Outcomes In Women Research Articles

Determinants of Conception and Adverse Pregnancy Outcomes in Women with Endometriosis: A Longitudinal Study.

Endometriosis, affecting approximately 10% of reproductive-aged women globally, poses significant challenges, including chronic pelvic pain, dysmenorrhea, and infertility. In low- and middle-income countries like India, accessibility to affordable infertility care remains a concern. This multicenter prospective cohort study, conducted across six tertiary care hospitals in India from 2017 to 2022, aims to explore the natural progression of conception and pregnancy outcomes in women with endometriosis. Of the 257 participants, 19.1% conceived during the study, revealing significant geographic and income-based variations (p < 0.001, p = 0.01). Dysmenorrhea (p < 0.001) and dyspareunia (p=0.027) were correlated with conception, while no such associations were found with chronic pelvic pain or menstrual factors. Lesion type, number, and severity showed no conclusive link with conception. Natural conception occurred in 70% of cases, with an average post-surgery conception time of 282.1 days. Live birth rate was 85.7%, while complications included placenta previa (16.4%), preeclampsia (4.1%), and preterm births (4.1%). This study, one of the first in India on endometriosis-related fertility progression, emphasizes the need for comprehensive understanding and management of conception and pregnancy outcomes. Considering India's substantial endometriosis burden, the study recommends prioritizing larger multicenter investigations for a better understanding and effective strategies for infertility management.

The Association of Hyperlipidemia at Late Pregnancy With Maternal and Neonatal Outcomes in Women With Gestational Diabetes

The Association of Hyperlipidemia at Late Pregnancy With Maternal and Neonatal Outcomes in Women With Gestational Diabetes

A Review of Psychosocial Factors on Birth Outcomes in Women with Substance Use Disorder in the United States: The Importance of Preventing Relapse During Sustained Remission

Infant mortality rate has been an area of concern for the United States for years. Many attributing factors, including psychosocial influences, have been identified. Pregnant patients with substance use disorder have also been shown to experience poor birth outcomes. This study examines trends related to socioeconomic hurdles and mental health in pregnant women with substance use disorder. Databases were searched to find resources that outlined these relationships. After assessing the study designs and associations of fifty-five resources, several patterns were observed, including an increased risk of adverse birth outcomes with higher maternal stress and lower socioeconomic status. In pregnant women with substance use disorder, post-traumatic stress and social stigma resulted in negative effects on mental health. Substance use-related pregnancy anxiety was amplified by triggers that resulted in feelings of fetal detachment and substance cravings. Most literature focused on pregnant patients with active addiction; however, these triggers may have an especially powerful effect on women who become pregnant while in substance use recovery. Studies on remission trajectories indicated a higher mortality risk in people with a history of substance use but have not yet calculated the proportion of women capable of bearing children in this category. This highlights the necessity to develop personalized treatment for pregnant women in sustained remission from substance use disorder to prevent relapse during this crucial time. This population would benefit from a screening tool that assesses for high-risk events like PTSD, psychological stress, and substance use triggers and intervention that includes evidence-based mental health resources.

The sFLT-1/PlGF Ratio for the Prediction of Preeclampsia-Related Adverse Fetal and Maternal Outcomes in Women with Preexisting Diabetes.

To evaluate the predictive value of the sFlt-1/PlGF ratio for the prediction of preeclampsia in women with preexisting diabetes mellitus. This is a monocentric retrospective observational study conducted between January 2018 and December 2020. All singleton pregnancies with preexisting diabetes mellitus, who had a dosage of the sFlt-1/PlGF ratio between 30 and 34 + 6 weeks of gestation were included. The principal outcome was preeclampsia. The secondary outcomes were preterm preeclampsia, gestational hypertension, placental abruption, intrauterine fetal death, IUGR, small for gestational age and a composite outcome named "hypertensive disorder of pregnancy" including gestational hypertension, preeclampsia and HELLP syndrome (hemolysis, elevated liver enzymes and low platelet count). Of 63 patients, 22% presented preeclampsia. The area under the curve of sFlt-1/PlGF ratio was 0.90 (95% CI: 0.79-0.96) for the prediction of preeclampsia. The receiver operator characteristic analysis suggested that the optimal sFlt-1/PlGF cutoff to predict preeclampsia was 29, with a sensitivity of 86% (95% CI: 60.1-96.0) and a specificity of 92% (95% CI: 80.8-96.8). A cut-off of 38 provided a sensitivity of 71% (95% CI: 45.4-88.3), a specificity of 92% (95% CI: 80.8-96.8). Further analysis using multivariable methods revealed nephropathy was significantly associated with PE (p = 0.014). The use of the sFlt-1/PlGF ratio during the third trimester of pregnancy seems to be of interest as a prognostic tool to improve multidisciplinary management of patients with preexisting diabetes mellitus.

