Early Term Birth Research Articles

Air pollution and preterm birth: A time-stratified case-crossover study in the San Joaquin Valley of California.

Air pollution is linked to preterm birth (PTB), but existing studies are primarily focused on chronic exposures, conducted in areas with moderate pollution, and/or subject to confounding. We investigated short-term associations between two pollutants [particulate matter <2.5microns (PM2.5 ) and ozone] and PTB, and estimated excess PTB cases potentially attributed to these pollutants. This time-stratified case-crossover study includes 196,970singleton pregnancies affected by PTB and early term birth from the San Joaquin Valley (SJV), California, USA (2007-2015). Daily ozone and PM2.5 concentrations were estimated by the SJV Air Pollution Control District and geospatially linked to maternal zip code. We used conditional logistic regression models to estimate the odds ratio (OR) and 95% confidence intervals (CI) for the associations between an interquartile range (IQR) increase in pollutants and very preterm (VPTB, 20-34weeks), moderate preterm (MPTB, 34-36weeks) and early term births (ETB, 37-38weeks). We adjusted all models for co-pollutants and meteorological factors. During warm seasons (May-October), an IQR increase in ozone was associated with 9-11% increased odds of VPTB from lag 0 (ORlag0 1.09, 95% CI 1.04,1.16) to lag 7 (ORlag7 1.11, 95% CI 1.04,1.16). Findings were consistent for MPTB and ETB. Ozone was potentially responsible for an excess of 3-6VPTBs, 7-9 PTBs and 24-42 ETBs per 1,000singleton deliveries. During cold seasons (November-April), increased PM2.5 exposure was associated with 5-6% increased odds of VPTB beginning at lag 3 (ORlag3 1.06, 95% CI 1.02,1.11). PM2.5 was associated with an excess of 1-3VPTBs, 0-3MPTBs and 6-18 ETBs per 1,000singleton deliveries. PM2.5 and ozone are associated with increased risk of VPTB, MPTB and ETB within one week of exposure and are potential contributors to the increasing PTB trend. More research is needed to further understand the role of air pollution on PTB risk.

Factors associated with breast-feeding initiation and continuation in Canadian-born and non-Canadian-born women: a multi-centre study.

To identify factors associated with breast-feeding initiation and continuation in Canadian-born and non-Canadian-born women. Prospective cohort of mothers and infants born from 2008 to 2012: the Canadian Healthy Infant Longitudinal Development (CHILD) Cohort Study. General community setting in four Canadian provinces. In total, 3455 pregnant women from Vancouver, Edmonton, Winnipeg and Toronto between 2008 and 2012. Of 3010 participants included in the current study, the majority were Canadian-born (75·5 %). Breast-feeding initiation rates were high in both non-Canadian-born (95·5 %) and Canadian-born participants (92·7 %). The median breast-feeding duration was 10 months in Canadian-born participants and 11 months in non-Canadian-born participants. Among Canadian-born participants, factors associated with breast-feeding initiation and continuation were older maternal age, higher maternal education, living with their partner and recruitment site. Rooming-in during the hospital stay was also associated with higher rates of breast-feeding initiation, but not continuation at 6-month postpartum. Factors associated with non-initiation of breast-feeding and cessation at 6-month postpartum were maternal smoking, living with a current smoker, caesarean birth and early-term birth. Among non-Canadian-born participants, maternal smoking during pregnancy was associated with lower odds of breast-feeding initiation and lower odds of breast-feeding continuation at 6 months, and older maternal age and recruitment site were associated with breast-feeding continuation at 6 months. Although Canadian-born and non-Canadian-born women in the CHILD cohort have similar breast-feeding initiation rates, breast-feeding initiation and continuation are more strongly associated with socio-demographic characteristics in Canadian-born participants. Recruitment site was strongly associated with breast-feeding continuation in both groups and may indicate geographic disparities in breast-feeding rates nationally.

Early-term birth and its association with universal two-child policy: a national cross-sectional study in China

ObjectiveTo describe the epidemiology of early-term birth (ETB) at the national level in China, and explore the association and mediating factors between ETB and policy between universal two-child policy and...

Risk of large for gestational age births at early, full and late term in relation to pre-pregnancy body mass index: Mediation by gestational diabetes status.

