Trimester Prenatal Care Research Articles

Maternal Recall of Obstetric Office-Based Activities That Promote Antepartum Tetanus-Diphtheria-Acellular-Pertussis Vaccination.

Objective: To explore associations between maternal characteristics and recall of obstetric provider actions in promoting antepartum tetanus-diphtheria-acellular-pertussis (Tdap) vaccination. Methods: A convenience sample of 1,682 postpartum women was surveyed in this cross-sectional study. Maternal characteristics and recall of four obstetric provider actions (recommending antepartum Tdap vaccine, offering it in clinic, providing written information, and referring patients elsewhere for vaccination) were collected. Univariate and multivariable logistic regression analyses were performed to characterize the association between maternal characteristics and each provider action. Results: Among 1,604 surveys (95% of total collected), maternal recall of an obstetric provider recommending Tdap vaccination, offering it in clinic, providing written information, or referring patients elsewhere was 68%, 59%, 53%, and 15%, respectively. Multivariable analysis revealed specific maternal characteristics that increased odds of recalling at least one obstetric provider action promoting Tdap vaccination, including receipt of first trimester prenatal care (adjusted odds ratio [aOR] 1.77, 95% confidence interval [CI] = 1.06-2.97), primiparity (aOR 1.35, 95% CI = 1.05-1.75), private health insurance (aOR 1.56, 95% CI = 1.16-2.04), higher household income (aOR ranging from 1.71 to 2.10 for ≥$150,000 for two actions), and non-White, non-Hispanic race/ethnicity (aOR ranging from 1.49 to 1.74 for Asian non-Hispanic for two actions and aOR 1.71 for Black non-Hispanic). Conclusion: Prenatal care, parity, insurance type, household income, and race/ethnicity are associated with recall of obstetric provider activities that impact antepartum Tdap vaccine promotion. Obstetric providers should recommend this potentially life-saving vaccine with each pregnancy, irrespective of differences in maternal characteristics, and policymakers should work to combat systemic factors that may cause disparities in uptake.

Births in the United States, 2023.

This report presents 2023 data on U.S. births compared with 2022 and 2021 for several key demographic and maternal and infant characteristics. Descriptive tabulations of data reported on the birth certificates of the 3.60 million births that occurred in 2023 are presented. Data are presented for the number of births, the general fertility rate, teenage birth rates, the distribution of births by trimester prenatal care began and the distribution of births by selected gestational age categories. Data for 2023 are compared with data for 2022 and 2021. A total of 3,596,017 births were registered in the United States in 2023, down 2% from 2022. The general fertility rate declined 3% in 2023 to 54.5 births per 1,000 females ages 15-44. Birth rates declined for females ages 15-19 (4%), 15-17 (2%), and 18-19 (5%), from 2022 to 2023. The percentage of mothers receiving prenatal care in the first trimester of pregnancy declined 1% to 76.1% in 2023 while the percentage of mothers with no prenatal care increased 5%. The preterm birth rate was essentially unchanged at 10.41% in 2023 but the rate of early term births rose 2%.

Chronic hypertension diagnosed by the American Heart Association and American College of Cardiology criteria is associated with increased risk of developing hypertensive disorders of pregnancy