Adjusting Current Hemoglobin Thresholds: A Way to Improve Outcome in Women Undergoing Major Surgery.

Background/Objective: In the perioperative setting, a suboptimal total hemoglobin (Hb) mass puts women and men at an unreasonable disadvantage. Anemia is an independent risk factor for transfusion, postoperative complications, and mortality. The Hb cut-off value for women was set at <12.0 g/dL by the World Health Organization (WHO) and has been rigorously debated for decades. The aim of this study was to elucidate the risk for postoperative complications in female patients with Hb levels < 12.0, 12.0-12.9, and ≥13.0 g/dL. Material and Methods: Single-center retrospective analysis of female patients undergoing major surgery. Results: In total, 6,516 patients ≥18 years of age had major surgery between 2018 and 2019 and 2,446 female patients were included in analysis. Mean age was 67.4 ± 16.6, 66.4 ± 15.6, and 64.5 ± 15.5 years in female patients with preoperative Hb levels <12.0, 12.0-12.9 and ≥13.0 g/dL, respectively. The transfusion rate of red blood cells (RBCs) was significantly higher in female patients with Hb <12.0 g/dL (53%) and with Hb 12.0-12.9 g/dL (31%) compared to female patients ≥13.0 g/dL (22%). Rates of pneumonia, acute kidney injury, and sepsis were significantly higher in patients with Hb <12.0 and 12.0-12.9 g/dL compared to patients with Hb ≥13.0 g/dL. Total length of hospital stay was significantly longer in female patients with Hb <12.0 g/dL than patients with Hb 12.0-12.9 g/dL and Hb ≥13.0 g/dL (10 days vs. 8 days). Conclusion: Taken together, our data show that Hb values below 12.9 g/dL are associated with increased probability of RBC transfusions and increased risk of postoperative complications. In addition, our results indicate that postoperative outcomes for women might be optimized by increasing cut-off values for anemia. The call to revise the anemia threshold for women by the WHO can no longer be disregarded.

Current concepts in postpartum anemia management.

Postpartum anemia (PPA) is common in women after childbirth and affects about 50-80% of all women worldwide. Iron deficiency (ID) is the main cause for anemia and constitutes a potentially preventable condition with great impact on the mother's physical and mental condition after delivery. In most cases, PPA is associated with antenatal ID and peripartum blood losses. Numerous published studies confirmed the positive effect of PPA diagnosis and treatment. Iron deficiency as well as iron deficiency anemia (IDA) are common in the postpartum period and represent significant health problems in women of reproductive age. Important movements towards early detection and therapy of postpartum anemia have been observed. However, postpartum anemia management is not implemented on a large scale as many healthcare professionals are not aware of the most recent findings in the field. Diagnosis and therapy of PPA, particularly iron supplementation in ID and IDA, has proven to be highly effective with a tremendous effect on women's wellbeing and outcome.

Long-Term Follow-Up Outcomes in Women with In Situ/Microinvasive Adenocarcinoma of the Uterine Cervix Undergoing Conservative Treatment-Cervical Adenocarcinoma Study Group Italian Society of Colposcopy and Cervico-Vaginal Pathology.

The present study aimed to assess long-term follow-up outcomes in women with in situ/microinvasive adenocarcinoma (AC) of the uterine cervix treated conservatively. Retrospective multi-institutional study including women with early glandular lesions and 5-year follow-up undergoing fertility-sparing treatment. Independent variables associated with recurrence were evaluated. Logistic regression analysis and Kaplan-Meier survival analysis with Logrank test were performed. Of 269 women diagnosed with in situ/microinvasive AC, 127 participants underwent conservative treatment. During follow-up, recurrences were found in nine women (7.1%). The only factor associated with recurrence during follow-up was positive high-risk Human Papillomavirus (hr-HPV) testing (odds ratio 6.21, confidence interval 1.47-26.08, p = 0.012). HPV positivity in follow-up showed a recurrence rate of 21.7% against 3.8% in patients who were HPV-negative (p = 0.002, Logrank test). Among women with negative high-risk HPV tests in follow-up, recurrences occurred in 20.0% of non-usual-type histology vs. 2.1% of usual-type cases (p = 0.005). HPV testing in follow-up is of pivotal importance in women with early glandular lesions undergoing conservative treatment, given its recurrence predictive value. However, women who are high-risk HPV-negative in follow-up with non-usual-type histopathology may represent a sub-population at increased risk of recurrences. Further studies should confirm these findings.