Maternal pre-pregnancy body mass index (BMI) is strongly associated with infant birthweight and the risk differs in pregnancies complicated by gestational diabetes (GDM). To examine the risk of large for gestational age (LGA) (≥97th percentile) singleton births at early term, full term and late term in relation to maternal pre-pregnancy BMI status mediated through GDM. We analysed data from the 2018 U.S. National Vital Statistics Natality File restricted to singleton term births (N=3,229,783). In counterfactual models for causal inference, we estimated the total effect (TE), natural direct effect (NDE) and natural indirect effect (NIE) for the association of pre-pregnancy BMI with subcategories of LGA births at early, full and late term mediated through GDM, using log-binomial regression and adjusting for race/ethnicity, age, education, parity and infant sex. Proportion mediated was calculated on the risk difference scale and potential unmeasured confounders were assessed using the E-value. Overall, 6.4% of women had GDM, and there were 3.6% LGA singleton term births. The highest prevalence of GDM was among pre-gestational overweight/obesity that also had the highest rates of LGA births at term. The TE estimates for the risk of LGA births were the strongest across women with higher pre-pregnancy BMI compared to women with normal pre-pregnancy BMI. The NDE estimates were higher than the NIE estimates for overweight/obese BMI status. The proportion mediated, which answers the causal question to what extent the total effect of the association between pre-pregnancy BMI and LGA births is accounted for through GDM, was the highest (up to 16%) for early term births. Term singleton births make up the largest proportion in a cohort of newborns. While the percentage mediated through GDM was relatively small, health risks arising from pre-pregnancy overweight, and obesity can be substantial to both mothers and their offspring.

Elective cesarean delivery at term and its effects on respiratory distress at birth in Japan: The Japan Environment and Children's Study.

Background and AimsEarly‐term birth between 37 and 38 weeks of gestation increases the risk of mortality and morbidity. This study investigated the status and impact of early‐term birth among neonates born by cesarean section in Japan.MethodsAll singleton live births that had data of gestational age at birth available in the Japan Environment and Children's Study (JECS), a nationwide birth cohort study launched in 2011, were eligible for this study. Neonates born by cesarean delivery at term without indications for early delivery were included to examine the association between early‐term birth and respiratory distress at birth. The gestational age at birth was categorized as 37 weeks 0 day to 38 weeks 6 days (early‐term), 39 weeks 0 day to 40 weeks 6 day (full‐term), and 41 weeks 0 day to 41 weeks 6 days (late‐term). Respiratory distress at birth included respiratory distress syndrome, transient tachypnea, and difficulty in breathing after birth. Univariable and multivariable analyses were performed using logistic regression models with a two‐tailed significance level of 5%. All statistical analyses were performed using SAS, version 9.4, for Windows (SAS Institute, Cary, NC).ResultsIn total, 32 078 of 100 011 (32.1%) neonates had early‐term birth. At 37 gestational weeks, 49.7% of the deliveries were via cesarean section, and half of the cesarean deliveries were due to a previous cesarean section. Among the 10 051 neonates born by elective cesarean delivery at term, neonates with early‐term births were more likely to have respiratory distress at birth (adjusted odds ratio: 4.19; 95% confidence interval, 1.70, 10.34) than those born at full term.ConclusionsEarly‐term birth is associated with a high risk of respiratory distress in births involving cesarean delivery without indication for early delivery. There is a need for guidelines for early delivery considering adverse effects of early‐term births.

Preterm or Early Term Birth and Risk of Autism.

Preterm birth has been linked with increased risk of autism spectrum disorder (ASD); however, potential causality, sex-specific differences, and association with early term birth are unclear. We examined whether preterm and early term birth are associated with ASD in a large population-based cohort. A national cohort study was conducted of all 4 061 795 singleton infants born in Sweden during 1973-2013 who survived to age 1 year, who were followed-up for ASD identified from nationwide outpatient and inpatient diagnoses through 2015. Poisson regression was used to determine prevalence ratios for ASD associated with gestational age at birth, adjusting for confounders. Cosibling analyses were used to assess the influence of unmeasured shared familial (genetic and/or environmental) factors. ASD prevalences by gestational age at birth were 6.1% for extremely preterm (22-27 weeks), 2.6% for very to moderate preterm (28-33 weeks), 1.9% for late preterm (34-36 weeks), 2.1% for all preterm (<37 weeks), 1.6% for early term (37-38 weeks), and 1.4% for term (39-41 weeks). The adjusted prevalence ratios comparing extremely preterm, all preterm, or early term versus term, respectively, were 3.72 (95% confidence interval, 3.27-4.23), 1.35 (1.30-1.40), and 1.11 (1.08-1.13) among boys and 4.19 (3.45-5.09), 1.53 (1.45-1.62), and 1.16 (1.12-1.20) among girls (P < .001 for each). These associations were only slightly attenuated after controlling for shared familial factors. In this national cohort, preterm and early term birth were associated with increased risk of ASD in boys and girls. These associations were largely independent of covariates and shared familial factors, consistent with a potential causal relationship.