ACOG uses a systolic blood pressure (SBP) ≥140 or diastolic blood pressure (DBP) ≥90 documented at <20 weeks of gestation to define chronic hypertension. In the nonpregnant state, the American Heart Association (AHA) and the American College of Cardiology (ACC) define chronic hypertension using lower diagnostic thresholds of SBP ≥130 or DBP ≥80. It remains unclear whether using more conservative guidelines in pregnancy improves identification of those at risk for gestational hypertension (GHTN) or preeclampsia (PRE). We sought to investigate whether subjects with chronic hypertension based on the American Heart Association and American College of Cardiology criteria had an increased risk for gestational hypertension and preeclampsia than those without chronic hypertension. We conducted a retrospective cohort study utilizing a clinical database at a diverse, large urban, safety-net hospital. Subjects aged 18 to 40 years with singleton gestations and first trimester prenatal care were included. We defined subjects that met the criteria for stage 1 chronic hypertension based on first trimester systolic blood pressure and diastolic blood pressure cutoffs satisfying the American Heart Association and American College of Cardiology criteria (systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥80 mm Hg). Those who did not meet these criteria had a systolic blood pressure <130 mm Hg and a diastolic blood pressure <90 mm Hg. We did not include those with chronic hypertension based on the American College of Obstetricians and Gynecologists criteria in this cohort (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg at <20 weeks); therefore, those who met the American Heart Association and American College of Cardiology criteria solely consisted of subjects with systolic blood pressure of 130 to 139 mm Hg and diastolic blood pressure of 80 of 89 mm Hg. By doing this, we were able to specifically investigate the increased risk for this specific population, which remains unclear. Diagnoses of gestational hypertension and preeclampsia were based on the established American College of Obstetricians and Gynecologists criteria. Preeclampsia included those with and without severe features. Tests for normality were performed. Student t-tests or rank sum tests were performed as appropriate for continuous variables; chi-square or Fisher's exact tests were performed for categorical variables. Generalized linear models were performed to calculate risk ratios while controlling for appropriate confounders. Of N=3354 subjects, 18% (n=629) were diagnosed with stage 1 chronic hypertension based on American Heart Association and American College of Cardiology criteria. Those with American Heart Association and American College of Cardiology stage 1 chronic hypertension had increased rates of gestational hypertension (35.4% vs 20%; P<.001) and preeclampsia (22.3% vs 10%; P<.001) than those without Stage 1 chronic hypertension based on these criteria. When controlling for maternal age, race, first trimester body mass index, pregestational diabetes, and substance use, those with the American Heart Association and American College of Cardiology stage 1 chronic hypertension had an almost 1.5-fold higher adjusted risk ratio of experiencing gestational hypertension (adjusted risk ratio, 1.49±0.10; P<.001) and almost 2-fold increased adjusted risk ratio of experiencing preeclampsia (adjusted risk ratio, 1.98±0.19; P<.001). Our data suggest an increased risk for developing gestational hypertension and preeclampsia for subjects satisfying the American Heart Association and American College of Cardiology cutoff for stage 1 chronic hypertension. Future studies need to consider whether diagnosis of chronic hypertension in pregnancy should conform with American Heart Association and American College of Cardiology criteria, and if those with stage 1 chronic hypertension based on American Heart Association and American College of Cardiology criteria require the same preventative measures and interventions utilized by those diagnosed by American College of Obstetricians and Gynecologists criteria.

Health Insurance and Differences in Infant Mortality Rates in the US

Health insurance status is associated with differences in access to health care and health outcomes. Therefore, maternal health insurance type may be associated with differences in infant outcomes in the US. To determine whether, among infants born in the US, maternal private insurance compared with public Medicaid insurance is associated with a lower infant mortality rate (IMR). This cohort study used data from the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research expanded linked birth and infant death records database from 2017 to 2020. Hospital-born infants from 20 to 42 weeks of gestational age were included if the mother had either private or Medicaid insurance. Infants with congenital anomalies, those without a recorded method of payment, and those without either private insurance or Medicaid were excluded. Data analysis was performed from June 2022 to August 2023. Private vs Medicaid insurance. The primary outcome was the IMR. Negative-binomial regression adjusted for race, sex, multiple birth, any maternal pregnancy risk factors (as defined by the CDC), education level, and tobacco use was used to determine the difference in IMR between private and Medicaid insurance. The χ2 or Fisher exact test was used to compare differences in categorical variables between groups. Of the 13 562 625 infants included (6 631 735 girls [48.9%]), 7 327 339 mothers (54.0%) had private insurance and 6 235 286 (46.0%) were insured by Medicaid. Infants born to mothers with private insurance had a lower IMR compared with infants born to those with Medicaid (2.75 vs 5.30 deaths per 1000 live births; adjusted relative risk [aRR], 0.81; 95% CI, 0.69-0.95; P = .009). Those with private insurance had a significantly lower risk of postneonatal mortality (0.81 vs 2.41 deaths per 1000 births; aRR, 0.57; 95% CI, 0.47-0.68; P < .001), low birth weight (aRR, 0.90; 95% CI, 0.85-0.94; P < .001), vaginal breech delivery (aRR, 0.80; 95% CI, 0.67-0.96; P = .02), and preterm birth (aRR, 0.92; 95% CI, 0.88-0.97; P = .002) and a higher probability of first trimester prenatal care (aRR, 1.24; 95% CI, 1.21-1.27; P < .001) compared with those with Medicaid. In this cohort study, maternal Medicaid insurance was associated with increased risk of infant mortality at the population level in the US. Novel strategies are needed to improve access to care, quality of care, and outcomes among women and infants enrolled in Medicaid.

Temporal trends and determinants of COVID-19 vaccine coverage and series initiation during pregnancy in Ontario, Canada, December 2020 to December 2021: A population-based retrospective cohort study.