Collider bias in strategy and management research: An illustration using women CEO's effect on other women's career outcomes

AbstractResearch SummaryCollider bias can cause spurious correlations when researchers condition on a variable that is caused by—or shares a common cause with—both the outcome and the exposure variable. Despite its threat to inference, empirical research in strategy and management has largely overlooked the issue of collider bias. We distinguish colliders from other threats to identification and estimation and illustrate its importance with replications of published work suggesting that having a woman CEO reduces the career outcomes (compensation and representation) of other women executives. After accounting for collider bias, we find no evidence that women CEOs damage the career outcomes of other women in their organizations. We close by providing generalizable approaches to identify and mitigate the risk of collider bias in applied research.Managerial SummaryCollider bias is a type of statistical problem that can generate misleading results in empirical research. Although research in strategy and management has given substantial attention to other types of statistical problems, the issue of collider bias has not received sufficient scrutiny. We illustrate this point with replications of published work suggesting that having a woman CEO reduces the career outcomes of other women executives. After accounting for collider bias, we find no evidence that women CEOs damage the career outcomes of other women in their organizations. We provide advice for detecting and addressing collider bias in empirical research.

Disease exposure in infancy affects women's reproductive outcomes and offspring health in southern Sweden 1905–2000

Ample evidence demonstrates that early-life adversity negatively affects morbidity and survival in late life. We show that disease exposure in infancy also has a continuous impact on reproduction and health across the female life course and even affects early-life health of the next generation. Using Swedish administrative data, obstetric records, and local infant mortality rates as a measure of disease exposure, we follow women's reproductive careers and offspring health 1905–2000, examining a comprehensive set of outcomes. Women exposed to disease in infancy give birth to a lower proportion of boys, consistent with notions that male fetuses are more vulnerable to adverse conditions and are more often miscarried. Sons of exposed mothers are also more likely to be born preterm and have higher birthweight suggesting in utero out-selection. Exposed women have a greater risk of miscarriage and of male stillbirth, but their overall likelihood of giving birth is not affected.

IDF23-0464 Glycemic Control, Insulin Requirements and Pregnancy Outcomes In Women With Type 1 Diabetes In Pregnancy.

IDF23-0464 Glycemic Control, Insulin Requirements and Pregnancy Outcomes In Women With Type 1 Diabetes In Pregnancy.

Visceral Adipose Tissue Percentage Compared to Body Mass Index as Better Indicator of Surgical Outcomes in Women With Obesity and Endometrial Cancer

Study ObjectiveTo assess the impact visceral adipose tissue percentage (VAT%) on surgical outcomes during minimally invasive surgery in obese women with endometrial cancer. DesignRetrospective observational cohort study. SettingMie University Hospital, Japan. PatientsOf the 73 women (body mass index [BMI] >30 kg/m2) with obesity and primary endometrial cancer, 52 underwent robotic surgery, while 21 underwent laparoscopic surgery between April 2014 and December 2022. InterventionsWe investigated the correlation between surgical outcomes (operative time and blood loss) and obesity (BMI and visceral adipose tissue percentage [VAT%]). Measurements and Main ResultsAbdominal fat-related parameters were measured at the level of the umbilicus using preoperative computed tomography. A weak negative correlation was found between BMI and VAT% (CC = −0.313, p = .001). Multivariate analysis showed that VAT% had a stronger correlation to total and practical operative time than BMI (β = 0.338 vs 0.267, β = 0.311 vs 0.209, respectively) and was an independent predictor of blood loss. VAT% was an independent predictive marker prolonged for operative time and increased blood loss during lymphadenectomy. ConclusionVAT% could be an indicator of surgical outcomes for patients with obesity and endometrial cancer.