Autism and Preterm Birth: Clarifying Risk and Exploring Mechanisms.

In the current issue of Pediatrics, the thoughtful work of Crump et al, entitled “Preterm or Early Term Birth and Risk of Autism” has added an important contribution to our understanding of associations between autism and prematurity.1 Building on the strengths of population-based registries, the authors were able to assess 4 061 795 singleton infants born in Sweden between 1973 and 2013 using the Swedish Medical Birth Register (which contains prenatal and birth information) and link clinical diagnoses of autism spectrum disorder (ASD) from hospital, outpatient, and primary care registries. Prevalence rates of ASD were inversely proportional to gestational age: 6.1% for extremely preterm (EPT) (22–27 weeks), 2.6% for very preterm to moderate preterm (28–33 weeks), 1.9% for late preterm (LPT) (34–36 weeks), 1.6% for early term (ET) (37–38 weeks), and 1.4% term (39–41 weeks). After adjusting for covariates and stratifying by sex, prevalence ratios revealed similar trends, ranging from 3.7 to 1.11 among EPT- to ET-born male infants and 4.19 to 1.16 among EPT- to ET-born female infants. In an attempt to assess influences of genetic and/or environmental factors, cosibling analysis was performed, with only modest mitigation of risk.As allowed with large cohort studies, the robust sample size and stratification by gestational age grouping allowed for the important finding that there is increased risk for ASD across the range of prematurity. The findings by Crump et al are consistent with previous work, also from Sweden, suggesting a dose response–type relationship between degree of prematurity and ASD risk.2 The elevated risk even in LPT infants is not completely surprising because a number of investigators have shown higher incidences of early cognitive, language motor and impairment, and school problems, social-emotional problems, and psychiatric disorders, some of which may extend to adulthood.3 Indeed, it was the Helsinki Birth Cohort study in which researchers yielded results of late adulthood cognitive impairment among those born LPT.4 In their works, Raju et al have clearly pointed out that infants born even a few weeks before term are at increased risk of respiratory, gastrointestinal, immunologic, and hormonal disturbances5 and that developmental maturation is a continuous process and not always linear. Thus, careful attention should be paid to biological vulnerabilities at later gestational ages. For example, between 34 and 40 weeks, brain weight increases nearly one-third, cortical volume increases nearly 50%, and absolute myelinated white matter volume increases fivefold.6,7Emerging evidence linking behavior and alterations in brain structure, function, and connectivity furthers our understanding of biological and environmental risks. Brain regions predominantly affected by preterm birth are also involved in sensory and social interactions, including white and gray matter.8 In a cohort of very preterm–born infants, Brown et al demonstrated that associations between atypical behavior and degree of white matter injury may be evident as early as term equivalent.9 Using quantitative MRI techniques, Rogers et al reported that disruptions in regional brain circuits at term-equivalent ages in preterm infants predicted social-emotional disturbances at age 5 years.10 As Crump et al point out in their discussion, neuroinflammation, which occurs in response to stress and infection, activate microglia, which results in a cascade of neuronal injury and alterations, pointing to potential mechanisms linking preterm birth to increased risk for ASD. Indeed, there are reports of associations between elevated cytokine levels at birth and subsequent diagnoses of ASD,11,12 and there is contemporary interest in the relationship more generally between immunologic factors and ASD risk.13 It is noted that the vulnerability of the preterm brain structure and function that is exposed to the inflammatory environment of prematurity is present until term gestation.The report by Crump et al is in many ways a definitive accounting of the elevated rates of ASD in preterm infants. And although the impact of prematurity on brain development may be part of the causal chain resulting in ASD (or other neurodevelopmental outcomes), these factors are operating in a complex biological landscape, with pathways to ASD outcomes that can be expected to be heterogeneous. In previous work, researchers suggest that suboptimal obstetric outcomes and perinatal complications may, in some cases, result from underlying ASD etiologies.14 Moreover, even when assuming that prematurity is part of the causal chain leading to ASD outcomes, it will be important to investigate the interactions between the underlying genetics of ASD and the impact of prematurity. In time, increased implementation of next-generation genetic testing in ASD15 will offer opportunities to understand such pathways, and studies of premature infants may yield unique opportunities for investigating the developmental emergence of ASD.

