identifier: CRD42018119031.

Background: Recent increases in maternal mortality and severe maternal morbidity highlight the need to improve systems for safe maternity care. We sought to identify whether publicly available state perinatal guidelines incorporate levels of maternal care (LoMC) criteria. Materials and Methods: We searched websites for 50 U.S. states and Washington, D.C. for LoMC guidelines. The Health Resources and Services Administration's Title V Program directors confirmed/updated search results through January 2018. Data abstracted included: (1) definitions of levels; (2) provider types; (3) facility capabilities and services; and (4) programmatic responsibilities as promoted in the 2015 Society for Maternal/Fetal Medicine and American College of Obstetricians and Gynecologists consensus document on LoMC. Results: LoMC guidelines were identified for 17 states; 12 defined four levels and five defined three levels of care. In Level I, 14/17 states specified obstetric provider availability for every birth and five specified an available surgeon to perform emergency cesareans. Fourteen states specified the availability of blood bank and laboratory services at all times. In the highest level (III or IV), 16/17 state guidelines specified a maternal/fetal medicine specialist; all but two specified anesthesia providers or services. Ten states referenced availability of an onsite intensive care unit in their highest level. All 17 state guidelines specified maternal transport and referral systems. Conclusions: Only one-third of states have publicly available perinatal guidelines incorporating LoMC criteria. Definitions, criteria, and nomenclature varied. Lack of LoMC guidelines with standardized criteria limits monitoring and evaluation of regionalized systems of maternal care.

Objective: To examine the association between neonatal jaundice and autism spectrum disorder (ASD) and non-ASD developmental disorder (DD)., Study Design: We analyzed data from the Study to Explore Early Development, a US multisite, case-control study conducted from 2007 to 2011. Developmental assessment classified children aged 2-5 years into: ASD (n = 636), DD (n = 777), or controls (POP; n = 926). Neonatal jaundice (n = 1054) was identified from medical records and maternal interviews. We examined associations between neonatal jaundice and ASD and DD using regression models to obtain adjusted odds ratios (aOR)., Results: Our results showed interaction between gestational age and neonatal jaundice. Neonatal jaundice was associated with ASD at 35-37 weeks (aOR = 1.83, 95%CI 1.05, 3.19), but not ≥38 weeks gestation (aOR = 0.97, 95%CI 0.76, 1.24). Similar results were observed with DD., Conclusions: Further exploration of timing and severity of neonatal jaundice and ASD/DD is warranted.

