Neonatal Abstinence Syndrome: Trend and Expenditure in Louisiana Medicaid, 2003–2013

Objectives Determine trends in incidence and expenditure for perinatal drug exposure and neonatal abstinence syndrome (NAS) among Louisiana’s Medicaid population. We also describe the maternal characteristics of NAS affected infants. Methods Retrospective cohort analysis using linked Medicaid and vital records data from 2003 to 2013. Conducted incidence and cost trends for drug exposed infants with and without NAS. Also performed comparison statistics among drug exposed infants with and without NAS and those not drug exposed. Results As rate of perinatal drug exposure increased, NAS rate per 1000 live Medicaid births also increased, from 2.1 (2003) to 3.6 (2007) to 8.0 (2013) (P for trend?<0.0001). Total medical cost paid by Medicaid also increased from $1.3 million to $3.6 million to $8.7 million (P for trend?<0.0001). Compared with drug exposed infants without NAS and those not drug exposed, infants with NAS were more likely to be white, have feeding difficulties, respiratory distress syndrome, sepsis, and seizures, all of which had an association at P?<?0.0001. Over one-third (33.2%) of the mothers of infants with NAS had an opioid dependency in combination with a mental illness; with depression being most common. Conclusions for Practice Over an 11-year period, NAS rate among Louisiana’s Medicaid infants quadrupled and the cost for caring for the affected infants increased six-fold. Medicaid, as the predominant payer for pregnant women and children affected by substance use disorders, must play a more active role in expanding access to comprehensive substance abuse treatment programs.     

Pregnancy Outcomes of American Indians: Contrasts Among Regions and with Other Ethnic Groups

Objectives The two-fold purpose of this analysis is first to contrast the maternal risk factors and birth outcomes of American Indians (AIs) with other race/ethnic groups and to compare the maternal risk factors and birth outcomes of AIs by region to assess whether there are geographic variations in the adverse outcomes that might suggest intervention strategies. Study Design This study used the National Center for Health Statistics live birth infant death cohort files from 1995–2001. Singleton live births to U.S. resident mothers were selected. The analyses were limited to non-Hispanic American Indians, including Aleuts and Eskimos (n = 239,494), Non-Hispanic White (n = 15,488,133), and Hispanic births (n = 5,284,978). Results This comparison of birth characteristics and outcomes by ethnic group revealed that AIs have more adverse maternal risk factors (e.g., unmarried and <18 years of age) than Whites and Hispanics. After adjustment for these factors, AIs have higher risks of low birth weight and preterm birth and elevated risks of postneonatal and infant mortality. Their cause-specific rates for perinatal, SIDS, injury and infection are also higher. The regional analysis indicated the South/Northeast have more low birth weight and preterm problems, but the Mid-West has the highest risks of infant mortality among LBW infants gestational age-specific mortality rates, and mortality from SIDS. Conclusions These data show that AIs are not a homogenous group as evinced by distinct regional differences. SIDS is mainly a problem in the Mid-West, suggesting the involvement of environmental factors in that region. Further investigation is needed to examine the current AI perinatal health concerns.     

Part C Early Intervention Enrollment in Low Birth Weight Infants At-Risk for Developmental Delays

Objectives To investigate enrollment patterns in Part C Early Intervention (EI) for low birth weight (LBW) infants (≤2500 g). A secondary aim is to characterize LBW infants that are not enrolled in EI, but would qualify by meeting criteria for a condition associated with a “high-probability” for developmental delays (i.e., Intraventricular Hemorrhage grade III or higher, Apgar score of ≤5 at 5 min, and/or birth weight of ≤1200 g). Methods Data were gathered from 165 LBW infants participating in a high-risk infant follow-up program. Developmental assessment was completed. Basic demographic information and data regarding enrollment in EI were collected via parent questionnaire. Medical variables were extracted from each infant’s electronic medical record. Results 71.5 % of LBW infants were not enrolled in EI. Factors influencing probability of EI enrollment included birth weight, gestational age, developmental test scores, and insurance status. Of the 107 infants living in Oregon who were not enrolled in EI, 42.1 % would qualify for services due to an early medical condition identified in Oregon as a condition associated with a “high-probability” for developmental delays. Conclusions Less than one third of LBW infants were enrolled in EI by their first visit to a high-risk infant follow-up program. Those infants demonstrating developmental delays and public insurance were more likely to be enrolled. The majority of infants who have readily identifiable medical risk factors that qualify them for EI were not enrolled. This study was limited by the constraints implicated by using a clinical sample.     