Association between prenatal exposures to ambient air pollutants and preterm birth in the Atlanta African American Mother-Child Cohort

BACKGROUND AND AIM: Exposures to air pollution during pregnancy have been associated with preterm birth (PTB). Communities of color, especially African American (AA), are disproportionately exposed to high levels of air pollution and experience elevated occurrences of PTB, warranting investigation into the attributable risk of PTB among AA women associated with prenatal exposure to ambient air pollution. METHODS: This study was conducted in the Atlanta AA Maternal-Child cohort. We linked ambient PM2.5, NO2, and O3 concentrations at 1-km resolution to 293 participants who delivered between 2014 and 2016. We used both single- and multi-pollutant logistic models with adjustment for potential confounders (i.e., sociodemographic, socioeconomic status, behavioral risk factors, season of conception, and meteorology) to examine associations between pollutant exposures (during each trimester, entire pregnancy, and 3 years before pregnancy) and PTB ( 37 weeks) and early-term birth (37-38 weeks) vs. full term birth. RESULTS:PM2.5 concentrations (in both single- and 3-pollutant models) and NO2 (single pollutant model) during the three years before pregnancy were associated with increased odds of PTB. In the 3-pollutant model, the odd ratio (OR) for PTB was 1.66 (95% CI: 1.01-2.73) per interquartile range (IQR) increase in NO2 throughout pregnancy. Both single- and 3-pollutant models showed NO2 levels during the 1st and 2nd trimesters, and during the entire pregnancy were significantly associated with increased odds of early-term birth; corresponding ORs for per IQR increment were 1.78, 1.63, and 1.52, respectively. PM2.5 during the 3rd trimester was also associated with elevated risk for early term birth in a single pollutant model (OR 1.95, 1.08-3.50). CONCLUSIONS:Long-term exposures to PM2.5 and NO2 before and during pregnancy were associated with preterm and early-term birth in the Atlanta AA birth cohort. This study supports targeted interventions to protect pregnant women from air pollution, especially AA populations who have a higher PTB rate. KEYWORDS: Air pollution, Multi-pollutant, Birth outcome

High-resolution metabolomics of exposure to tobacco smoke during pregnancy and adverse birth outcomes in the Atlanta African American Maternal-Child cohort

BACKGROUND AND AIM: Exposure to tobacco smoke during pregnancy has been associated with a series of adverse reproductive outcomes; however, the underlying molecular mechanisms are not well-established. In this analysis, we measured urinary cotinine, a widely used biomarker of tobacco exposure, and conducted high-resolution metabolomics (HRM) to identify biological perturbations associated with prenatal tobacco smoke exposures and adverse birth outcomes. METHODS: We collected early and late pregnancy urine samples for cotinine measurement and serum samples for HRM profiling from 105 pregnant women from the Atlanta African American Maternal-Child cohort (2014-2016). Using an untargeted HRM workflow, we investigated how the biological perturbations in maternal metabolome mediate the association between prenatal smoke exposures and adverse birth outcomes (preterm birth, early term birth vs. full term birth; gestational age at birth) using a meet-in-the-middle approach. RESULTS:The median maternal urinary cotinine level was 4.77 ug/g creatinine, with 29 subjects higher than 100 ug/g creatinine. In total, 16,481 and 13,043 metabolic features were extracted from serum samples using hilic and c18 columns, respectively. Thirteen metabolic pathways were found to be associated with cotinine level and adverse birth outcomes during early and late pregnancy, including tryptophan, histidine, urea cycle, arginine, and proline metabolism. We confirmed 47 metabolites associated with cotinine exposure, preterm birth, and shorter gestational length, which include glutamate, serine, choline, and taurine; these metabolites are closely involved in endogenous inflammation, vascular reactivity, and lipid peroxidation processes. CONCLUSIONS:The metabolic perturbations associated with cotinine exposure were closely connected within a metabolic network related to inflammation, oxidative stress, placental vascularization, and insulin action, which could contribute to shorter gestations. The findings support the future development of targeted interventions to reduce adverse birth outcomes associated with tobacco smoke exposure, especially among African American who are disproportionately exposed to high tobacco smoke and experience higher rates of adverse birth outcomes. KEYWORDS: Tobacco Smoke Exposures, Metabolomics, Birth Outcomes, Preterm Birth

The Timing of Planned Delivery: Is It Time to Make the Case for 41 Weeks?