Population-based COVID-19 vaccine coverage estimates among pregnant individuals are limited. We assessed temporal patterns in vaccine coverage (≥1 dose before or during pregnancy) and evaluated factors associated with vaccine series initiation (receiving dose 1 during pregnancy) in Ontario, Canada. We linked the provincial birth registry with COVID-19 vaccination records from December 14, 2020 to December 31, 2021 and assessed coverage rates among all pregnant individuals by month, age, and neighborhood sociodemographic characteristics. Among individuals who gave birth since April 2021-when pregnant people were prioritized for vaccination-we assessed associations between sociodemographic, behavioral, and pregnancy-related factors with vaccine series initiation using multivariable regression to estimate adjusted risk ratios (aRR) and risk differences (aRD) with 95% confidence intervals (CI). Among 221,190 pregnant individuals, vaccine coverage increased to 71.2% by December 2021. Gaps in coverage across categories of age and sociodemographic characteristics decreased over time, but did not disappear. Lower vaccine series initiation was associated with lower age (<25 vs. 30-34years: aRR 0.53, 95%CI 0.51-0.56), smoking (vs. non-smoking: 0.64, 0.61-0.67), no first trimester prenatal care visit (vs. visit: 0.80, 0.77-0.84), and residing in neighborhoods with the lowest income (vs. highest: 0.69, 0.67-0.71). Vaccine series initiation was marginally higher among individuals with pre-existing medical conditions (vs. no conditions: 1.07, 1.04-1.10). COVID-19 vaccine coverage among pregnant individuals remained lower than in the general population, and there was lower vaccine initiation by multiple characteristics.

2218. Spatial Epidemiology of Gonorrhea Incidence Among Women in Chicago

Abstract Background Neisseria gonorrhea is the second most prevalent sexually transmitted infection (STI) in the US with increasing incidence. Untreated, it leads to devastating sequelae for nonpregnant women, pregnant women, and their neonates. Geographic clustering of gonorrhea coincides with clustering of other risk factors and may help guide interventions. We utilize Geographic Information Systems (GIS) software to map gonorrhea incidence among women in Chicago, and examine factors associated with the spatial distribution of infection. Methods Chicago Department of Public Health data sets and shape files were available through the Chicago Data Portal. ArcGIS was utilized for map illustrating and data analysis. Ordinary Least Squares (OLS) Regression was utilized using the dependent variable of Gonorrhea incidence in women per Chicago Community Area (CCA), with various explanatory variables. Within the OLS, the Koenker Statistic (KS) was reported and from this a Geographically Weighted Regression (GWR) tool was run for combinations with statistically significant KS. Results The highest incidence is shown in the southern and western CCA’s, with hospitals clustered in the northern and southeastern CCA’s &amp; clinics with gaps primarily noted in the southern and northwestern CCA’s. (Figure 1.) Teen pregnancy incidence (TP), infant mortality (IM), and first trimester prenatal care, had statistical significance of the robust probability for all of their explanatory variables, and VIF’s less than 2 for all explanatory variables, JBS were not statistically significant, and AICc were approximately 1170 demonstrating stable OLS. (Figure 2&amp;3) TP &amp; IM did have a statistically significant KS and GWR was run demonstrating random spatial pattern. This confirms TP &amp; IM as predictors for gonorrheal incidence had variable predictability throughout the CCA’s and GWR improves the model outcome. Both combinations spatially explain gonorrhea incidence. Map of Gonorrhea Incidence among Females in 2006-2010 Figure 1:The data of the incidence of gonorrhea in females was mapped with 5 separate classifications created and displayed in the form of a map. Also included on the map were hospitals in the city, and Chicago Department of Public Health clinic locations where free STI management could take place. illustrates gonorrhea incidence rates (per 100,000) within the 77 Chicago Community Areas (CCA) of the city. The darker shades of green correspond with higher incidence. The highest incidence is shown to be greatest in the southern and western CCA’s. Also illustrated are the locations of the hospitals within the city in addition to CDPH clinics that are Federally Qualified Health Clinics (FQHC) that offer services for treatment at a reduced or free cost depending on health insurance status. The majority of the hospitals are shown to clustered in the northern and southeastern CCA’s. The clinics are more evenly spaced out with gaps primarily noted in the southern and northwestern CCA’s. The Ordinary Least Squares (OLS) regression results are illustrated in Table 1 above. The results are shown for six separate regressions: chlamydia incidence, Natality (teen pregnancy incidence [TP], percent of live births that were preterm [Preterm], fetal low birth percentage [LBW], prenatal care in the 1st trimester rate [PNC 1T], infant mortality rate [IM]), poverty (total # below poverty line per 100,000), poverty &amp; chlamydia, TP &amp; IM, TP &amp; IM &amp; PNC 1T, and all coefficients (natality incidence, poverty incidence, chlamydia incidence, fertility rate). Utilizing ArcGIS software, OLS Regression was mapped with the 77 Chicago Community Areas (CCA) with Gonorrhea Infection Incidence per CCA as the dependent variable and Teen Pregnancy (TP), Infant Mortality (IM) and 1st trimester prenatal care (1TM) incidence per CCA as the explanatory variables. Regression reported with standard deviation (SD) and color coded based off quantity of SD. Map shapefile is of the 77 CCA’s. Overlying are Hospitals and Chicago Department of Public Health (CDPH) clinic locations as made available through CDPH public domain website. Conclusion Teen pregnancy rates, infant mortality rates, and prenatal care in the first trimester explain some of the spatial patterns of gonorrhea incidence of females in Chicago. Identification of these factors identified should prompt providers to ensure enhanced testing of gonorrhea and other STI’s to reduce burden in areas of high incidence. Disclosures All Authors: No reported disclosures.