Deployment and Adverse Pregnancy Outcomes: Primary Findings and Methodological Considerations

Objective To characterize the pregnancy outcomes of women Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans including prevalence of preterm delivery, low birth weight, and macrosomia, and to highlight methodological limitations that can impact findings. Methods A retrospective cohort study was conducted starting in 2014 analyzing data from the 2009 to 2011 National Health Study for a New Generation of US Veterans, which sampled Veterans deployed and not deployed to OIF/OEF. All pregnancies resulting in a live birth were included, and categorized as occurring among non-deployers, before deployment, during deployment, or after deployment. Outcomes included preterm birth, low birth weight, and macrosomia. The association of deployment with selected outcomes was estimated using separate general estimating equations to account for lack of outcome independence among women contributing multiple pregnancies. Adjustment variables included maternal age at outcome, and race/ethnicity. Results There were 2276 live births (191 preterm births, 153 low birth weight infants, and 272 macrosomic infants). Compared with pregnancies before deployment, pregnancies among non-deployers and those after deployment appeared to have greater risk of preterm birth [non-deployers: odds ratio (OR) = 2.16, 95 % confidence interval (CI) 1.25, 3.72; after deployment: OR = 1.90, 95 % CI 0.90, 4.02]. A similar pattern was observed for low birth weight. No association of deployment with macrosomia was detected. Discussion Compared with non-deployers, those who eventually deploy appear to have better pregnancy outcomes prior to deployment, but this advantage is no longer apparent after deployment. Non-deployers may not be an appropriate reference group to study the putative health impacts of deployment on pregnancy outcomes.     

Group Prenatal Care Results in Medicaid Savings with Better Outcomes: A Propensity Score Analysis of CenteringPregnancy Participation in South Carolina

Objectives This study was undertaken to determine the cost savings of prevention of adverse birth outcomes for Medicaid women participating in the CenteringPregnancy group prenatal care program at a pilot program in South Carolina. Methods A retrospective five-year cohort study of Medicaid women was assessed for differences in birth outcomes among women involved in CenteringPregnancy group prenatal care (n = 1262) and those receiving individual prenatal care (n = 5066). The study outcomes examined were premature birth and the related outcomes of low birthweight (LBW) and neonatal intensive care unit (NICU) visits. Because women were not assigned to the CenteringPregnancy group, a propensity score analysis ensured that the inference of the estimated difference in birth outcomes between the treatment groups was adjusted for nonrandom assignment based on age, race, Clinical Risk Group, and plan type. A series of generalized linear models were run to estimate the difference between the proportions of individuals with adverse birth outcomes, or the risk differences, for CenteringPregnancy group prenatal care participation. Estimated risk differences, the coefficient on the CenteringPregnancy group indicator variable from identity-link binomial variance generalized linear models, were then used to calculate potential cost savings due to participation in the CenteringPregnancy group. Results This study estimated that CenteringPregnancy participation reduced the risk of premature birth (36 %, P < 0.05). For every premature birth prevented, there was an average savings of $22,667 in health expenditures. Participation in CenteringPregnancy reduced the incidence of delivering an infant that was LBW (44 %, P < 0.05, $29,627). Additionally, infants of CenteringPregnancy participants had a reduced risk of a NICU stay (28 %, P < 0.05, $27,249). After considering the state investment of $1.7 million, there was an estimated return on investment of nearly $2.3 million. Conclusions Cost savings were achieved with better outcomes due to the participation in CenteringPregnancy among low-risk Medicaid beneficiaries.     

Utility of Population Attributable Fraction Assessment in Guiding Interventions to Reduce Low Birthweight in the High-Altitude State of Colorado

Objectives We evaluated the ability of population attributable fraction (PAF) assessments to alter significant modifiable risks for low birthweight (LBW) and the impact of high altitude as a risk for LBW in Colorado. Methods Logistic regression analysis of birth certificate parameters in 1995–1997 identified risk factors for PAF assessment. PAF for birth at high altitude, multiple births, and LBW in singleton births were determined. Subsequent analysis of singleton LBW risks, using number needed to treat (NNT) analysis, estimated how elimination of major modifiable risk factors could reduce LBW in the study population. Public health interventions were initiated and PAF analysis conducted 12 years afterward to determine the effect of interventions. Results PAF in singleton births revealed low maternal weight gain in pregnancy and maternal smoking as the greatest modifiable attributable risk factors for LBW (12.7/12.5 %, respectively, in 1995–1997 and 12.9/7.1 % in 2007–2009). Significant interaction between these variables resulted in PAF of 34.4 % when the two occurred together in 1995–1997, decreasing to 19.4 % in 2007–2009. NNT analysis of singleton births in 1995–1997 revealed that eliminating low maternal weight gain, smoking, late prenatal care in all women and interpregnancy intervals <1 year in multiparous women reduced LBW by 46.5 %. The respective proportional reductions in PAF of 40.3 and 46.3 % for maternal smoking and weight gain/smoking interaction were associated with a 1.4 % LBW reduction in singleton births between the two study periods. Conclusions for Practice PAF and NNT analyses are valuable tools to predict intervention targets to lower LBW.     

