Prenatal Care Utilization Research Articles

Posttraumatic stress and prenatal care adequacy among Black/African American women

Black/African American women with trauma histories experience a disproportionate burden of adverse perinatal outcomes. One mechanism for this association is inadequate prenatal care, as avoidant symptoms are a hallmark of posttraumatic stress disorder (PTSD). The objective of this study is to examine the association between PTSD symptoms and adequacy of prenatal care among Black/African American women. This retrospective cohort study included all pregnant women who self-identified as Black/African American and were referred to a hospital’s integrated mental health program between 2017-2021. All participants completed a PTSD Checklist -Civilian Version (PCL-C) as a part of an initial mental health evaluation. The EHR was reviewed to codify adequacy of prenatal care, which was assessed in three ways: late initiation of prenatal care (defined as gestational age at the first prenatal visit > 12 weeks), the ratio of no-show to attended prenatal visits, and the Adequacy of Prenatal Care Utilization (APNCU) Index. Bivariable analyses were performed. A propensity score for a positive PTSD screen was generated using confounders generated from a directed acyclic graph. This propensity score was included in multivariable models to control for imbalance across the exposure. Of the 111 women who met inclusion criteria, 57 (51%) screened positive on the PCL-C. Sample characteristics, stratified by a positive screen, are shown in Table 1. PCL-C score was associated with late initiation of prenatal care, the ratio of no-show to attended prenatal visits, and non-adequate prenatal care defined by the APNCU index (Table 2). The associations between late initiation of care and non-adequate APNCU index persisted in multivariable analyses. In this sample of pregnant Black/African American women with an identified mental health condition, PTSD symptoms were associated with inadequate prenatal care. The high prevalence of PTSD symptoms and the association with prenatal care emphasizes the importance of future research focused on trauma-related interventions for Black/African-American women.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Pregnancy and posttraumatic stress disorder: associations with infant outcomes and prenatal care utilization

Background Posttraumatic stress disorder (PTSD) affects 3.6–9.7% of women, and has been associated with adverse outcomes in pregnancy; however, associations with prenatal care (PNC) utilization are not clear. Objective To evaluate associations of PTSD in pregnancy with PNC utilization and adverse infant outcomes in an active-duty military population (a population with universal health insurance). Methods This was a retrospective cohort study of pregnant active-duty service members in Department of Defense Birth and Infant Health Research program data from 2007 to 2014. Administrative medical encounter data were used to define PTSD cases and outcomes of interest. Descriptive statistics and multivariable log-binomial regression compared PNC utilization and adverse infant outcomes (preterm birth, small for gestational age [SGA], major birth defects) among service members with current PTSD (defined as PTSD in the year prior to pregnancy or during pregnancy) to those without current PTSD. Results Of the 103,221 singleton live births identified, 1657 (1.6%) were born to active-duty service members diagnosed with current PTSD. Service members with PTSD were more likely to initiate PNC in the first trimester (93.5% vs. 90.2%) and score adequate plus on the Adequacy of Prenatal Care Utilization Index (63.2% vs. 40.0%) compared to service members without PTSD. PTSD case status was not associated with preterm birth, SGA, or major birth defects, regardless of the adjustment set used (fully adjusted RR 0.96, 95% CI 0.82–1.13; RR 1.08, 95% CI 0.79–1.48; and RR 1.03, 95% CI 0.79–1.34, respectively). Conclusion For pregnant service members with current PTSD, no associations with adverse infant outcomes were noted, and these patients initiated care earlier and had higher PNC utilization scores compared to pregnant service members without current PTSD. Universal health care coverage and utilization of PNC in this population may mitigate adverse pregnancy outcomes observed in civilian populations of patients with PTSD.

Group Prenatal Care and Emergency Room Utilization.

Pregnancy-related complaints are a significant driver of emergency room (ER) utilization among women. Because of additional time for patient education and provider relationships, group prenatal care may reduce ER visits among pregnant women by helping them identify appropriate care settings, improving understanding of common pregnancy discomforts, and reducing risky health behaviors. We conducted a retrospective cohort study, utilizing Medicaid claims and birth certificate data from a statewide expansion of group care, to compare ER utilization between pregnant women participating in group prenatal care and individual prenatal care. Using propensity score matching methods, we found that group care was associated with a significant reduction in the likelihood of having any ER utilization (-5.9% among women receiving any group care and -6.0% among women attending at least five group care sessions). These findings suggest that group care may reduce ER utilization among pregnant women and encourage appropriate health care utilization during pregnancy.