163 Private or Public Health Insurance and Infant Outcomes in the United States

OBJECTIVES/GOALS: Health insurance status is associated with differences in access to healthcare and health outcomes. The objective of this study was to test the hypothesis that among infants born in the United States, maternal private insurance compared with public Medicaid insurance would be associated with a lower infant mortality rate (IMR). METHODS/STUDY POPULATION: This ecological study used data from the Center for Disease Control and Prevention (CDC) WONDER expanded linked birth and infant death records database 2017-2018. We included hospital-born infants from 20 to 42 weeks of gestational age (wga) if the mother had either private or Medicaid insurance. We excluded infants with congenital anomalies and infants who died due to congenital anomalies. We used negative-binomial regression adjusted for race, sex, multiple birth, and any maternal pregnancy risk factors (as defined by the CDC) to determine the difference in IMR between private and Medicaid insurance. Chi-square or Fishers exact test was used to compare differences in categorical variables between groups. RESULTS/ANTICIPATED RESULTS: We included 6,901,328 infants; 53.6% had private insurance and 46.4% were insured by Medicaid. Privately insured infants had a lower IMR compared with Medicaid insured infants (2.84/1000 vs. 5.32/1000; adjusted relative risk (aRR) 0.71; 95% confidence intervals (CI) 0.62 to 0.81; p&lt;.0001). The privately insured had higher rates of 1st trimester prenatal care compared to those with Medicaid (85.6% vs. 66.6%; p&lt;.00001). Rates of infant morbidity and maternal morbidity (per CDC definitions) were lower among the privately insured compared to those with Medicaid (both p&lt;.00001). The privately insured had lower rates of preterm (9.1% vs. 11.0%), extremely preterm (0.5% vs. 0.7%), low birth weight (7.1% vs. 9.6%), and extremely low birth weight (0.5% vs. 0.7%) births compared to those with Medicaid (all p&lt;0.001). DISCUSSION/SIGNIFICANCE: Private insurance is associated with a lower IMR compared to Medicaid insurance. Privately insured pregnancies also have higher rates of early prenatal care, less morbidity, and less preterm and low birth weight births. There may be opportunities to improve access to care and pregnancy outcomes among Medicaid insured pregnancies in the United States.

Characteristics Associated with Prenatal Cannabis Use Vary with Legality of Recreational Cannabis.

Background: Increasing prenatal cannabis use over recent years has been associated with changes in state-level cannabis policies. Yet, how correlates of prenatal cannabis use differ by recreational cannabis legality has not been examined. We aim to estimate prenatal cannabis use prevalence and examine how maternal factors associated with use vary across states with and without recreational cannabis legalization. Methods: In 2020, we performed a cross-sectional analysis using 2018 Pregnancy Risk Assessment Monitoring System data, providing population-level estimates of prenatal cannabis use among included states. Across 14 states, we examined characteristics of prenatal cannabis users via chi-square tests and multivariate logistic regression models. We present odds ratios (ORs) of prenatal cannabis use, stratified by recreational cannabis legality. Results: Self-reported prenatal cannabis use in states with and without legalized recreational cannabis were 6.29% and 5.22%, respectively. Adjusted analyses found that regardless of recreational cannabis legalization, women who were unmarried, reported Medicaid as their prenatal care insurer, did not receive first trimester prenatal care, or reported having prenatal depression or anxiety were 1-4 times more likely to report prenatal cannabis use. Women residing in states where recreational cannabis was legal were significantly more likely to report concurrent cannabis and tobacco use while pregnant (OR: 8.66, 95% confidence interval [CI], 5.40-13.86) compared with women in states yet to legalize (OR: 5.49, 95% CI, 3.97-7.59). Conclusions: Our findings suggest a need for focused cannabis prevention efforts for nonpregnant women of reproductive age to stop initial uptake of the drug. Additionally, as women in these states were three times more likely to report concurrent cannabis and tobacco use during pregnancy, we recommend that states with recreational cannabis focus on prevention and intervention of cosubstance use among pregnant women.