The Timing of Planned Delivery: Is It Time to Make the Case for 41 Weeks?

The association of COVID-19 infection in pregnancy with preterm birth: A retrospective cohort study in California

Introduction: Our understanding of the association between coronavirus disease 19 (COVID-19) and preterm or early term birth among racially and ethnically diverse populations and people with chronic medical conditions is limited.Methods: We determined the association between COVID-19 and preterm (PTB) birth among live births documented by California Vital Statistics birth certificates between July 2020 and January 2021 (n=240,147). We used best obstetric estimate of gestational age to classify births as very preterm (VPTB, <32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks), as each confer independent risks to infant health and development. Separately, we calculated the joint effects of COVID-19 diagnosis, hypertension, diabetes, and obesity on PTB and VPTB.Findings: COVID-19 diagnoses on birth certificates increased for all racial/ethnic groups between July 2020 and January 2021 and were highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). There was no effect modification of the overall association by race/ethnicity or insurance status. COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity.Interpretation: In a large population-based study, COVID-19 diagnosis increased the risk of VPTB, PTB, and early term birth, particularly among people with medical comorbidities. Considering increased circulation of COVID-19 variants, preventative measures, including vaccination, should be prioritized for birthing persons.Funding: UCSF-Kaiser Department of Research Building Interdisciplinary Research Careers in Women's Health Program (BIRCWH) National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH) [K12 HD052163] and the California Preterm Birth Initiative, funded by Marc and Lynn Benioff.

Medically Indicated Late-Preterm and Early-Term Deliveries

ABSTRACT: The neonatal risks of late-preterm and early-term births are well established, and the potential neonatal complications associated with elective delivery at less than 39 0/7 weeks of gestation are well described. However, there are a number of maternal, fetal, and placental complications in which either a late-preterm or early-term delivery is warranted. The timing of delivery in such cases must balance the maternal and newborn risks of late-preterm and early-term delivery with the risks associated with further continuation of pregnancy. Deferring delivery to the 39th week is not recommended if there is a medical or obstetric indication for earlier delivery. If there is a clear indication for a late-preterm or early-term delivery for either maternal or newborn benefit, then delivery should occur regardless of the results of lung maturity testing. Conversely, if delivery could be delayed safely in the context of an immature lung profile result, then no clear indication for a late-preterm or early-term delivery exists. Also, there remain several conditions for which data to guide delivery timing are not available. Some examples of these conditions include uterine dehiscence or chronic placental abruption. Delivery timing in these circumstances should be individualized and based on the current clinical situation.

Temporal association of maternal weight gain with early-term and preterm birth and low birth weight babies.

Low birth weight and preterm or early-term babies may have a higher risk of poor health. One of the main factors is the weight gain of a pregnant woman during gestational weeks in the second and third trimesters. Changes in weight over a month in a pregnant woman might also have an impact on infant outcomes. This study aimed to investigate the association between maternal weight at different time points and low birth weight and preterm or early-term babies (premature babies). A total of 156 pregnant women were recruited. Maternal weight was collected at different gestational weeks. Maternal age, body mass index, delivery mode, delivery week, and infant weight were also recorded. Maternal data were restructured into a person-period format before mixed-effects multiple logistic regression was used. Various weight variables with either a fixed effect or time-varying effects were tested in the model. Thirty (19.23%) women had delivered low birth weight or premature babies. Multiple logistic regression model demonstrated that mothers with higher increases in weight at 32 weeks of gestation than that in the predelivery stage had a lower probability of having a low birth weight or premature baby (odds ratio [OR] = 0.64; 95% CI, 0.49-0.85; p < 0.001). Women with a weight increase of more than 2 kg in a 4-week gestation period had a higher probability of having a low birth weight or premature baby than those with an increment of <1 kg (OR = 8.43; 95% CI, 2.90-24.54; p < 0.001). An increase in weight gain after 32 weeks was shown to reduce the risk of low birth weight and premature babies. Maternal weight monitoring was suggested to be conducted every 4 weeks to minimize the chance of having a low birth weight and premature baby.