Utilization of Maternal Health Care Among Immigrant Mothers in New York City, 2016\u20132018

Immigrant women represent half of New York City (NYC) births, and some immigrant groups have elevated risk for poor maternal health outcomes. Disparities in health care utilization across the maternity care spectrum may contribute to differential maternal health outcomes. Data on immigrant maternal health utilization are under-explored in the literature. We conducted a cross-sectional analysis of the population-based NYC Pregnancy Risk Assessment Monitoring System survey, using 2016–2018 data linked to birth certificate variables, to explore self-reported utilization of preconception, prenatal, and postpartum health care and potential explanatory pathways. We stratified results by maternal nativity and, for immigrants, by years living in the US; geographic region of origin; and country of origin income grouping. Among immigrant women, 43% did not visit a health care provider in the year before pregnancy, compared to 27% of US-born women (risk difference [RD] = 0.16, 95% CI [0.13, 0.20]), 64% had no dental cleaning during pregnancy compared to 49% of US-born women (RD = 0.15, 95% CI [0.11, 0.18]), and 11% lost health insurance postpartum compared to 1% of US-born women (RD = 0.10, 95% CI [0.08, 0.11]). The largest disparities were among recent arrivals to the US and immigrants from countries in Central America, South America, South Asia, and sub-Saharan Africa. Utilization differences were partially explained by insurance type, paternal nativity, maternal education, and race and ethnicity. Disparities may be reduced by collaborating with community-based organizations in immigrant communities on strategies to improve utilization and by expanding health care access and eligibility for public health insurance coverage before and after pregnancy.

Pre-conception and prenatal factors influencing gestational weight gain: a prospective study in Tigray\xa0region, northern Ethiopia

BackgroundIn low-income countries, the high prevalence of pre-pregnancy undernutrition remains a challenge for the future health of women and their offspring. On top of good nutrition, adequate gestational weight gain has been recognized as an essential prerequisite for optimal maternal and child health outcomes. However, good-quality data on factors influencing gestational weight gain is lacking. Therefore, this study was aimed to prospectively identify pre-conception and prenatal factors influencing gestational weight gain in Ethiopia.MethodsA population based prospective study was undertaken between February 2018 and January 2019 in the Tigray region, northern Ethiopia. Firstly, the weight of non-pregnant women of reproductive age living in the study area was measured between August and October 2017. Subsequently, eligible pregnant women identified during the study period were included consecutively and followed until birth. Data were collected through an interviewer-administered questionnaire and anthropometric measurements complemented with secondary data. Gestational weight gain, i.e., the difference between 32 to 36 weeks of gestation and pre-pregnancy weights, was classified as per the Institute of Medicine (IOM) guideline. Linear, spline, and logistic regression models were used to estimate the influence of pre-conception and prenatal factors on gestational weight gain.ResultsThe mean gestational weight gain (standard deviation[SD]) was 10.6 (2.3) kg. Overall, 64.0% (95% CI 60.9, 67.1) of the women did not achieve adequate weight gain. Factors associated with higher gestational weight gain were higher women empowerment (B 0.60, 95% CI 0.06, 1.14), dietary diversity (B 0.39, 95% CI 0.03, 0.76), pre-pregnancy body mass index (B 0.13, 95% CI 0.05, 0.22), and haemoglobin (B 0.54, 95% CI 0.45, 0.64). Additionally, adequate prenatal care (B 0.58, 95% CI 0.28, 0.88) was associated with higher gestational weight gain.ConclusionsAdequate gestational weight gain was not achieved by most women in the study area, primarily not by those who were underweight before pregnancy. Interventions that advance women’s empowerment, dietary quality, pre-pregnancy nutritional status, and prenatal care utilization may improve gestational weight gain and contribute to optimizing maternal and child health outcomes.