Assessment of Postmastectomy Radiation Therapy Receipt by Age and Association With Outcomes in Women With Breast Cancer

PurposePostmastectomy radiation therapy (PMRT) reduces locoregional recurrence (LRR) and improves overall survival (OS) in patients with breast cancer. Young age has been recognized as a risk factor for LRR. The primary objective of this study was to determine if recommendations for PMRT differed among patients younger than 50 years as compared to women aged 50 years or older. MethodsWe reviewed medical records of patients with breast cancer who underwent mastectomy with or without PMRT from 2010 through 2018. Univariable and multivariable models were used to estimate the association of age with PMRT. ResultsOf 2471 patients, 839 (34%) were <50 years; 1632 (66%) were ≥50 years. Patients <50 years had a higher percentage of grade 3 tumors, hormone receptor (HR) negative and/or Her-2/neu positive tumors, clinical stage T2/T3 tumors, and nodal involvement. Compared with patients ≥50 years, patients <50 years were more likely to undergo PMRT (OR 1.57; P = .001) and regional node irradiation (RNI) to the internal mammary nodes. Advanced clinical and pathologic stage, invasive tumor histology, the presence of lymphovascular invasion, and treatment with systemic chemotherapy were predictors of PMRT receipt for patients <50 years (P < .05). PMRT was associated with improved OS and recurrence free survival (RFS) among all patients (P < .01). ConclusionPatients <50 years were more likely to undergo PMRT and to receive RNI to the internal mammary nodes but were also more likely to have other risk factors for recurrence that would warrant a PMRT recommendation. PMRT improved OS and RFS for all patients.

Management and Outcome of Women with Placenta Accreta Spectrum and Treatment with Uterine Artery Embolization.

Placenta accreta spectrum (PAS) disorders are a continuum of placental pathologies with increased risk for hemorrhage, blood transfusion and maternal morbidity. Uterine artery embolization (UAE) is a safe approach to the standardization of complex PAS cases. The aim of this study is to analyze anemia and transfusion rate, outcome and anesthesiological management of women who underwent caesarean delivery with subsequent UAE for the management of PAS. This retrospective observational study included all pregnant women admitted to the University Hospital Frankfurt between January 2012 and September 2023, with a diagnosis of PAS who underwent a two-step surgical approach for delivery and placenta removal. Primary procedure included cesarean delivery with subsequent UAE, secondary procedure included placenta removal after a minim of five weeks via curettage or HE. Maternal characteristics, anesthesiological management, complications, anemia rate, blood loss and administration of blood products were analyzed. In total, 17 women with PAS were included in this study. Of these, 5.9% had placenta increta and 94.1% had placenta percreta. Median blood loss was 300 (200-600) mL during primary procedure and 3600 (450-5500) mL during secondary procedure. In total, 11.8% and 62.5% of women received red blood cell transfusion during the primary and secondary procedures, respectively. After primary procedure, postpartum anemia rate was 76.5%. The HE rate was 64.7%. Regional anesthesia was used in 88.2% during primary procedure. The embolization of the uterine artery for women diagnosed with PAS is safe. Anemia management and the implementation of blood conservation strategies are crucial in women undergoing UAE for the management of PAS.

The Effects of Thiamine Supplementation on General Health and Infertility Treatment Outcomes in Women with Polycystic Ovary Syndrome: A Triple-Blinded Randomized Placebo-Controlled Clinical Trial.

The aim of this study was to evaluate the effects of thiamine (vitamin B1) on general health and infertility treatment outcomes in women with polycystic ovary syndrome (PCOS). The study is a triple-blinded, randomized, placebo-controlled clinical trial performed on 64 infertile women with PCOS referred to Sarem Hospital in Tehran, Iran. The primary outcomes of the study were general health and infertility treatment outcomes. Eligible women were randomly assigned to the vitamin B1 group (n=32, vitamin B1 tablet at a dose of 300 mg/day for 4 weeks) or the placebo group (n=32, placebo tablet daily for 4 weeks). A general health questionnaire was completed before and after the intervention by both groups, and treatment success was evaluated at the end of the study. Data were analyzed using SPSS software ver.16 P<0.05 was considered statistically significant. The mean age of participants in the vitamin B1 (VB1) group was 30.4 ± 3.27 years and in the placebo (Pl) group was 29.1 ± 2.66 years with the mean duration of marriage 12.7 ± 3.01 and 13.2 ± 2.97 years respectively. Our results showed that there were significant differences between the two groups in overall score (P<0.001) and scores for all domains of the general health questionnaire including somatic symptoms (P<0.001), anxiety and insomnia (P<0.001), social dysfunction (P=0.028), and severe depression (P<0.001) after the intervention. Four weeks consumption of vitamin B1 also resulted in higher numbers of positive pregnancy tests (P=0.006), although the number of fetuses was not significantly different between the two groups after the intervention. The results of the current study support a possible favourable effect of vitamin B1 on improving general health, infertility treatment outcome, and retrieved follicle count without changing the number of fetuses in women with polycystic ovary syndrome (registration number: IRCT201510266917N3).

