Laura Jelliffe-Pawlowski

Abstract

Objective Increasing the vaginal birth after cesarean (VBAC) rate to 18% was a Healthy People 2020 goal. Detailed data on racial/ethnic differences in VBAC rates is lacking and can inform efforts to equitably increase VBAC rates. This study aimed to assess racial/ethnic variation in VBAC rates and to describe group trends in VBAC rates in California between 2011 and 2021. Study Design This retrospective cohort study used a database of birth certificates linked to hospital discharge records. We analyzed singleton, term live births among people who had a history of at least one prior cesarean birth, no identified contraindications to a vaginal birth, and self-identified their racial/ethnic group as Hispanic or non-Hispanic (American Indian-Alaskan Native (AIAN), Asian, Black, Hawaiian/Pacific Islander, or white). VBAC births were identified from birth certificate records. Differences between VBAC rates were assessed using univariable and multivariable Poisson log-linear regression while adjusting for potential confounders. Results A total of 607,808 birthing people were included (2,234 AIAN, 84,899 Asian, 34,217 Black, 2,559 Hawaiian/Pacific Islander, 334,116 Hispanic, 149,783 white). Over the study period, Hawaiian/Pacific Islander birthing people had the highest average VBAC rate at 11.5% (AIAN, 6.5%; Asian, 8.8%; Black, 8.0%; Hispanic, 7.4%; white, 9.5%). In adjusted models, Black (aRR = 1.06, 95% CI: 1.01-1.11) and Hawaiian/Pacific Islander (aRR = 1.43, 95% CI: 1.27-1.61) birthing people were more likely to have a VBAC compared with white birthing people, while Hispanic birthing people were less likely (aRR = 0.96, 95% CI: 0.93-0.98). VBAC rates increased significantly (p < 0.001) over time for all groups except AIAN birthing people. Conclusion VBAC rates increased for most racial/ethnic groups in California. With the exception of the Hawaiian/Pacific Islander group, there were small and likely not clinically significant differences in the chances for a VBAC across groups. No group in California met the Healthy People 2020 goal VBAC rate of 18%. Key Points VBAC rates increased for most racial/ethnic groups. The VBAC rate for AIAN birthing people did not increase. No group met the Healthy People 2020 goal VBAC rate of 18%.

Abstract

Objectives: We investigated the association between maternal leukocyte telomere length (LTL) in the immediate postpartum period and moderate to late preterm birth (32– < 37 weeks) among Latinas, a population at high risk for preterm birth. Methods: Maternal LTL was measured using quantitative polymerase chain reaction at delivery in a prospective San Francisco primarily Latina birth cohort. Logistic regression models were used to investigate the association between postpartum maternal LTL and preterm birth. Maternal LTL was analyzed as a continuous predictor. Results: Out of 194 participants, 23 (11.9%) had preterm delivery. Longer postnatal maternal LTL was associated with preterm birth (crude OR 4.68; 95% confidence interval (CI) 1.07, 20.6, p = 0.039; adjusted OR 12.8, 95% CI 1.83, 99.9, p = 0.010). Age-stratified analysis showed that being under 35 years increased the effect size of the association between maternal LTL and preterm birth (adjusted OR 32.5, 95% CI 2.58, 597, p < 0.01). Conclusions for Practice: Latina mothers with moderate to late preterm infants had longer LTL in the immediate postpartum period compared to those with term infants. This association was stronger for mothers under the age of 35 years. LTL may serve as a biomarker to better understand the pathophysiology and risk of preterm birth and could inform targeted interventions for prevention and early detection. Future studies are needed to understand physiological changes in maternal LTL from the prenatal to postnatal period in relation to birth outcomes.

Abstract

Objective: Examine the association between clinical risk factors for preterm birth (PTB) and small for gestational age delivery (SGA) among United States (US)- and African-born Black women. Study design: Population-based study of singleton births to 171,051 US- and 19,269 African-born women in California (2011–2020). Associations between PTB and SGA with 14 clinical risk factors were examined. Adjusted Poisson regression models estimated the association between each clinical factor and the outcomes, while assessing interaction by nativity. Results: The prevalence of PTB, SGA, and clinical factors was greater among US-born Black women, with the exception of gestational diabetes. On average, the risk of PTB and SGA among women with each clinical risk factor was significantly higher for African- compared to US-born Black women. Conclusions: Clinical risk factors were higher among US-born women, however associations between each factor and adverse perinatal outcomes were stronger for African-born women.