Association between early-term birth and delayed neurodevelopment at the age of 2 years: results from a cohort study in China

A growing body of evidence indicates that early-term births (37-38 weeks of gestational age) have an increased risk of short-term and long-term complications. Here, we sought to explore the association between early-term births and the risk of delayed neurodevelopment at age 2 years. Pregnant women and their live singleton birth were recruited from a single tertiary hospital between October 2013 and February 2017. Mental and Psychomotor Development Indexes (MDI and PDI) were assessed using the Bayley Scales of Infant Development (BSID). Delayed neurodevelopment was defined as scores of PDI or MDI less than -1SD relative to the mean score of the study population. In total, 1678 full-term infants and 727 early-term infants were assessed when they were 2 years old. After adjustment for potential confounders, early-term birth was related to 43% increased odds of neurodevelopmental delay in the PDI domain as compared with full-term birth (OR: 1.43; 95% CI: 1.12, 1.82). The observed associations were more prominent among those infants born by cesarean (OR: 1.44; 95% CI: 1.03, 2.00) and among males (OR: 1.66; 95% CI: 1.20, 2.28). No statistical difference in the MDI domain was found between early-term and full-term births.Conclusions: Our findings suggest that early-term birth was associated with increased odds of delayed neurodevelopment in the PDI domain as measured by BSID assessments at age 2 years. Health professionals should be aware of the influence of early-term birth on the risk of delayed neurodevelopment. What is Known: • Evidence indicates that early-term births have an increased risk of short-term and long-term complications. • The association between early-term births and delayed neurodevelopment at their early childhood has not been widely studied. What is New: • Early-term birth was associated with increased odds of delayed neurodevelopment in PDI domain as measured by BSID assessments at age 2 years. • The observed associations were more prominent among infants born by cesarean section and among male infants.

Incidence, Risk Factors, and Outcomes of Preterm and Early Term Births: A Population-Based Register Study.

Preterm birth (PTB) and early term birth (ETB) are associated with high risks of perinatal mortality and morbidity. While extreme to very PTBs have been extensively studied, studies on infants born at later stages of pregnancy, particularly late PTBs and ETBs, are lacking. In this study, we aimed to assess the incidence, risk factors, and feto-maternal outcomes of PTB and ETB births in Qatar. We examined 15,865 singleton live births using 12-month retrospective registry data from the PEARL-Peristat Study. PTB and ETB incidence rates were 8.8% and 33.7%, respectively. PTB and ETB in-hospital mortality rates were 16.9% and 0.2%, respectively. Advanced maternal age, pre-gestational diabetes mellitus (PGDM), assisted pregnancies, and preterm history independently predicted both PTB and ETB, whereas chromosomal and congenital abnormalities were found to be independent predictors of PTB but not ETB. All groups of PTB and ETB were significantly associated with low birth weight (LBW), large for gestational age (LGA) births, caesarean delivery, and neonatal intensive care unit (NICU)/or death of neonate in labor room (LR)/operation theatre (OT). On the other hand, all or some groups of PTB were significantly associated with small for gestational age (SGA) births, Apgar < 7 at 1 and 5 min and in-hospital mortality. The findings of this study may serve as a basis for taking better clinical decisions with accurate assessment of risk factors, complications, and predictions of PTB and ETB.

Maternal depressive symptoms, sleep, and odds of spontaneous early birth: implications for racial inequities in birth outcomes.

Delivery prior to full term affects 37% of US births, including ~400,000 preterm births (<37 weeks) and >1,000,000 early term births (37-38 weeks). Approximately 70% of cases of shortened gestation are spontaneous-without medically-indicated cause. Elucidation of modifiable behavioral factors would have considerable clinical impact. This study examined the role of depressive symptoms and sleep quality in predicting the odds of spontaneous shortened gestation among 317 women (135 black, 182 white) who completed psychosocial assessment in mid-pregnancy. Adjusting for key covariates, black women had 1.89 times higher odds of spontaneous shortened gestation compared to White women (OR [95% CI] = 1.89 [1.01, 3.53], p = 0.046). Women who reported only poor subjective sleep quality (PSQI > 6) or only elevated depressive symptoms (CES-D ≥ 16) exhibited no statistically significant differences in odds of spontaneous shortened gestation compared to those with neither risk factor. However, women with comorbid poor sleep and depressive symptoms exhibited markedly higher odds of spontaneous shortened gestation than those with neither risk factor (39.2% versus 15.7% [OR (95% CI) = 2.69 (1.27, 5.70)], p = 0.01). A higher proportion of black women met criteria for both risk factors (23% of black women versus 11% of white women; p = 0.004), with a lower proportion experiencing neither risk factor (40.7% of black versus 64.3% of white women; p < 0.001). Additive effects of poor subjective sleep quality and depressive symptoms were observed with markedly higher odds of spontaneous shortened gestation among women with both risk factors. Racial inequities in rates of comorbid exposure corresponded with inequities in shortened gestation. Future empirical studies and intervention efforts should consider the interactive effects of these commonly co-morbid exposures.