The Impact of a Population-Based System of Care Intervention on Enhanced Prenatal Care and Service Utilization Among Medicaid-Insured Pregnant Women

Enhanced prenatal/postnatal care home visiting programs for Medicaid-insured women have significant positive impacts on care and health outcomes. However, enhanced prenatal care participation rates are typically low, enrolling <30% of eligible women. This study investigates the impacts of a population-based systems approach on timely enhanced prenatal care participation and other healthcare utilization. This quasi-experimental, population-based, difference-in-differences study used linked birth certificates, Medicaid claims, and enhanced prenatal care data from complete statewide Medicaid birth cohorts (2009 to 2015), and was analyzed in 2019-2020. The population-based system intervention included cross-agency leadership and work groups, delivery system redesign with clinical-community linkages, increased enhanced prenatal care-Community Health Worker care, and patient empowerment. Outcomes included enhanced prenatal care participation and early participation, prenatal care adequacy, emergency department contact, and postpartum care. Enhanced prenatal care (7.4 percentage points, 95% CI=6.3, 8.5) and first trimester enhanced prenatal care (12.4 percentage points, 95% CI=10.2, 14.5) increased among women served by practices with established clincial-community linkages, relative to that among the comparator group. First trimester enhanced prenatal care improved in the county (17.9, 95% CI=15.7, 20.0), emergency department contact decreased in the practices (-11.1, 95% CI= -12.3, -9.9), and postpartum care improved in the county (7.1, 95% CI=6.0, 8.2). Enhanced prenatal care participation for Black women served by the practices improved (4.4, 95% CI=2.2, 6.6) as well as early enhanced prenatal care (12.3, 95% CI=9.0, 15.6) and use of postpartum care (10.4, 95% CI=8.3, 12.4). A population systems approach improved selected enhanced prenatal care participation and service utilization for Medicaid-insured women in a county population, those in practices with established clinical-community linkages, and Black women.

Demographic and Clinical Predictors of Postpartum Blood Pressure Screening Attendance.

Background: Hypertensive disorders of pregnancy (HDP) cause substantial preventable maternal morbidity and mortality. Postpartum hypertension that worsens after women are discharged is particularly dangerous, as it can go undiagnosed and cause complications. The American College of Obstetricians and Gynecologists recommends women with HDP undergo blood pressure (BP) screening 7-10 days after delivery to detect postpartum hypertension. This study aimed to describe predictors of postpartum BP screening attendance among a high-risk safety-net population in Atlanta, Georgia. Materials and Methods: We conducted a population-based cohort study of pregnant women who delivered at a large public hospital in Atlanta between July 1, 2016, and June 30, 2018. We manually abstracted demographic and clinical data from electronic medical records and used multivariable log binomial regression to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (95% CIs) for associations with BP screening attendance. Results: Of 1260 women diagnosed with HDP, 13.7% attended a BP screening visit within 10 days of delivery. Women with preeclampsia with severe features were more likely to attend a BP visit than women with gestational hypertension (aRR 2.10, 95% CI 1.35-3.27). Rates of BP screening attendance were lower for women with inadequate (aRR 0.42, 95% CI 0.26-0.67) and intermediate (aRR 0.40, 95% CI 0.21-0.74) prenatal care utilization relative to women with adequate utilization. Conclusions: Among a high-risk safety-net population with HDP, most women did not attend a BP screening visit within 10 days of delivery. Addressing this gap requires further research and creative solutions to address barriers at the individual, provider, and system levels.

Prenatal Care Adequacy Among Women With Disabilities: A Population-Based Study

This study examines prenatal care adequacy among women with physical, sensory, and intellectual/developmental disabilities, compared with that among women without disabilities. A population-based cohort study using linked health administrative data in Ontario, Canada was completed. The study population comprised women with physical (n=83,752), sensory (n=25,685), intellectual/developmental (n=1,219), and multiple (n=4,966) disabilities and women without disabilities (n=953,766), with a birth in 2003-2017. Analyses were conducted in 2020. Women with disabilities were identified using algorithms applied to healthcare encounters before conception. The main outcome was prenatal care adequacy, measured using the Revised Graduated Prenatal Care Utilization Index. Multivariable nominal logistic regression was used to compute the AORs and 95% CIs for no, inadequate, and intensive (versus adequate) care comparing each disability group with women without disabilities, adjusting for sociodemographic and health characteristics. Women with physical disabilities, compared with those without disabilities, had increased odds of intensive prenatal care (AOR=1.22, 95% CI=1.19, 1.24) and decreased odds of no prenatal care (AOR=0.94, 95% CI=0.89, 0.99) versus adequate care. Women with sensory disabilities had increased odds of intensive (AOR=1.11, 95% CI=1.08, 1.14), inadequate (AOR=1.06, 95% CI=1.02, 1.09), and no (AOR=1.24, 95% CI=1.14, 1.35) prenatal care. Women with intellectual/developmental disabilities had increased odds of inadequate (AOR=1.25, 95% CI=1.08, 1.44) and no (AOR=1.64, 95% CI=1.16, 2.34) prenatal care. Women with multiple disabilities had increased odds of intensive (AOR=1.41, 95% CI=1.32, 1.51) and inadequate (AOR=1.14, 95% CI=1.05, 1.22) prenatal care. There are variations in prenatal care adequacy by maternal disability status. Disparities in prenatal care access for women with disabilities, particularly those with intellectual/developmental disabilities, need to be addressed.