Impact of Medicaid expansion in Oregon on access to prenatal care

Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) has the potential to improve reproductive health by allowing low-income women access to healthcare before and early in pregnancy. The aim of this study was to examine the effects of Oregon's Medicaid expansion on timely and adequate prenatal care. We included live births in Oregon from 2012 to 2015 and used individually-linked birth certificate and Medicaid eligibility data. Outcomes were receipt of first trimester prenatal care and receipt of adequate prenatal care. We also assessed Medicaid enrollment one month prior to pregnancy. We estimated the overall effect of Medicaid expansion on prenatal care utilization using probit regression models. Additionally, we assessed the impact of Medicaid expansion on prenatal care utilization via pre-pregnancy Medicaid enrollment using bivariate probit models. Overall, receipt of first trimester prenatal care increased post-expansion by 1.5 percentage points (p < 0.01) after expansion. Receipt of adequate prenatal care also increased significantly post-expansion with an incremental increase of 2.8 percentage points (p < 0.001). Pre-pregnancy Medicaid enrollment increased following Medicaid expansion (β = 0.55, p < 0.001) and was associated with both timely (β = 0.48, p < 0.001) and adequate receipt of prenatal care (β = 0.14, p < 0.001). Using two years of post-ACA data we found that Medicaid expansion had significant positive associations with Medicaid enrollment prior to pregnancy, which subsequently increased receipt of timely and adequate prenatal care. Our study provides evidence that expanding Medicaid has positive effects on women's use of healthcare.

Effects of changes in earned income tax credit: Time-series analyses of Washington DC.

Poverty has numerous deleterious effects on health, and the Earned Income Tax Credit (EITC) is the major policy tool used to alleviate poverty in the U.S. We evaluate effects of four distinct changes in earned income tax credit law in Washington, DC on maternal behaviors and infant outcomes. An interrupted time-series design was used with 312 monthly measures from 1990 through 2015 analyzed in 2018 (total n = 225,933 births). States with no EITC were included as the comparison group; analyses involved ARIMA modeling. Outcomes were derived from birth certificates, and included percent of live births below 2500 g, mean birth weight, mean gestation weeks, first trimester prenatal care, and maternal smoking during pregnancy. We found a pattern of significant improvements across all three infant outcome measures, with the size of the effect estimate monotonically matching the magnitude of the tax credit—ranging from a 1.9 (-2.9, -0.9) reduction in rate per 100 births of low birth weight for the smaller 10% credit, to a 4.7 (-5.4, -4.0) reduction with the 40% credit. Results for maternal smoking and prenatal care were mixed. Results suggest that earned income tax credit policies improve birth outcomes; mechanisms for this effect deserve further study.

741: The impact of Medicaid expansion on outcomes in women with pregestational diabetes

Pregnancy outcomes for women with diabetes mellitus (DM) are improved by preconception care, and access to preconception care is enhanced by insurance coverage. We therefore sought to determine whether expanded access to care through Medicaid after enactment of the Affordable Care Act was associated with improved birth outcomes in women with pregestational DM. This is a population-based retrospective cohort study using National Vital Statistics data. All women covered by Medicaid who delivered singleton gestations and had pregestational DM coded on the birth certificate in states using the 2003 birth certificate revision were included. We classified states as “expanded” if they implemented expansion programs in 2014. We compared maternal and neonatal outcomes in 2013 (before policy changes) and 2015 (1 year after Medicaid expansion was enacted) using a difference-in-differences approach to account for secular trends in outcomes unrelated to Medicaid expansion. We then constructed a multilevel model to investigate the association of Medicaid expansion with outcomes adjusted for age, race, education, parity, and clustering by state. Of 27,113 women who delivered during the study period, 12,795 (47.2%) were in states that expanded Medicaid. First trimester prenatal care entry was more common in 2015 than in 2013 in both expanded states (+4.6%) and non-expanded states (+3.4%), and was not associated with Medicaid expansion (adjusted odds ratio (aOR) 1.09, 95% CI 0.94-1.27). Primary cesarean delivery was less common in 2015 than in 2013 in both expanded (- 0.8%) and non-expanded states (-0.9%), and these differences were not associated with Medicaid expansion (aOR 1.00, 95% CI 0.89-1.14). Although fewer infants were large-for-gestational age in 2015 than in 2013 in both expanded (-1.0%) and non-expanded states (-0.6%), frequency of neonatal morbidity (NICU admission at term, NICU admission overall, and >6 hours of respiratory support) increased over the study period; these changes were all independent of Medicaid expansion. (Table) Medicaid expansion was not associated with differences in early prenatal care, maternal or neonatal outcomes among women with pregestational DM. Access to preconception care is necessary, but insurance access alone may not be sufficient to improve outcomes in this population.

Previous cesarean delivery associated with subsequent preterm birth in the United States.