Objective: To estimate sex-specific differences in late preterm outcomes and evaluate whether betamethasone modifies this association., Study Design: We conducted a secondary analysis of a multicenter trial of women at risk for late preterm birth randomized to receive betamethasone or placebo. We included women who delivered at 34 to 37 weeks and excluded major fetal anomalies. The primary outcome was severe neonatal morbidity (mechanical ventilation, respiratory distress syndrome, bronchopulmonary dysplasia, sepsis, necrotizing enterocolitis, and intraventricular hemorrhage). Maternal characteristics were compared using chi-square test, t -test, or Mann-Whitney U -test. Multivariable logistic regression estimated the association between sex and morbidity, and likelihood ratio testing assessed for effect modification by betamethasone., Results: Of 2,831 women in the primary trial, 2,331 met the inclusion criteria: 1,236 delivered males and 1,095 delivered females. Betamethasone modified the association between sex and severe morbidity ( p  = 0.047). Among those who received betamethasone, male sex was associated with higher odds of severe morbidity (adjusted odds ratio: 1.95, 95% confidence interval: 1.25-3.05), compared with female sex. Among those who did not receive betamethasone, there was no significant association between sex and morbidity., Conclusion: Male sex is a risk factor for adverse late preterm outcomes, including severe neonatal morbidity after betamethasone receipt., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Pregnancy and childrearing can impact women's health and alter chronic disease trajectories in later life, including cardiovascular disease. The purpose of this study was to assess measures of women's cardiovascular health by time since last live birth. Materials and Methods: Data were from 4,021 nonpregnant U.S. women, 20-44 years of age, participating in the 2007-2014 National Health and Nutrition Examination Survey (NHANES). Cardiovascular health was assessed using physical measures, laboratory measures, self-reported behaviors, medical conditions, and selected psychosocial factors by time since last live birth. Results: Women reported their last live birth within the past 12 months ("mothers of infants"; 7.4%), >12 months, but <3 years ago ("mothers of toddlers"; 10.0%), or ≥3 years ago ("mothers of older children"; 45.2%); 37.3% were nulliparous. Compared with nulliparous women, mothers of older children had a higher prevalence of selected cardiovascular risk factors, including unhealthy diet (75.6% vs. 68.8%) and smoking (28.1% vs. 21.9%), after adjustment for sociodemographics (including age). Mothers of toddlers had a higher prevalence of unhealthy diet (78.0% vs. 68.8%). Mothers also had poorer metabolic health as indicated by a higher prevalence of low HDL cholesterol among mothers of toddlers and older children (44.2% and 40.4%, respectively, vs. 33.6%), and a higher prevalence of high waist circumference among mothers of infants (65.6% vs. 53.8%). Some mothers also had a higher prevalence of other cardiovascular risk factors, including low physical activity and poor sleep. Conclusion: Prior pregnancy and childrearing may be associated with selected cardiovascular risk factors among nonpregnant reproductive-aged U.S. women.

Objectives: To characterize the health and health care experiences of children in the U.S. Virgin Islands (USVI), assess differences by household poverty status, and provide comparisons to the general U.S. child population., Methods: Data are from the 2011-2012 National Survey of Children's Health, which included 2342 USVI children, aged 0-17 years. Parent-reported measures of health status and health conditions, behavioral characteristics, and health care access and utilization were assessed. Weighted prevalence estimates were calculated and compared by household poverty status using Chi square tests., Results: Overall, 31.3% of USVI children lived in households below 100% of the federal poverty level (FPL). Children in these low-income households were more likely to have public insurance (33.0% vs. 8.4%) and unmet health needs (11.6% vs. 6.3%) as compared to those in households with incomes ≥ 100% FPL (all p < 0.01). They were also less likely to have a medical home (22.5% vs. 42.2%), including a usual source of sick care (p < 0.01). Compared with U.S. children in general, USVI children had lower rates of preventive medical visits, preventive dental visits, and care received in a medical home., Conclusions: USVI children experience challenges in accessing and utilizing health care services, particularly those in low-income households, and fare worse than U.S. children on many of these measures. These findings will serve as a baseline comparison for an upcoming survey of maternal and child health to be conducted in eight U.S. territories including the USVI.

While a mean age at menopause of 51 years has been reported in the United States (U.S.), some U.S. women experience menopause before age 45, possibly increasing risk of cardiovascular mortality; however, the role in all-cause and cerebrovascular-related mortality is unclear. The purpose of this study was to investigate the association between age at menopause and all-cause and cause-specific mortality by race, hormone replacement therapy (HRT) use, and smoking status. REasons for Geographic and Racial Differences in Stroke (REGARDS) is a population-based study of 30,239 participants aged ≥45 years enrolled between 2003 and 2007 of whom 14,361 were postmenopausal women. Age at menopause was defined as <45 (early) or ≥45. All-cause and cause-specific mortality were ascertained through 2013. Cox proportional hazards models estimated hazard ratios (HR) and 95% confidence intervals (CI) for the association between age at menopause and mortality, adjusting for baseline measures. Of 11,287 eligible women (6403 white; 4884 black), mean menopause age was 45.2 (SD 7.9) with 1524 deaths over 7.1 years. Significant interactions were detected between early age at menopause (39%) and HRT use in association with all-cause mortality ( p  < 0.01), mortality from coronary heart disease ( p  = 0.06), and mortality from all other causes ( p  = 0.04). An association between early age at menopause and all-cause mortality was observed among ever-HRT users (HR = 1.31, 95% CI: 1.10-1.56), but not never-HRT users (HR = 1.01, 95% CI: 0.85-1.20). There were no differences in associations examined by race or smoking status. Increased all-cause mortality risk was observed for ever-HRT users with menopause before age 45., Competing Interests: None.