Trend in the utilization of antenatal care during pregnancy among the adolescents in Bangladesh: Evidence from national survey data 2012/2013 and 2019

AbstractIntroductionPregnancy during adolescence is a global health problem and the leading cause of maternal mortality. This study was aimed to explore the trends of the utilization of prenatal care or antenatal care (ANC) services during 2012/2013 and 2019, and to identify the factors associated with the use of ANC among adolescents in Bangladesh.MethodsThis study was based on the secondary data set of two consecutive surveys of Bangladesh Multiple Indicator Cluster Survey (MICS) 2012/2013 and 2019.ResultsThe prevalence of utilizing ANC among Bangladeshi adolescents is in increasing trend; however, as per WHO recommendation, the prevalence of utilizing 4+ ANC visits was very low in 2019 (34.1%), which was 26.2% in 2012/2013. Educational status of the adolescents, area of residence, household wealth status, administrative division, and status of watching television were independent predictors of receiving 4+ ANC visits among the pregnant adolescent girls in Bangladesh.ConclusionsThe status of ANC among Bangladeshi adolescents is still very low. Awareness building programs among adolescents and their family members through health education interventions should be taken.

Maternal Exposure to Emission of Using New Furniture during Pregnancy and Preterm Birth

To evaluate the association between maternal exposure to emission of using new furniture during Pregnancy and Preterm Birth (PTB). To further assess potential modification effects on this association from maternal prenatal care utilization, working on irregular shifts periconceptionally and multivitamin intake during pregnancy.

Trends, regional inequalities and determinants in the utilization of prenatal care and skilled birth attendant in Ethiopia: A multilevel analysis

BackgroundEthiopia has made a substantial reduction in maternal mortality over the last two decades. However, maternal health care utilization among 15–49 aged women remains low despite this progress. The study aimed to examine trends, regional inequalities, and potential determinants associated with prenatal care utilization and a skilled birth attendant from 2000 to 2016 in Ethiopia. MethodsNationally representative data extracted from the 2000 to 2016 Ethiopia Demographic and Health Surveys (EDHS), conducted every five years among 15–49 age women in Ethiopia. We used multilevel logistic analysis incorporating the demographic, socioeconomic, and health variables that are independently associated with prenatal care (PNC) and skilled birth attendant (SBA) use. ResultsThe prevalence of prenatal care utilization was relatively stagnant between 2000 and 2011 but showed an overall increase nationwide from 26.7% to 62.4% between 2000 and 2016 (p-value < 0.001). The prevalence of skilled birth assistance increased only by 16.5% in the past fifteen years, from 5.6% in 2000 to 22.1% in 2016. Rural type of residence, lower maternal education, lower household wealth index, lower partner's education, an immense distance of getting medical help were steadily significantly associated with prenatal health care use and skilled birth attendants. Further, male household heads, younger age women, and no covered health insurance were associated with lower odds of skilled birth attendant use. ConclusionsThough overall prenatal care and skilled birth attendant use prevalence have improved nationally, the regional disparity is uneven. Therefore, to sustain the progress equals more attention is needed for Afar, Somali, and Oromia regions to increase maternal health care services utilization in Ethiopia.