Communication Intervention Using Digital Technology to Facilitate Informed Choices at Childbirth in the Context of the COVID-19 Pandemic: Protocol for a Randomized Controlled Trial.

BackgroundIn Brazil and other low- and middle-income countries, excess interventions in childbirth are associated with an increase in preterm and early-term births, contributing to stagnant morbidity and mortality of mothers and neonates. The fact that women often report a negative experience with vaginal childbirth, with physical pain and feelings of unsafety, neglect, or abuse, may explain the high acceptability of elective cesarean sections. The recognition of information needs and of the right to informed choice during childbirth can help change this reality. The internet has been the main source of health information, but its quality is highly variable.ObjectiveThis study aimed to develop and evaluate an information and communication strategy through a smartphone app with respect to childbirth, to facilitate informed choices for access to safer and evidence-based care in the context of the COVID-19 pandemic.MethodsA randomized controlled trial, with 2 arms (intervention and control) and a closed, blind, parallel design, will be conducted with a smartphone app designed for behavior and opinion research in Brazil, with women of reproductive age previously registered on the app. After completing an entry questionnaire to verify the eligibility criteria and obtaining ethical consent, approximately 20,000 participants will be randomly allocated to the intervention and control groups at a 1:1 ratio. Participants allocated to the intervention group will be invited to engage in a digital information and communication strategy, which is designed to expand evidence-based knowledge on the advantages and disadvantages of options for labor and childbirth and the safety of the care processes. The information is based on the guidelines of the Ministry of Health and the World Health Organization for a positive childbirth experience and has been updated to include the new challenges and disruptions in maternity care within the context of the COVID-19 pandemic. The control group will receive information regarding disposable and reusable diapers as a placebo intervention. The groups will be compared in their responses in generating the birth plan and the entry and exit questionnaires, regarding responses less or more aligned with the guidelines for a positive childbirth experience. A qualitative component to map information needs is included.ResultsThe digital trial started recruiting participants in late October 2020, and data collection has been projected to be complete by December 2020.ConclusionsThis study will evaluate an innovative intervention that has the potential to promote better communication between women and providers, such that they can make better choices using an approach suitable for use during the COVID-19 pandemic.Trial RegistrationThe Brazilian Clinical Trials Registry U1111-1255-8683; http://www.ensaiosclinicos.gov.br/rg/RBR-3g5f9f/International Registered Report Identifier (IRRID)PRR1-10.2196/25016

Cost-effectiveness analysis of a quality improvement program to reduce caesarean sections in Brazilian private hospitals: a case study

BackgroundIn 2015, a quality improvement project of childbirth care called Adequate Childbirth Project (“Projeto Parto Adequado”- PPA) was implemented in Brazilian public and private hospitals, aiming to improve the quality of childbirth care and to reduce caesarean sections without clinical indications. The objective of this study is to conduct an economic analysis of two models of care existing in a private Brazilian hospital—the model following the recommendations of the PPA and the standard of care model—in reducing the proportion of caesarean sections.MethodsWe conducted a cost-effectiveness analysis using data from one of the private hospitals included in the PPA project. The main outcome was the proportion of caesarean section. We used total cost of hospitalization for women and newborns, from the health care sector perspective, during the length of the observed hospital stay. We did not apply discount rates and inflation rate adjustments due to the short time horizon. We conducted univariate sensitivity analysis using the minimum and maximum costs observed in hospitalizations and variation in the probabilities of caesarean section and of maternal and neonatal complications.Results238 puerperal women were included in this analysis. The PPA model of care resulted in a 56.9 percentage point reduction in the caesarean section probability (88.6% vs 31.7%, p < 0.001) with an incremental cost-effectiveness ratio of US$1,237.40 per avoided caesarean section. Women in the PPA model of care also had a higher proportion of spontaneous and induced labor and a lower proportion of early term births. There were no maternal, fetal or neonatal deaths and no significant differences in cases of maternal and neonatal near miss. The cost of uncomplicated vaginal births and caesarean sections was the parameter with the greatest impact on the cost-effectiveness ratio of the PPA model of care.ConclusionThe PPA model of care was cost-effective in reducing caesarean sections in women assisted in a Brazilian private hospital. Moreover, it reduced the frequency of early term births and did not increase the occurrence of severe negative maternal and neonatal outcomes.