To examine the relationship between previous cesarean delivery and subsequent preterm birth in the second pregnancy among women in the United States with registered birth records. We conducted a retrospective cohort study utilizing United States birth certificate data to generate the study population, which consisted of women delivering a singleton infant in their second live birth (n = 1,076,517) in the year 2016. Preterm birth and previous cesarean delivery measures were derived from United States birth certificates. Covariates included maternal age, race/ethnicity, education, marital status, payer source for delivery, pre-pregnancy body mass index, previous preterm birth, interpregnancy interval, and factors in the second pregnancy such as hypertensive disorders, diabetes, and cigarette use, trimester prenatal care began, weight gain during pregnancy, and presence of congenital anomalies. Women who experienced a cesarean delivery in the first pregnancy were compared to those who did not. When controlling for all covariates, women who had a cesarean delivery in their first pregnancy were 14% more likely to have a preterm birth in their second pregnancy (OR = 1.137, 95% CI = 1.117-1.158) compared to women who had not previously experienced a cesarean delivery. When risk was analyzed by sub categories of preterm birth based on gestational age, a differential association was noted, with a 10% increased risk of delivering before 34 weeks, a 1% increased risk for delivery between 34-36 weeks and no increased risk for delivery after 36 weeks compared to delivery at 39-40 weeks. This small, but statistically significant association between previous cesarean section and subsequent preterm birth suggests that efforts to reduce the number of index cesarean sections may contribute to reducing the overall preterm birth rate in the United States.

Integrated perinatal mental health care: a national model of perinatal primary care in vulnerable populations.

Perinatal mood and anxiety disorders (PMADs) are the most common complication of pregnancy and have been found to have long-term implications for both mother and child. In vulnerable patient populations such as those served at Denver Health, a federally qualified health center the prevalence of PMADs is nearly double the nationally reported rate of 15-20%. Nearly 17% of women will be diagnosed with major depression at some point in their lives and those numbers are twice as high in women who live in poverty. Women also appear to be at higher risk for depression in the child-bearing years. In order to better address these issues, an Integrated Perinatal Mental Health program was created to screen, assess, and treat PMADs in alignment with national recommendations to improve maternal-child health and wellness. This program was built upon a national model of Integrated Behavioral Health already in place at Denver Health. A multidisciplinary team of physicians, behavioral health providers, public health, and administrators was assembled at Denver Health, an integrated hospital and community health care system that serves as the safety net hospital to the city and county of Denver, CO. This team was brought together to create a universal screen-to-treat process for PMAD's in perinatal clinics and to adapt the existing Integrated Behavioral Health (IBH) model into a program better suited to the health system's obstetric population. Universal prenatal and postnatal depression screening was implemented at the obstetric intake visit, a third trimester prenatal care visit, and at the postpartum visit across the clinical system. At the same time, IBH services were implemented across our health system's perinatal care system in a stepwise fashion. This included our women's care clinics as well as the family medicine and pediatric clinics. These efforts occurred in tandem to support all patients and staff enabling a specially trained behavioral health provider (psychologists and L.C.S.W.'s) to respond immediately to any positive screen during or after pregnancy. In August 2014 behavioral health providers were integrated into the women's care clinics. In January 2015 universal screening for PMADs was implemented throughout the perinatal care system. Screening has improved from 0% of women screened at the obstetric care intake visit in August 2014 to >75% of women screened in August 2016. IBH coverage by a licensed psychologist or licensed clinical social worker exists in 100% of perinatal clinics as of January 2016. As well, in order to gain sustainability, the ability to bill same day visits as well as to bill, and be reimbursed for screening and assessment visits, continues to improve and provide for a model that is self-sustaining for the future. Implementation of a universal screening process for PMADs alongside the development of an IBH model in perinatal care has led to the creation of a program that is feasible and has the capacity to serve as a national model for improving perinatal mental health in vulnerable populations.

Adequate Weight Gain during Pregnancy by Pre-Pregnancy Body Mass Index: Who Gets It Right? [19C

INTRODUCTION: In 2009, the IOM issued new guidelines for gestational weight gain (GWG), based on pre-pregnancy body mass index (PPBMI). This study was conducted to understand who is currently meeting these recommendations, exploring sociodemographic characteristics. METHODS: Using 2015 vital statistics (birth) data collected by the National Center for Health Statistics, GWG was calculated using pre-pregnancy weight and delivery weight to determine inadequate, adequate, and excess GWG categories by PPBMI, per the new guidelines. Chi-square tests and multivariate logistic regression analyses were used to assess the 12-category GWG/PPBMI variable by age, race/ethnicity, education, marital status, insurance at delivery, WIC receipt, trimester prenatal care began and smoking status. RESULTS: Of 3,404,491 singleton deliveries with complete information on PPBMI and GWG, 3.6% were underweight, 45.2% were normal weight, 25.9% were overweight, and 25.3% were obese pre-pregnancy. Percentages of meeting the IOM guidelines ranged from 23.7% among obese women to 42.9% among underweight women; among obese women, 54.1% gained more than the recommended weight during pregnancy. All socio-demographic variables were significantly associated with not meeting the GWG recommendations. Compared to obese women who followed the recommendation, those who gained more were more likely to be younger [OR = 1.355 (95% CI: 1.317-1.394] and were less likely to have entered prenatal care in the first trimester [OR = 0.808 (95% CI: 0.787-0.829]. CONCLUSION: In this study, GWG outside of the IOM recommendations was associated with key demographic risk factors. Additional resources may be needed to help these populations better achieve healthy weight gain during pregnancy.