Pritchard's Regimen: The Effect of 12-Hour Versus 24-Hour Magnesium Sulphate Maintenance Regimen on the Occurrence of Seizures and Maternal Outcome in Women with Severe Features of Preeclampsia: A Triple-Blind Randomized Controlled Trial.

Magnesium sulphate (MgSO4) administered for twenty-four hours is the drug of choice for seizure prophylaxis in patients with preeclampsia with severe features. Due to its narrow therapeutic index, a reduction in the duration of MgSO4 administered in the postpartum period may not only prevent the occurrence of seizures but also reduce the adverse effects associated with this drug. This study aimed to compare the efficacy of the 12-hour and 24-hour Pritchard's MgSO4 maintenance regimen on the occurrence of seizures and maternal outcomes in patients with preeclampsia with severe features. A triple-blind randomized controlled trial was conducted among women with preeclampsia with severe features between 1st June 2022 and January 31st, 2023. The primary outcome measure was the occurrence of seizure in either arm of the study. One hundred and forty-six women were randomized into two groups, those who received a 12-hour MgSO4 regimen and placebo for the remaining twelve hours (Group I) and those who received a 24-hour MgSO4 regimen in the postpartum period (Group II). The collected data was coded and analyzed using Statistical Product and Service Solutions (SPSS) version 26 and p<0.05 was considered significant. There was no statistically significant difference between the two groups concerning the occurrence of seizures, the need to recommence MgSO4, clinical evidence of toxicity and adverse effects of MgSO4. There was also no statistically significant difference between the two groups in the total dose of MgSO4 administered, duration of urethral catheterization and duration of hospital admission. No maternal mortality was recorded in this study. The results of this study suggest that the 12-hour MgSO4 maintenance regimen is as efficacious as the traditional 24-hour regimen in preventing seizures without worsening maternal outcomes.

Impact of Restricted Treatment Duration of Metoclopramide on Clinical Outcomes in Women with Hyperemesis Gravidarum

Impact of Restricted Treatment Duration of Metoclopramide on Clinical Outcomes in Women with Hyperemesis Gravidarum

Prevalence of Adverse Pregnancy Outcomes in Women With and Without Gestational Diabetes Mellitus in Al-Baha Region, Saudi Arabia.

Gestational diabetes mellitus (GDM) is a condition characterized by glucose intolerance that develops during pregnancy. It is associated with adverse maternal and fetal outcomes and has long-term health implications for both the mother and the child. This study aimed to estimate the prevalence of adverse pregnancy outcomes in women with and without GDM in the Al-Baha region, Saudi Arabia. A cross-sectional study was conducted in the Al-Baha region from April 2023 to November 2023. The study included mothers residing in the Al-Baha region who were willing to participate and had access to a social media account. A simple random sampling technique was used, and the estimated sample size was 422. A self-administered electronic questionnaire was used to collect data on socio-demographic and lifestyle factors, as well as the pregnancy outcomes of diabetic and non-diabetic mothers. Descriptive and inferential statistical analyses were performed using IBM SPSS Statistics for Windows, Version 28.0 (Released 2012; IBM Corp., Armonk, New York, United States). We included 422 women in the study with the majority of participants in the age group of 36-40 years(15.4%, n=74). Most participants (66.6%, n=321) had attained a university degree, and a significant proportion resided in Al-Baha City (52.3%, n=252). Maternal outcomes indicated a significant association between GDM and the development of eclampsia (OR = 8.296, 95%CI: 4.353-15.810, p < 0.001), as well as an increased risk of thyroid diseases (OR = 2.723, 95%CI: 1.428-5.193, p = 0.002). Fetal outcomes revealed a significant association between GDM and respiratory distress/lack of oxygen in newborns (OR = 2.032, 95%CI: 1.085-3.805, p = 0.024), and infants of GDM patients had a higher risk of hypoglycemia (OR = 8.099, 95%CI: 3.350-19.581, p < 0.001). We found that GDM increased the risk of complications such as eclampsia, thyroid problems, and postpartum hemorrhage.GDM was also associated with shorter pregnancy durations, higher cesarean section rates, and an increased risk of developing type 2 diabetes post pregnancy. The study emphasized the importance of comprehensive GDM therapy and monitoring.