Vaginal Microbiome Composition in Early Pregnancy and Risk of Spontaneous Preterm and Early Term Birth Among African American Women.

ObjectiveTo evaluate the association between the early pregnancy vaginal microbiome and spontaneous preterm birth (sPTB) and early term birth (sETB) among African American women.MethodsVaginal samples collected in early pregnancy (8-14 weeks’ gestation) from 436 women enrolled in the Emory University African American Vaginal, Oral, and Gut Microbiome in Pregnancy Study underwent 16S rRNA gene sequencing of the V3-V4 region, taxonomic classification, and community state type (CST) assignment. We compared vaginal CST and abundance of taxa for women whose pregnancy ended in sPTB (N = 44) or sETB (N= 84) to those who delivered full term (N = 231).ResultsNearly half of the women had a vaginal microbiome classified as CST IV (Diverse CST), while one-third had CST III (L. iners dominated) and just 16% had CST I, II, or V (non-iners Lactobacillus dominated). Compared to vaginal CST I, II, or V (non-iners Lactobacillus dominated), both CST III (L. iners dominated) and CST IV (Diverse) were associated with sPTB with an adjusted odds ratio (95% confidence interval) of 4.1 (1.1, infinity) and 7.7 (2.2, infinity), respectively, in multivariate logistic regression. In contrast, no vaginal CST was associated with sETB. The linear decomposition model (LDM) based on amplicon sequence variant (ASV) relative abundance found a significant overall effect of the vaginal microbiome on sPTB (p=0.034) but not sETB (p=0.320), whereas the LDM based on presence/absence of ASV found no overall effect on sPTB (p=0.328) but a significant effect on sETB (p=0.030). In testing for ASV-specific effects, the LDM found that no ASV was significantly associated with sPTB considering either relative abundance or presence/absence data after controlling for multiple comparisons (FDR 10%), although in marginal analysis the relative abundance of Gardnerella vaginalis (p=0.011), non-iners Lactobacillus (p=0.016), and Mobiluncus curtisii (p=0.035) and the presence of Atopobium vaginae (p=0.049), BVAB2 (p=0.024), Dialister microaerophilis (p=0.011), and Prevotella amnii (p=0.044) were associated with sPTB. The LDM identified the higher abundance of 7 ASVs and the presence of 13 ASVs, all commonly residents of the gut, as associated with sETB at FDR < 10%.ConclusionsIn this cohort of African American women, an early pregnancy vaginal CST III or IV was associated with an increased risk of sPTB but not sETB. The relative abundance and presence of distinct taxa within the early pregnancy vaginal microbiome was associated with either sPTB or sETB.

Early term birth is associated with the risk of preterm and recurrent early term birth in women with 3 consecutive deliveries

BackgroundWe assessed the association of early term at first birth (ETB) with the risk of preterm birth (PTB) and ETB in women with 3 consecutive deliveries. MethodsWe conducted a retrospective cohort study of all women with 3 consecutive singleton births at a single institute from 1994 to 2013. The risk of PTB (<37 weeks), spontaneous PTB and ETB (37−38 weeks) in the 3rd delivery was explored. ResultsOf 49,259 women delivered in our center during the study period, 4038 met inclusion criteria. The rate for subsequent PTB, spontaneous PTB and recurrent ETB in the 3rd delivery significantly increased as the number of prior ETBs increased. The order of a single prior ETB in one of the first two deliveries was differently associated with the risk of complications in the 3rd delivery, which was higher when the prior ETB was more recent to the third delivery. ConclusionA history of ETB is associated with the risk of future PTB and recurrent ETB. The risk is related to the number and order of prior ETBs.