Previous studies have shown complications of pregnancy, often examined in aggregate, to be associated with autism spectrum disorder (ASD). Results for specific complications, such as maternal diabetes and hypertension, have not been uniformly consistent and should be investigated independently in relation to ASD in a large community-based sample. The Study to Explore Early Development (SEED), a US multisite case-control study, enrolled children born in 2003-2006 at 2-5 years of age. Children were classified into three groups based on confirmation of ASD (n = 698), non-ASD developmental delay (DD; n = 887), or controls drawn from the general population (POP; n = 979). Diagnoses of any diabetes or hypertensive disorder during pregnancy were identified from prenatal medical records and maternal self-report. Logistic regression models estimated adjusted odds ratios (aOR) and confidence intervals (CI) adjusting for maternal age, race/ethnicity, education, smoking during pregnancy, and study site. Models for hypertension were additionally adjusted for parity and plurality. Among 2,564 mothers, we identified 246 (9.6%) with any diabetes and 386 (15.1%) with any hypertension in pregnancy. After adjustment for covariates, any diabetes during pregnancy was not associated with ASD (aOR = 1.10 [95% CI 0.77, 1.56]), but any hypertension was associated with ASD (aOR = 1.69 [95% CI 1.26, 2.26]). Results were similar for DD, and any diabetes (aOR = 1.29 [95% CI 0.94, 1.78]) or any hypertension (aOR = 1.71 [95% CI 1.30, 2.25]). Some pregnancy complications, such as hypertension, may play a role in autism etiology and can possibly serve as a prompt for more vigilant ASD screening efforts. Autism Res 2019, 12: 967-975. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We studied if common complications in pregnancy are associated with autism spectrum disorder (ASD) in a large sample of mothers and children. Our results show an association between conditions marked by high blood pressure and ASD, but no association with conditions marked by high blood sugar and ASD. Associations were similar for children who had a developmental disorder that was not ASD, suggesting that this relationship may not be specific to ASD., (© 2019 International Society for Autism Research, Wiley Periodicals, Inc.)

Background: Previous studies are inconclusive on the relationship between parity and cardiovascular disease (CVD), with few evaluating multiple cardiovascular outcomes. It is also unclear if any relationship between parity and CVD is independent of breastfeeding. We examined the associations between parity and cardiovascular outcomes, including breastfeeding adjustment. Materials and Methods: Data were from 8,583 White and African American women, 45-64 years of age, in the Atherosclerosis Risk in Communities Study. Coronary heart disease (CHD), myocardial infarction (MI), heart failure, and strokes were ascertained from 1987 to 2016 by annual interviews and hospital surveillance. Parity and breastfeeding were self-reported. Cox proportional hazards regression estimated hazard ratios (HR) for the association between parity and cardiovascular outcomes, adjusting for baseline sociodemographic, clinical and lifestyle factors, and breastfeeding. Results: Women reported no pregnancies (6.0%), or having 0 (1.6%), 1-2 (36.2%), 3-4 (36.4%), or 5+ (19.7%) live births. During 30 years follow-up, there were 1,352 CHDs, 843 MIs, 750 strokes, and 1,618 heart failure events. Compared with women with 1-2 prior births, those with prior pregnancies and no live births had greater incident CHD (HR = 1.64, 95% confidence interval 1.14-2.42) and heart failure risk (1.46, 1.04-2.05), after adjustment for baseline characteristics. Women with 5+ births had greater risk of CHD (1.29, 1.10-1.52) and hospitalized MI (1.38, 1.13-1.69), after adjustment for baseline characteristics and breastfeeding. Conclusions: In a diverse U.S. cohort, a history of 5+ live births is associated with CHD risk, specifically, MI, independent of breastfeeding. Having a prior pregnancy and no live birth is associated with greater CHD and heart failure risk.