First Trimester Prenatal Care Initiation Among Hispanic Women Along the U.S.-Mexico Border

Background First trimester prenatal care (FTPNC) is associated with improved birth outcomes. U.S.-Mexico border Hispanic women have lower FTPNC than non-border or non-Hispanic women. This study aimed to identify (1) what demographic, knowledge and care-seeking factors influence FTPNC among Hispanic women in border counties served by five Healthy Start sites, and (2) what FTPNC barriers may be unique to this target population. Healthy Starts work to eliminate disparities in perinatal health in areas with high poverty and poor birth outcomes. Methods 403 Hispanic women of reproductive age in border communities of California, Arizona, New Mexico and Texas were surveyed on knowledge and behaviors related to prenatal care (PNC) and basic demographic information. Chi square analyses and logistic regressions were used to identify important relationships. Results Chi square analyses revealed that primiparous women were significantly less likely to start FTPNC than multiparous women (χ2 = 6.8372, p = 0.0089). Women with accurate knowledge about FTPNC were more likely to obtain FTPNC (χ2 = 29.280, p < .001) and more likely to have seen a doctor within the past year (χ2 = 5.550, p = .018). Logistic regression confirmed that multiparity was associated with FTPNC and also that living in Texas was negatively associated with FTPNC (R2 = 0.066, F(9,340) = 2.662, p = .005). Among 27 women with non-FTPNC, barriers included late pregnancy recognition (n = 19) and no medical insurance (n = 5). Conclusions This study supports research that first time pregnancies have lower FTPNC, and demonstrated a strong association between delayed PNC and late pregnancy recognition. Strengthened investments in preconception planning could improve FTPNC in this population.

Trends in Early Prenatal Care Among Women with Pre-Existing Diabetes: Have Income Disparities Changed?

Women with pre-existing diabetes are at high maternal risk for comorbidities and death, particularly when early prenatal care is not received. Low income is a known barrier to early prenatal care. It is unknown whether recent policies to expand access to prenatal care have reduced income disparities. We hypothesized that income disparities would be minimized and that the odds of receipt of first trimester prenatal care among women with pre-existing diabetes would become similar across income strata over time. Using the Colorado birth certificate registry from 2007 to 2014, receipt of prenatal care was assessed retrospectively in 2,497 women with pre-existing diabetes. Logistic regression was used to examine the association between high (>$50,000), medium ($25,000-50,000), and low (<$25,000) income strata and receipt of first trimester prenatal care by birth year, adjusted for demographics. High, medium, and low income represented 29.5%, 19.0%, and 51.5% of the cohort, respectively. Women with high income were more likely to receive first trimester care than women with low income from 2007 [adjusted odds ratio, 95% confidence interval: 2.16 (1.18, 3.96)] through 2013 [1.66 (1.01, 2.73)], but significant differences were no longer observed in 2014 [1.59 (0.89, 2.84)]. The likelihood of receiving first trimester prenatal care was not significantly different between medium- and low-income strata from 2007 [1.07 (0.66, 1.74)] through 2014 [0.77 (0.48, 1.23)]. From 2007 to 2013, women in Colorado with diabetes were more likely to receive early prenatal care if they were in the highest income stratum than in the lowest stratum. In 2014, receipt of first trimester care became equitable across all income strata. Future work should examine national patterns of income with receipt of prenatal care and outcomes among women with pre-existing diabetes.