Evaluation of a telemedicine program managing high-risk pregnant women with pre-existing diabetes in Arkansas's Medicaid program

ObjectiveWe aim to evaluate the effects of the telemedicine program, High-Risk Pregnancy Program at University of Arkansas for Medical Sciences (UAMS), on health services utilization and medical expenditures among pregnant women with pre-existing diabetes and their newborns. Research design and methodsThe study sample was selected from the Arkansas Medicaid claims linked to infant birth/death certificates and UAMS telemedicine records from 2013 through 2016. We used propensity score matching based on participants’ characteristics to create three groups - UAMS telemedicine care, UAMS in-person care, and non-UAMS prenatal care. We compared inpatient and outpatient care services, medication use and caesarean section rates, severe maternal morbidity, infant mortality and preterm birth rates and medical expenditures. ResultsThe UAMS telemedicine group had fewer inpatient admissions (1.18 vs 1.31; 95% CI: -0.27, 0.00), lower insulin use rates (41.86% vs 59.88%; 95% CI: -29.00%, -7.05%) and lower maternal care expenditures ($7,846 vs $10,644; 95% CI: -$4,089, -$1,507) compared with the UAMS in-person care group. Women receiving UAMS telemedicine had more prenatal care visits (10.45 vs 8.57; 95% CI: -2.96, -0.81), higher insulin use rates (41.86% vs 26.74%: 95% CI: 4.63%, 25.60%) and similar maternal care expenditures ($7,846 vs $7,051), compared with those receiving non-UAMS in-person care. Caesarean section, severe maternal morbidity, and infant mortality rates were similar across the three groups. ConclusionUAMS telemedicine was associated with improved utilization of prenatal care among pregnant women with pre-existing diabetes. Telemedicine services did not differ from usual in-person services in clinical outcomes and medical expenditures.

A qualitative assessment of structural barriers to prenatal care and congenital syphilis prevention in Kern County, California.

Congenital syphilis is the result of placental transmission from mother to fetus of Treponema pallidum. Although congenital syphilis is preventable through timely treatment, the rate of new infections in the United States (US) has increased each year since 2013, and is increasing at a noticeably greater pace in California (CA). Most research into congenital syphilis has focused on individual psychosocial and behavioral factors that contribute to maternal vulnerability for syphilis. The aim of this study was to evaluate structural barriers to prenatal care access and utilization and congenital syphilis prevention in Kern County, CA. Transcripts from 8 in-depth interviews with prenatal care providers and 5 focus group discussions with 42 pregnant and postpartum persons were examined using thematic analysis. Structural barriers experienced by pregnant and postpartum persons to prenatal care access and utilization included (1) burdens of poverty; (2) stigma around substance use in pregnancy; (3) citizenship status; (4) lack of healthcare coverage; (5) low sexual health literacy; and (6) gender inequality Structural barriers experienced by prenatal care providers in congenital syphilis prevention included (1) limited guidance on clinical management of syphilis in pregnancy; (2) decay in public health infrastructure; and (3) inadequate support for managing patients’ social comorbidities. The response to congenital syphilis prevention will require an examination of the complex context of social determinants of health in which persons diagnosed with syphilis live in.

Association between Prenatal Care Adequacy Indexes and Low Birth Weight Outcome.

To investigate the association between prenatal care (PNC) adequacy indexes and the low birth weigth (LBW) outcome. A total of 368,093 live term singleton births in the state of Rio de Janeiro (Brazil) from 2015 to 2016 were investigated using data from the Brazilian Live Birth Information System (Sistema de Informações sobre Nascidos Vivos, SINASC, in Portuguese). Seven PNC adequacy indexes were evaluated: four developed by Brazilian authors (Ciari Jr. et al., Coutinho et al., Takeda, and an index developed and used by the Brazilian Ministry of Health - MS) and three by authors from other countries (Kessner et al., the Adequacy of Prenatal Care Utilization index - APNCU, and the Graduated Prenatal Care Utilization Index - GINDEX). Adjusted odds ratios were estimated for the PNC adequacy indexes by means of multivariate logistic regression models using maternal, gestational and newborn characteristics as covariates. When the PNC is classified as "inadequate", the adjusted odds ratios to the LBW outcome increase between 42% and 132%, depending on which adequacy index is evaluated. Younger (15 to 17 years old) and older (35 to 45 years old) mothers, those not married, of black or brown ethnicity, with low schooling (who did not finish Elementary School), primiparous, with preterm births, as well as female newborns had increasing odds for LBW. The models presented areas under the receiver operating characteristic (ROC) curve between 80.4% and 81.0%, and sensitivity and specificity that varied, respectively, between 57.7% and 58.6% and 94.3% and 94.5%. Considering all PNC adequacy indexes evaluated, the APNCU had the best discriminatory power and the best ability to predict the LBW outcome.