Background: The intrauterine environment is critical in the development of child obesity., Objective: To investigate the association between maternal lipid levels during pregnancy and child weight status., Methods: Maternal lipid levels (total cholesterol, high-density and low-density lipoprotein cholesterol, triglycerides) collected from fasting blood samples collected at less than 20 and 24-29 weeks' gestation and child weight status at age 3 were examined prospectively among 183 mother-child dyads enrolled in the Pregnancy, Infection, and Nutrition. Measured height and weight at 3 years were used to calculate age- and sex-specific body mass index z-scores. Child risk of overweight/obesity was defined as body mass index greater than or equal to 85th percentile for age and sex. Regression models estimated the association between maternal lipid levels and child body mass index z-score and risk of being affected by overweight/obesity, respectively., Results: Higher triglyceride levels at less than 20 and 24-29 weeks of pregnancy were associated with higher body mass index z-scores (β = 0.23; 95% CI: 0.07-0.38 and β = 0.15; 95% CI: 0.01-0.29; respectively) after adjusting for confounders. There was no evidence of an association between total or low-density lipoprotein cholesterol and child weight status at age 3., Conclusions: Early childhood body mass index may be influenced by maternal triglyceride levels during pregnancy., (© 2018 World Obesity Federation.)

Objectives: To use the latest data to estimate the prevalence and correlates of currently diagnosed depression, anxiety problems, and behavioral or conduct problems among children, and the receipt of related mental health treatment., Study Design: We analyzed data from the 2016 National Survey of Children's Health (NSCH) to report nationally representative prevalence estimates of each condition among children aged 3-17 years and receipt of treatment by a mental health professional. Parents/caregivers reported whether their children had ever been diagnosed with each of the 3 conditions and whether they currently have the condition. Bivariate analyses were used to examine the prevalence of conditions and treatment according to sociodemographic and health-related characteristics. The independent associations of these characteristics with both the current disorder and utilization of treatment were assessed using multivariable logistic regression., Results: Among children aged 3-17 years, 7.1% had current anxiety problems, 7.4% had a current behavioral/conduct problem, and 3.2% had current depression. The prevalence of each disorder was higher with older age and poorer child health or parent/caregiver mental/emotional health; condition-specific variations were observed in the association between other characteristics and the likelihood of disorder. Nearly 80% of those with depression received treatment in the previous year, compared with 59.3% of those with anxiety problems and 53.5% of those with behavioral/conduct problems. Model-adjusted effects indicated that condition severity and presence of a comorbid mental disorder were associated with treatment receipt., Conclusions: The latest nationally representative data from the NSCH show that depression, anxiety, and behavioral/conduct problems are prevalent among US children and adolescents. Treatment gaps remain, particularly for anxiety and behavioral/conduct problems., (Published by Elsevier Inc.)

Objectives To estimate the rate of pregnancy-associated emergency care visits and identify maternal and pregnancy characteristics associated with high utilization of emergency care among pregnant Medicaid recipients in North Carolina. Methods A retrospective cohort study using linked Medicaid hospital claims and birth records of 107,207 pregnant Medicaid recipients who delivered a live-born infant in North Carolina between January 1, 2008 and December 31, 2009. Rates were estimated per 1000 member months of Medicaid coverage. High utilization was defined as ≥ 4 visits. Emergency care visits included encounters in the emergency department or obstetric triage unit during pregnancy that did not result in hospital admission. Results During the study period, 57.5% of pregnant Medicaid recipients sought emergency care at least once during pregnancy. There were 171,909 emergency care visits with an overall rate of 202.3 visits per 1000 member months. Among the subset of pregnant women with Medicaid coverage for the majority of their pregnancy (n = 75,157), 18.1% were high utilizers. High emergency care utilization was associated with young age, black race, lower education, tobacco use, late preterm delivery, multifetal gestation, and having ≥ 1 comorbidity. Threatened labor and abdominal pain were the leading indications for visits. Conclusion Utilization of hospital-based emergency care services was common in this cohort of pregnant Medicaid recipients. Additional research is needed to assess the drivers for accessing care through the emergency department, and to examine differences in pregnancy outcomes and health care costs between high and low utilizers.