Abstract

Pregnancy is a vital period affecting both maternal and fetal health, with impacts on maternal metabolism, fetal growth, and long-term development. While the maternal metabolome undergoes significant changes during pregnancy, longitudinal shifts in maternal urine have been largely unexplored. In this study, we applied liquid chromatography–mass spectrometry-based untargeted metabolomics to analyze 346 maternal urine samples collected throughout pregnancy from 36 women with diverse backgrounds and clinical profiles. Key metabolite changes included glucocorticoids, lipids, and amino acid derivatives, indicating systematic pathway alterations. We also developed a machine learning model to accurately predict gestational age using urine metabolites, offering a non-invasive pregnancy dating method. Additionally, we demonstrated the ability of the urine metabolome to predict time-to-delivery, providing a complementary tool for prenatal care and delivery planning. This study highlights the clinical potential of urine untargeted metabolomics in obstetric care.

Abstract

Background: Prenatal anxiety affects between 20% and 30% of pregnant people and is associated with adverse prenatal health conditions, birth outcomes, and postpartum mental health challenges. Individuals from racial and ethnic minority groups, sexual and gender minority groups, and those with low income are all at heightened risk for prenatal anxiety due to disproportionate exposure to adverse social determinants of health. Digital cognitive behavioral therapy (dCBT) has been shown to reliably reduce anxiety in mostly White and middle- to higher-income samples, but its efficacy in low-income and marginalized pregnant people is understudied. Objective: We propose a randomized controlled trial of a dCBT (Daylight app, Big Health, Ltd) in a sample of low-income pregnant people oversampled for racial, ethnic, sexual, and gender minority identity. Methods: Participants (N=132) will be randomized to the intervention or waitlist control group using a 1:1 allocation ratio. The intervention will be a self-guided application that uses an online therapist to teach and encourage the practice of 4 key cognitive behavioral therapy skills (eg, identifying catastrophic thinking and increasing physical relaxation) that can reduce anxiety. The primary outcome will be generalized anxiety symptoms; secondary outcomes will include depressive symptoms, stress, pregnancy-specific anxiety, and insomnia symptoms. Focus groups with a subset of participants will provide qualitative data about the acceptability of dCBT. Results: Recruitment began in June 2024. Data will be analyzed using linear mixed models, which will be fit with treatment condition (dCBT and waitlist control group) as the between-group factor, time (baseline, 3, 6, and 10 weeks post randomization) as a within-group factor, and a group-by-time interaction. Linear mixed models produce unbiased parameter estimates in situations where there are different numbers of observations per record and will accommodate intent-to-treat and sensitivity analyses. Conclusions: This clinical trial will evaluate the efficacy and acceptability of a self-guided dCBT for prenatal anxiety among low-income and marginalized pregnant people, a group that continues to experience substantial barriers to accessing in-person evidence-based psychotherapy.

Abstract

Purpose: Mental health conditions are the leading cause of preventable maternal mortality and morbidity, yet few investigations have examined perinatal bipolar disorders. This study sought to examine racial differences in the odds of having a bipolar disorder diagnosis in perinatal women across self-reported racial groups in a large sample in California, USA. Method: This cross-sectional study uses data from 3,831,593 women who had singleton live births in California, USA from 2011 to 2019 existing in a linked dataset which included hospital discharge records and birth certificates. International Classification of Diseases codes were used to identify women with a bipolar disorder diagnosis code on the hospital discharge record. Medical charts and birth certificate data was used to extract information on clinical and demographic covariate characteristics. Multivariable logistic regression was used to estimate the odds of having a bipolar disorder diagnosis across different self-reported racial groups. Results: We identified 19,262 women with bipolar disorder diagnoses. Differences in the presence of a bipolar disorder diagnosis emerged by self-reported race. In the fully adjusted model, Multiracial (selection of two races self-reported) women, compared to single-race White women had the highest odds of having a bipolar disorder diagnosis. Further examination of the all-inclusive Multiracial category revealed differences across subgroups where White/Black, White/American Indian Alaskan Native, and Black/American Indian Alaskan Native women had increased odds for bipolar disorder compared to single race White women. Conclusions: Differences in bipolar disorder diagnoses exist across racial categories and when compared to White women, Multiracial women had the highest odds of bipolar disorder and thus represent a perinatal population of focus for future intervention studies. The increased burden of mental health problems among Multiracial women is consistent with recent research that employs disaggregated race data. More studies of Multiracial women are needed to determine how self-reported racial categories are related to increased risk for perinatal bipolar disorder.