Off‐farm employment and body mass index among agrarian women in sub‐Saharan Africa

AbstractThe relationship between employment and women's weight outcomes in sub‐Saharan Africa (SSA) is less studied. In this study, we use nearest‐neighbor matching to analyze the association between off‐farm employment and women's body mass index (BMI), using data from 364,426 adult women from 36 SSA countries. We find that employment off‐farm is associated with improvement in women's weight status. Off‐farm employment is associated with higher BMI in women (by 1.6%), and lower BMI among obese and overweight women (by 28% and 16%, respectively). These findings provide information that could guide policymakers working at the intersection of women's health and employment.

Fetal Outcome in Women of Pre-Eclampsia

Background: Pre-eclampsia, a serious condition characterized by high blood pressure in pregnant women, presents significant health risks for both the mother and fetus. This study aimed to assess the impact of pre-eclampsia on fetal outcomes in the Pakistani population, recognizing the condition's high prevalence and its role in maternal and neonatal morbidity and mortality. Objective: To evaluate the fetal outcome in women with pre-eclampsia in the Pakistani population. Methods: This descriptive case series was conducted at the Department of Obstetrics and Gynaecology, University College of Medicine and Dentistry Lahore, from January to June 2023. A total of 93 patients were enrolled to study the effects of pre-eclampsia on mothers and fetuses. Results: Among the 93 patients, the mean age was 37.59±6.37 years. The age distribution predominantly included women aged 31-35 years, followed by those in the 36-40 and 41-45 age groups. Severe pre-eclampsia was observed in 69.9% of patients, while 30.1% had mild pre-eclampsia. The fetal outcomes were as follows: 65.5% good, 12.9% stillbirth, and 21.5% neonatal death, with an insignificant P-value. Conclusion: The study concluded that the high prevalence of pre-eclampsia in the community is alarming, significantly increasing the risk of adverse outcomes for infant health and well-being. There is a critical need to educate women about the signs and symptoms of pre-eclampsia.

Characteristics and Outcomes of Women and Infants Who Received Prenatal Care While Incarcerated in Arkansas State Prison System, 2014-2019.

Prisons face challenges in meeting the unique health care needs of women, especially those who are pregnant. This retrospective chart review sought to describe the maternal and infant health outcomes of incarcerated women who received prenatal care while in an Arkansas prison. Using a hospital-based electronic medical records (EMR) system, we examined the maternal health history and current pregnancy characteristics of 219 pregnant women who received prenatal care while incarcerated from June 2014 to May 2019. We also examined labor and delivery characteristics and postpartum and infant birth outcomes for the 146 women from this cohort who delivered a living child while still incarcerated. Most records indicated complex health histories with several chronic illnesses, mental health diagnoses, history of substance use, and lifetime medical complications. Despite comorbid illness, substance use disorder (SUD), trauma-history, and post-traumatic stress disorder (PTSD) prevalence was lower than expected. Previous and current obstetrical complications were common. Although the Neonatal Intensive Care Unit (NICU) admission rate (41%) was high, few infants required extensive treatment intervention. Postpartum complications were rare; however, a small portion of women who gave birth in custody experienced severe complications and were re-admitted to the hospital post-discharge. Incarcerated pregnant women and their infants are a marginalized population in great need of health care advocacy. To optimize maternal-infant outcomes, carceral agencies must recognize the health needs of incarcerated pregnant women and provide appropriate prenatal care. Expansion of carceral perinatal care to include screening for SUD and psychiatric symptoms (e.g., PTSD) and referral to appropriate care is highly encouraged. Policies related to NICU admission for non-medical reasons should be further examined.