Background: Meta-analyses of observational studies have shown that women with a shorter interpregnancy interval (the time from delivery to start of a subsequent pregnancy) are more likely to experience adverse pregnancy outcomes, such as preterm delivery or small for gestational age birth, than women who space their births further apart. However, the studies used to inform these estimates have methodological shortcomings., Methods: In this commentary, we summarise the discussions of an expert workgroup describing good practices for the design, analysis, and interpretation of observational studies of interpregnancy interval and adverse perinatal health outcomes., Results: We argue that inferences drawn from research in this field will be improved by careful attention to elements such as: (a) refining the research question to clarify whether the goal is to estimate a causal effect vs describe patterns of association; (b) using directed acyclic graphs to represent potential causal networks and guide the analytic plan of studies seeking to estimate causal effects; (c) assessing how miscarriages and pregnancy terminations may have influenced interpregnancy interval classifications; (d) specifying how key factors such as previous pregnancy loss, pregnancy intention, and maternal socio-economic position will be considered; and (e) examining if the association between interpregnancy interval and perinatal outcome differs by factors such as maternal age., Conclusion: This commentary outlines the discussions of this recent expert workgroup, and describes several suggested principles for study design and analysis that could mitigate many potential sources of bias., (© 2018 The Authors. Paediatric and Perinatal Epidemiology Published by John Wiley & Sons Ltd.)

Background: The World Health Organization (WHO) recommends that women wait at least 24 months after a livebirth before attempting a subsequent pregnancy to reduce the risk of adverse maternal, perinatal, and infant health outcomes. However, the applicability of the WHO recommendations for women in the United States is unclear, as breast feeding, nutrition, maternal age at first birth, and total fertility rate differs substantially between the United States and the low- and middle-resource countries upon which most of the evidence is based., Methods: To inform guideline development for birth spacing specific to women in the United States, the Office of Population Affairs (OPA) convened an expert work group meeting in Washington, DC, on 14-15 September 2017 among reproductive, perinatal, paediatric, social, and public health epidemiologists; obstetrician-gynaecologists; biostatisticians; and experts in evidence synthesis related to women's health., Results: Presentations and discussion topics included the methodological quality of existing studies, evaluation of the evidence for causal effects of short interpregnancy intervals on adverse perinatal and maternal health outcomes, good practices for future research, and identification of research gaps and priorities for future work., Conclusions: This report provides an overview of the presentations, discussions, and conclusions from the expert work group meeting., (© 2018 The Authors. Paediatric and Perinatal Epidemiology Published by John Wiley & Sons Ltd.)