Adequacy of prenatal care and stillbirth.

There is limited literature on adequacy of prenatal care during pregnancy especially in case of stillbirth. This retrospective study consisted of 103 patients with stillbirths and 197 patients with live births. The Adequacy of Prenatal Care Utilization Index (APNCU) was used to determine prenatal care adequacy (Canadian Task Force Classification II-2). Among high-risk patients, the APNCU categories of inadequate (OR=3.81, 95% CI: 1.16-12.57, P<0.05) and adequate plus (OR=2.58, 95% CI: 1.23-5.38, P<0.05) were each significantly associated with greater odds for stillbirth. Diabetes, multifetal gestations, and fetal anomalies were each significantly associated with increased odds for stillbirth. Our findings emphasize the importance of clinicians in the role of providing appropriate prenatal care in the prevention of stillbirth. Clinicians also should realize that even with the best care approach of adequate plus prenatal care, certain high-risk patients will still be at risk for stillbirth.

Substance Use and Utilization of Prenatal and Postpartum Care.

Prenatal and postpartum care for women with substance use is important due to increased risk of poor health outcomes. The influence of substance use on perinatal care utilization is not well characterized, especially postpartum care. The objective of this study was to examine the effect of substance use during pregnancy on prenatal and postpartum care utilization in a nationally representative sample and to identify maternal characteristics associated with inadequate prenatal and postpartum care among women with substance use. Pregnancy Risk Assessment Monitoring System data (2016-2018) from 8 states were used for this study. Logistic regression models adjusted for complex survey weights and confounder variables were used to estimate the odds of not receiving adequate prenatal care and postpartum care. Weighted Rao-Scott chi-square tests were used to examine maternal characteristics associated with care utilization among women who reported substance use during pregnancy. The study included 15,131 women, with 5.3% who reported illicit substance use during pregnancy. In multivariable models, substance use was associated with an increase in the odds of not receiving adequate prenatal care (OR 1.69, CI 1.32, 2.17) and not receiving postpartum care (OR: 1.47, CI 1.10, 1.95). Among women who reported substance use, depression and smoking status were associated with not receiving adequate prenatal or postpartum care. Substance use during pregnancy is independently associated with disparities in prenatal and postpartum care access. Future studies are needed to identify how barriers lead to care inequalities and importantly, to identify strategies to improve care utilization.

Does Increasing Access to Prenatal Care Reduce Racial Disparities in Birth Outcomes?

PurposeTo examine the effectiveness of early and adequate prenatal care (PNC) in reducing racial disparities in pre-term birth (PTB) among low-income women. Design and methodsThis retrospective study examined birth records for 14,950 low-income Black and White women. The primary outcome of interest was racial disparities in PTB. Exposures of interest were first trimester entry into, and adequacy of, PNC. Maternal residential proximity to nearest PNC provider was calculated. Bivariate analyses were performed for PTB by race. Binary logistic regression was performed, controlling for maternal age, smoking status and racial segregation. Attributable risk of PTB for no or late entry into PNC, and percent difference by race was calculated. ResultsWe find that early and adequate PNC significantly decreases the risk of preterm birth, however, we find no evidence that this reduces racial disparities. Low income black females in a large metropolitan county have greater geographic access to and utilization of PNC than low-income white females, yet racial disparities in preterm birth remain. Attributable risk of PTB for no or late entry into PNC was lower for Black women (32.2%) than White women (39.4%). ConclusionsOur findings suggest that adequate PNC alone does not reduce the marked racial disparities in preterm birth. Practice implicationsPublic health agencies and health care providers need to look beyond access to care, to achieve racial equity in birth outcomes. Expansion of evidence-based, comprehensive nursing interventions shown to reduce preterm birth, such as the Nurse Family Partnership home visiting program, could contribute to these efforts.

Heightened immigration enforcement impacts US citizens' birth outcomes: Evidence from early ICE interventions in North Carolina.