First Trimester Prenatal Care and Local Obstetrical Delivery Options for Women in Poverty in Rural Virginia

Healthy People 2020 recommends improvements in rural women’s health in the United States, and specifically, prenatal care. A rural Virginia health department requested this study to assess prenatal care and obstetrical delivery options for impoverished women in the Central Shenandoah Valley. Births to resident mothers between 2000 and 2011 were examined by payer source, care source, first prenatal visit timing, and delivery location. Providers, public health nurses, and women were interviewed to assess barriers. Resident women delivered 32,423 infants between 2000 and 2011. Prenatal care initiation differed by payer source and care source. Approximately 89% of privately insured patients initiated prenatal care in the 1st trimester, compared to 66% of Medicaid, and 57% of uninsured women. Approximately 80% of private care women initiated prenatal care as recommended; 50% of public care women did so. Overall 21% of Central Valley women were unable to obtain 1st trimester prenatal care. Most obstetrical deliveries occur at two community hospitals. High risk deliveries are referred to a university hospital outside the region. Family practitioners are not credentialed for regional hospitals deliveries and provide no prenatal care. Most prenatal care is provided by four obstetrical practices. Interviewees differed regarding barriers to timely prenatal care. Providers identified insurance and cultural barriers. Public health nurses viewed referral mechanisms, insurance, culture, pregnancy denial, and transportation. Women identified finances and culture as barriers, but described them in complex ways. Culture, in their view, constructs a financial barrier and one they worked hard to overcome. Transportation was not identified as a barrier but rather a matter of course in rural areas. It is not surprising that impoverished women frequently fail to obtain timely prenatal care. Policy solutions to improve this situation include addressing financial barriers. However, given that impoverished women face many social barriers in addition to finances, solutions that enhance evidence-based case management and home visiting programs recommend to achieve the best outcomes.

First trimester initiation of prenatal care in the US-Mexico border region.

To systematically examine prevalence of first trimester prenatal care (FTPNC) in the 44 US counties and 80 Mexican municipios of the binational border region; and to describe disparities between border and nonborder areas within states, border states, and countries. We combined 2009 records of singleton live births from the 10 US-Mexico border states (N=1,370,206) into a single file. We included FTPNC; county/municipio, state, and country of maternal residence; and demographic variables common to all records. We computed prevalence of FTPNC for border and nonborder residents by state and country. Using multivariable regression, we computed adjusted prevalence ratios (aPR) for FTPNC in border relative to nonborder residents, states relative to one another, and the US relative to Mexico. In 2009, 68.8% of US-Mexico border mothers and 72.9% of nonborder mothers received FTPNC. After adjustment, nonborder residents had higher prevalence of FTPNC than border residents in Sonora, New Mexico, Arizona, Coahuila, and Chihuahua (aPR=1.09-124). In US states, prevalence was 13%-36% higher in New Mexico, Arizona, and California than Texas. In Mexico, when compared with Coahuila, adjusted prevalence was 12%-20% higher in neighboring states. Between countries, FTPNC prevalence in border counties/municipios was higher in Mexico among women with low parity/low education and in the United States among women with high parity/high education. In the US and Mexico, women in border counties/municipios receive less timely prenatal care than their nonborder counterparts, but the magnitude of the disparity varies by state. Lack of a consistent, binational approach to birth data collection requires cautious interpretation of findings.

Prenatal Care, Childhood Obesity, and Ethnic Health Disparities: Analyses from a Unique Population Database

This paper explores the association between prenatal care and childhood obesity across racial/ethnic groups, with special focus on Asians, Native Hawaiian and other Pacific Islanders (NHOPI), and non-Hispanic Whites. Data were drawn from a statewide population-based data source that linked vital and administrative records for a large cohort of children (n=227,032). Multivariate logistic regression was used to estimate odds of overweight and obesity among children whose mothers received first trimester prenatal care versus those who did not. Compared with White and Asian women, NHOPI women had later initiation of prenatal care. However, NHOPI women who initiated early prenatal care had children with significantly lower risks of obesity and overweight than their counterparts who delayed such care. Timely prenatal care may be associated, with lower childhood obesity through focused monitoring and counseling on pregnancy-related weight gain as well as through reducing other potentially deleterious prenatal behaviors for this high-risk and underserved population.

Three Population‐Patient Care Outcome Indicators for Public Health Nursing: Results of a Consensus Project

Difficulties in recruiting nurses into public health settings threaten the public's health. Gaps in existing data make determining the health impact of workforce changes numbers difficult to perform. Public health practice leaders are left to make difficult staffing and program decisions without knowing how the health of their vulnerable populations will be affected. The objective of this study was to identify indicators that could be used to document the effect of the shortage of public health nurses (PHNs) on the health of a population. A consensus-building process was used. Nursing directors from 6 local health departments (LHDs) in 2 states participated along with 3 public health system researchers. The findings from this collaborative process suggest that it is possible to identify outcome indicators across states and multiple LHDs that may be sensitive to PHN staffing levels and interventions. Possible connections between PHN staffing and each population-patient care indicator (rates of Chlamydia, first trimester prenatal care, early childhood immunization) are presented. The process used here in identifying these indicators and the proposed nursing-sensitive population outcome indicators themselves provide a template for the development and analysis of additional outcome indicators sensitive to the quality of nursing and other health care.