: media-1vid110.1542/5839990273001PEDS-VA&#95;2017-4161 Video Abstract OBJECTIVES: To estimate the national prevalence of parent-reported autism spectrum disorder (ASD) diagnosis among US children aged 3 to 17 years as well as their treatment and health care experiences using the 2016 National Survey of Children's Health (NSCH)., Methods: The 2016 NSCH is a nationally representative survey of 50 212 children focused on the health and well-being of children aged 0 to 17 years. The NSCH collected parent-reported information on whether children ever received an ASD diagnosis by a care provider, current ASD status, health care use, access and challenges, and methods of treatment. We calculated weighted prevalence estimates of ASD, compared health care experiences of children with ASD to other children, and examined factors associated with increased likelihood of medication and behavioral treatment., Results: Parents of an estimated 1.5 million US children aged 3 to 17 years (2.50%) reported that their child had ever received an ASD diagnosis and currently had the condition. Children with parent-reported ASD diagnosis were more likely to have greater health care needs and difficulties accessing health care than children with other emotional or behavioral disorders (attention-deficit/hyperactivity disorder, anxiety, behavioral or conduct problems, depression, developmental delay, Down syndrome, intellectual disability, learning disability, Tourette syndrome) and children without these conditions. Of children with current ASD, 27% were taking medication for ASD-related symptoms, whereas 64% received behavioral treatments in the last 12 months, with variations by sociodemographic characteristics and co-occurring conditions., Conclusions: The estimated prevalence of US children with a parent-reported ASD diagnosis is now 1 in 40, with rates of ASD-specific treatment usage varying by children's sociodemographic and co-occurring conditions., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Introduction CenteringPregnancy® is well-regarded as an innovative group model of prenatal care. In 2009, Georgia's Southwest Public Health District partnered with local obstetricians and medical centers to expand prenatal care access and improve perinatal outcomes for low-income women by implementing Georgia's first public health administered CenteringPregnancy program. This paper describes the successful implementation of CenteringPregnancy in a public health setting with no prior prenatal services; assesses the program's first 5-year perinatal outcomes; and discusses several key lessons learned. Methods Prenatal and hospital medical records of patients were reviewed for the time period from October 2009 through October 2014. Descriptive analyses were conducted to examine demographic and clinical characteristics of women initiating prenatal care and to assess perinatal outcomes among patients with singleton live births who attended at least three CenteringPregnancy sessions or delivered prior to attending the third session. Results Six hundred and six low-income women initiated prenatal care; 55.4 and 36.4% self-identified as non-Hispanic black and Hispanic, respectively. The median age was 23 years (IQR 20, 28). Nearly 69% initiated prenatal care in the first trimester. Perinatal outcomes were examined among 338 singleton live births. The 2010-2014 preterm birth rate (% of births < 37 weeks gestation at delivery) and low birth weight rate (% of births < 2500 g) were 9.1 and 8.9%, respectively. Nearly 77% of women initiated breastfeeding. Discussion CenteringPregnancy administered via public-private partnership may improve access to prenatal care and perinatal outcomes for medically underserved women in low-resource settings.

Objective: To estimate the association between lipoprotein particle concentrations in pregnancy and gestational age at delivery., Design: Prospective cohort study., Setting: The study was conducted in the USA at the University of North Carolina., Population: We assessed 715 women enrolled in the Pregnancy, Infection, and Nutrition study from 2001 to 2005., Methods: Fasting blood was collected at two time points (<20 and 24-29 weeks of gestation). Nuclear magnetic resonance (NMR) quantified lipoprotein particle concentrations [low-density lipoprotein (LDL), high-density lipoprotein (HDL), very-low density lipoprotein (VLDL)] and 10 subclasses of lipoproteins. Concentrations were assessed as continuous measures, with the exception of medium HDL which was classified as any or no detectable level, given its distribution. Cox proportional hazards models estimated hazard ratios (HR) for gestational age at delivery adjusting for covariates., Main Outcome Measures: Gestational age at delivery, preterm birth (<37 weeks of gestation), and spontaneous preterm birth., Results: At <20 weeks of gestation, three lipoproteins were associated with later gestational ages at delivery [large LDL NMR (HR 0.78, 95% CI 0.64-0.96), total VLDL NMR (HR 0.77, 95% CI 0.61-0.98), and small VLDL NMR (HR 0.78, 95% CI 0.62-0.98], whereas large VLDL NMR (HR 1.19, 95% CI 1.01-1.41) was associated with a greater hazard of earlier delivery. At 24-28 weeks of gestation, average VLDL NMR (HR 1.25, 95% CI 1.03-1.51) and a detectable level of medium HDL NMR (HR 1.90, 95% CI 1.19-3.02) were associated with earlier gestational ages at delivery., Conclusion: In this sample of pregnant women, particle concentrations of VLDL NMR , LDL NMR , IDL NMR , and HDL NMR were each independently associated with gestational age at delivery for all deliveries or spontaneous deliveries <37 weeks of gestation. These findings may help formulate hypotheses for future studies of the complex relationship between maternal lipoproteins and preterm birth., Tweetable Abstract: Nuclear magnetic resonance spectroscopy may identify lipoprotein particles associated with preterm delivery., (© 2017 Royal College of Obstetricians and Gynaecologists.)