We examine how increased Immigration and Customs Enforcement (ICE) activities impacted newborn health and prenatal care utilization in North Carolina around the time Section 287(g) of the Immigration and Nationality Act was first being implemented within the state. Focusing on administrative data between 2004 and 2006, we conduct difference-in-differences and triple-difference case-control regression analysis. Pregnancies were classified by levels of potential exposure to immigration enforcement depending on parental nativity and educational attainment. Contrast groups were foreign-born parents residing in nonadopting counties and all US-born non-Hispanic parents. The introduction of the program was estimated to decrease birth weight by 58.54 grams (95% confidence interval [CI], -83.52 to -33.54) with effects likely following from reduced intrauterine growth. These results are shown to coexist with a worsening in the timing of initiation and frequency of prenatal care received. Since birth outcomes influence health, education, and earnings trajectories, our findings suggest that the uptick in ICE activities can have large socioeconomic costs over US-born citizens.

540 Effect of timely treatment of acute severe intrapartum hypertension on risk of severe maternal morbidity

Hypertensive disorders of pregnancy (HDP) are among the leading causes of maternal mortality and severe maternal morbidity (SMM) worldwide. Studies have demonstrated an elevated risk of SMM in those with HDP who develop severe intrapartum hypertension (SIH), as well as a decreased risk of SMM with timely treatment of SIH. Our study sought to evaluate if the development of SIH was associated with SMM among patients at an urban safety net hospital and if timely treatment of SIH was associated with a reduction in SMM within this same population. Population cohort study of deliveries at a single urban safety net hospital in Atlanta, Georgia between 2016 and 2018. Among deliveries with HDP, we identified those with persistent SIH (>160/105 mmHg) and further classified women as having received timely (within 60 minutes) or delayed treatment. We used Fisher’s exact test and multivariable robust Poisson regression to compare SMM risk for women with SIH according to timing of treatment. Of the 3,723 deliveries within the study timeframe, 1,204 (32.0%) had HDP without SIH and 211 (0.6%) had HDP with SIH. Among deliveries with SIH, 49.0% received timely treatment. An SMM event complicated 27.0% of deliveries with SIH. Of those who received timely treatment, 23.3% experienced an SMM event compared to 30.6% of patients who received delayed treatment. After controlling for age, race, insurance status, prenatal care utilization, and multiple gestations, the adjusted risk ratio was 0.72 (CI 0.44-1.16). Comparison of specific SMM events between groups showed that timely treatment of SIH was associated with a statistically significant decrease in risk of acute renal failure (aRR 0.40, CI 0.15-1.05). Patients with HDP diagnoses are at an increased risk of SMM overall, with those with SIH at greatest risk of SMM. Within our patient population, timely treatment of SIH was associated with specific reduction in risk of acute renal failure, as well as a reduction in overall risk of SMM. These findings support efforts to expedite treatment of SIH.

123 Is housing instability a social determinant of prenatal care utilization and perinatal outcomes?

To evaluate whether housing instability is associated with differences in prenatal care utilization and perinatal outcomes. In this observational cohort study, women were surveyed during their postpartum hospitalization regarding housing instability during pregnancy and their medical records were reviewed. Women were considered housing unstable if they answered affirmatively to at least one of six screening items (Figure). The primary outcome was adequacy of prenatal care measured by the Adequacy of Prenatal Care Utilization index, comparing adequate or intermediate care versus inadequate care. Secondary maternal outcomes were gestational weight gain, cesarean delivery, and hypertensive disorders of pregnancy; neonatal outcomes were preterm birth, large for gestational age status, and NICU transfer. Propensity scoring was performed using sociodemographic and clinical covariates. Multivariable logistic regression models were adjusted for propensity score weighting. In this cohort (N=489), 11.0% (N=54) experienced housing instability during pregnancy. Unstably housed women were more likely to be minority race, have less than a college education, be single, be unemployed and have had a prior preterm birth. Unstably housed women were more likely to have had inadequate prenatal care (16.7% vs 3.9%, p<0.001), but findings were not significant after propensity score adjustment (Table). There was no statistically significant association with maternal or neonatal secondary outcomes. One in 10 women in this urban population experienced housing instability during pregnancy. Housing instability appears to be a risk marker that is related to other social determinants of health; however, in this population, it does not appear to be an independent risk factor for inadequate prenatal care or other perinatal outcomes. Given the range of housing instability experiences, future research must investigate specific types of housing instability and the potential perinatal consequences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)