Abstract

Background: Previous findings related to the association of adverse pregnancy outcomes with anorexia nervosa are mixed. Objective: This study aimed to investigate the association of adverse live-born pregnancy outcomes with anorexia nervosa using adjustment modeling accounting for confounding factors, and a mediation analysis addressing the contribution of underweight prepregnancy body mass index and gestational weight gain to those outcomes. Study Design: The sample included California live-born singletons with births between 2007 and 2021. The administrative data set contained birth certificates linked to hospital discharge records. Anorexia nervosa diagnosis during pregnancy was obtained from International Classification of Diseases codes on hospital discharge records. Adverse pregnancy outcomes examined included gestational diabetes, gestational hypertension, preeclampsia, anemia, antepartum hemorrhage, premature rupture of membranes, premature labor, cesarean delivery, oligohydramnios, placenta previa, chorioamnionitis, placental abruption, severe maternal morbidity, small for gestational age, large for gestational age, low birthweight, and preterm birth (by timing and indication). Risk of each adverse outcome was calculated using Poisson regression models. Unadjusted risk of each adverse outcome was calculated, and then the risks were adjusted for demographic factors. The final adjusted model included demographic factors, anxiety, depression, substance use, and smoking. A mediation analysis was performed to estimate the excess risk of adverse outcomes mediated by underweight prepregnancy body mass index and gestational weight gain below the American College of Obstetricians and Gynecologists recommendation. Results: The sample included 241 pregnant people with a diagnosis of anorexia nervosa and 6,418,236 pregnant people without an eating disorder diagnosis. An anorexia nervosa diagnosis during pregnancy was associated with many adverse pregnancy outcomes in unadjusted models (relative risks ranged from 1.65 [preeclampsia] to 3.56 [antepartum hemorrhage]) in comparison with people without an eating disorder diagnosis. In the final adjusted models, birthing people with an anorexia nervosa diagnosis were more likely to have anemia, preterm labor, oligohydramnios, severe maternal morbidity, a small for gestational age or low-birthweight infant, and preterm birth between 32 and 36 weeks with spontaneous preterm labor (adjusted relative risks ranged from 1.43 to 2.55). Underweight prepregnancy body mass index mediated 7.78% of the excess in preterm births and 18.00% of the excess in small for gestational age infants. Gestational weight gain below the recommendation mediated 38.89% of the excess in preterm births and 40.44% of the excess in low-birthweight infants. Conclusion: Anorexia nervosa diagnosis during pregnancy was associated with a number of clinically important adverse pregnancy outcomes in comparison with people without an eating disorder diagnosis. Adjusting for anxiety, depression, substance use, and smoking during pregnancy decreased this risk. A substantial percentage of the excess risk of adverse outcomes was mediated by an underweight prepregnancy body mass index, and an even larger proportion of excess risk was mediated by gestational weight gain below the recommendation. This information is important for clinicians to consider when caring for patients with anorexia nervosa. Considering and treating anorexia nervosa and comorbid conditions and counseling patients about mediating factors such as preconception weight and gestational weight gain may improve live-born pregnancy outcomes among people with anorexia nervosa.

Abstract

In neonatal, symptomatic tetralogy of Fallot (sTOF), data are lacking on whether high-risk groups would benefit from staged (SR) or complete repair (CR). We studied the association of gestational age (GA) at birth and z-score for birth weight (BWz), with management strategy and outcomes in sTOF. California population-based cohort study (2011–2017) of infants with sTOF (defined as catheter or surgical intervention prior to 44 weeks corrected GA) was performed, comparing management strategy and timing by GA and BWz categories. Multivariable models evaluated composite outcomes and days alive and out of hospital (DAOOH) in the first year of life. Among 345 patients (SR = 194; CR = 151), management strategy did not differ by GA or BWz with complete repair defined as prior to 44 weeks corrected gestational age; however, did differ by GA with regard to complete/timely repair (defined as complete repair within first 30 days of life). Full-term and early-term neonates underwent CR 20 (95%CI: − 27.1, − 14.1; p < 0.001) and 15 days (95%CI: − 22.1, − 8.2; p < 0.001) sooner than preterm neonates. Prematurity and major anomaly were associated with mortality or non-cardiac morbidity, while only major anomaly was associated with mortality or cardiac morbidity (OR = 3.5, 95%CI: 1.8,6.7, p < .0001). Full-term infants had greater DAOOH compared to preterm infants (35.2 days, 95%CI: 4.0, 66.5, p = 0.03). LGA infants and those with major anomaly had significantly lower DAOOH. In sTOF, patient specific risk factors such as prematurity and major anomaly were more associated with outcomes than management strategy.