Objectives Statute for the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program requires that states and territories receiving Program funding assess improvements for participating families across six areas that address maternal and child well-being. In 2015, the MIECHV Program performance measurement system was redesigned to allow for national-level analyses and cross-grantee comparisons. The new measures were aligned with other federal performance measures to help ensure context for program analyses. The number of measures was also reduced to lessen reporting burden. This paper describes the redesign process and resulting national performance measures. Methods The redesign process included holding listening sessions with stakeholders and experts; reviewing the findings from other home visiting performance initiatives; consulting with experts; soliciting and responding to public comment on draft measures; seeking clearance from the Office of Management and Budget; and specifying each measure with detailed eligibility criteria, the timing and frequency of assessments, and the window for data collection. Results The redesign resulted in a set of 19 measures that all MIECHV-funded home visiting programs began collecting in 2016. This is nearly half the number of measures that MIECHV awardees had been reporting prior to the redesign. The measures are aligned with other federal measures, including those used in Healthy People 2020 and those used for other maternal and child health programs. Conclusions for Practice Data reported by MIECHV Program awardees will be used to assess their performance, identify areas for targeted technical assistance to support continuous improvement, and ensure meaningful impacts for at-risk families.

Competing Interests: Conflict of Interest: None.

Background: Preterm birth is the leading cause of neonatal morbidity and mortality in nonanomalous neonates in the United States. Women with a previous early spontaneous preterm birth are at highest risk for recurrence. Weekly intramuscular 17-alpha hydroxyprogesterone caproate reduces the risk of recurrent prematurity. Although current guidelines recommend 17-alpha hydroxyprogesterone caproate initiation between 16 and 20 weeks, in clinical practice, 17-alpha hydroxyprogesterone caproate is started across a spectrum of gestational ages., Objective: The objective of the study was to examine the relationship between the gestational age at 17-alpha hydroxyprogesterone caproate initiation and recurrent preterm birth among women with a prior spontaneous preterm birth 16-28 weeks' gestation., Study Design: This was a retrospective cohort study of women from a single tertiary care center, 2005-2016. All women with ≥1 singleton preterm births because of a spontaneous onset of contractions, preterm prelabor rupture of membranes, or painless cervical dilation between 16 and 28 weeks followed by a subsequent singleton pregnancy treated with 17-alpha hydroxyprogesterone caproate were included. Women were grouped based on quartiles of gestational age of 17-alpha hydroxyprogesterone caproate initiation (quartile 1, 14 0/7 to 16 1/7 ; quartile 2, 16 2/7 to 17 0/7 ; quartile 3, 17 1/7 to 18 6/7 ; and quartile 4, 19 0/7 to 27 5/7 ). Women with a gestational age of 17-alpha hydroxyprogesterone caproate initiation in quartiles 1 and 2 were considered to have early-start 17-alpha hydroxyprogesterone caproate; those in quartiles 3 and 4 were considered to have late-start 17-alpha hydroxyprogesterone caproate. The primary outcome was recurrent preterm birth <37 weeks' gestation. Secondary outcomes included recurrent preterm birth <34 and <28 weeks' gestation and composite major neonatal morbidity (diagnosis of grade III or IV intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis stage II or III, or death). Gestational age at delivery was compared by quartile of 17-alpha hydroxyprogesterone caproate initiation using Kaplan-Meier survival curves and the log-rank test. Logistic regression models estimated odds ratios for the association between gestational age at 17-alpha hydroxyprogesterone caproate initiation and preterm birth <37 weeks' gestation, adjusting for demographics, prior pregnancy and antenatal characteristics., Results: A total of 132 women met inclusion criteria; 52 (39.6%) experienced recurrent preterm birth <37 weeks in the studied pregnancy. 17-Alpha hydroxyprogesterone caproate was initiated at a mean 17 6/7 ± 2.5 weeks. Demographic and baseline characteristics were similar between women with early-start 17-alpha hydroxyprogesterone caproate (quartiles 1 and 2) compared with those with late-start 17-alpha hydroxyprogesterone caproate (quartiles 3 and 4). Women with early-start 17-alpha hydroxyprogesterone caproate trended toward lower rates of recurrent preterm birth <37 weeks compared with those with late-start 17-alpha hydroxyprogesterone caproate (41.3% vs 57.7%, P = .065). Delivery gestational age was inversely proportional to gestational age at 17-alpha hydroxyprogesterone caproate initiation (quartile 1, 37 4/7 weeks vs quartile 2, 36 5/7 vs quartile 3, 36 1/7 weeks vs quartile 4, 34 0/7 , P = .007). In Kaplan-Meier survival analyses, these differences in delivery gestational age by 17-alpha hydroxyprogesterone caproate initiation quartile persisted across pregnancy (log-rank P < .001). In regression models, later initiation of 17-alpha hydroxyprogesterone caproate was significantly associated with increased odds of preterm birth <37 weeks. Women with early 17-alpha hydroxyprogesterone caproate initiation also had lower rates of major neonatal morbidity than those with later 17-alpha hydroxyprogesterone caproate initiation (1.5% vs 14.3%, P = .005)., Conclusion: Rates of recurrent preterm birth among women with a prior spontaneous preterm birth 16-28 weeks are high. Women beginning 17-alpha hydroxyprogesterone caproate early deliver later and have improved neonatal outcomes. Clinicians should make every effort to facilitate 17-alpha hydroxyprogesterone caproate initiation at 16 weeks., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Obesity is a risk factor for intensive care unit (ICU) admission in nonpregnant populations. Less is known about maternal obesity and ICU admission risk. The objective of this study was to estimate the association between maternal obesity and ICU admission among women who delivered via cesarean section or vaginal birth after cesarean section (VBAC)., Material and Methods: This is a retrospective cohort analysis of women who delivered via VBAC or cesarean section in the Maternal-Fetal Medicine Unit (MFMU) Cesarean Registry. We defined exposure as body mass index (BMI) at delivery stratified as non-obese (BMI 18.5-29.9 kg/m 2 ), class I or II obese (BMI 30-39.9 kg/m 2 ), morbidly obese (BMI 40-49.9 kg/m 2 ), and super obese (BMI ≥ 50 kg/m 2 ). The primary outcome was ICU admission. Modified Poisson regression models estimated relative risk (RR) of ICU admission by obesity strata, after adjusting for confounders. Mediation analysis was used to estimate the proportion of ICU admission risk attributable specifically to obesity., Results: We included 68 455 women; 40% non-obese, 46% class I or II obese, 12% morbidly obese, and 2% super obese. Super obese women were at higher risk for ICU admission compared with non-obese women (0.7 vs. 1.3%, adjusted RR 1.61; 95% CI 1.01-2.65), after adjusting for confounders. Among super obese women, medical comorbidities mediated 58% of ICU admission risk, suggesting that a significant proportion of ICU admission is driven by maternal obesity., Conclusions: Super obese women who deliver by cesarean section or VBAC are at increased risk of peripartum ICU admission. Obstetricians and critical care specialists should consider possible ICU admission during delivery planning., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)