Changing patterns of low birthweight and preterm birth in the United States, 1981-98

Low birthweight (LBW) and preterm birth are primary risk factors for infant morbidity and mortality in the US. With increasing multiple births and delayed childbearing, it is important to examine the separate contributions of these characteristics to the increases in LBW and preterm birth rates. US natality records from 1981, 1990 and 1998 were used to calculate LBW (% births <1500, 1500-2499, <2500 g) and preterm (% births <29, 29-32, 33-36, <37 weeks gestation) rates. Data were stratified by maternal race (black or white) and plurality (singleton vs. multiple birth). LBW and preterm rates among singletons were adjusted for maternal age to examine the influence of demographic shifts on LBW trends. From 1981 to 1998, LBW increased 12% among white infants, but remained relatively stable among black infants. During the same time, preterm birth increased 23% among white infants compared with 3% among black infants. For both black and white infants, the increase in LBW and preterm births was greater among multiple births than among singletons. Adjustment for maternal age did not reduce the temporal increase in LBW or preterm birth among singletons. Black infants continue to experience a markedly higher incidence of LBW and preterm birth, but the racial gap in these outcomes has narrowed slightly in recent years as a result of increasing LBW and preterm birth among white births. The differing trends for white and black infants are the consequence of a disparate trend in the incidence and outcome of multiple births coupled with increases in LBW and preterm birth among white singletons. Understanding the differential patterns in birth outcomes among white and black infants is necessary to develop effective interventions designed to decrease racial disparities in pregnancy outcome.     

The Relation of Maternal Birth Weight to African-American and Non-Latina White Twin Pregnancy Outcomes: A Population-Based Study

Objectives The authors investigated the association between maternal birth weight and adverse birth outcome as measured by rates of low birth weight (<2500 g, LBW), preterm birth (<37 weeks, PTB), and small for gestational age (weight <10th percentile for gestational age, SGA) among African American and White twin pregnancies. Methods Stratified and multivariable regression analyses were performed on the Illinois transgenerational dataset of non-Latina African American and non-Latina White twin pairs (born 1989–1991) and their mothers (born 1956–1976). Results Former LBW (n = 104) and non-LBW (n = 742) African American mothers had LBW rates in both twins of 76 and 56 %, respectively; RR (95 % CI) = 1.4 (1.2–1.6). Former LBW (n = 105) and non-LBW (n = 2136) White mothers had LBW rates in both twins of 41 and 34 %, respectively; RR = 1.2 (0.9–1.5). In multivariable regression models, the adjusted (controlling for maternal age, education, marital status, parity, prenatal care usage, and cigarette smoking) RR of LBW in both twins among former LBW (compared to non-LBW) African American and White mothers equaled 1.4 (1.2–1.6) and 1.2 (0.9–1.5), respectively. Maternal LBW was associated with a modestly increased risk of PTB but not SGA among African American twin pregnancies: adjusted RR = 1.3 (1.1–1.4) and 1.1 (0.8–1.5), respectively. Conclusions In African American twin pregnancies, maternal LBW is a risk factor for LBW in both twins. Further research is needed to determine whether a similar generational association occurs among non-Latina White twin pregnancies.     

Racial Differences in DNA-Methylation of CpG Sites Within Preterm-Promoting Genes and Gene Variants

Objective To evaluate the role DNA methylation may play in genes associated with preterm birth for higher rates of preterm births in African-American women. Methods Fetal cord blood samples from births collected at delivery and maternal demographic and medical information were used in a cross-sectional study to examine fetal DNA methylation of genes implicated in preterm birth among black and non-black infants. Allele-specific DNA methylation analysis was performed using a methylation bead array. Targeted maximum likelihood estimation was applied to examine the relationship between race and fetal DNA methylation of candidate preterm birth genes. Receiver-operating characteristic analyses were then conducted to validate the CpG site methylation marker within the two racial groups. Bootstrapping, a method of validation and replication, was employed. Results 42 CpG sites were screened within 20 candidate gene variants reported consistently in the literature as being associated with preterm birth. Of these, three CpG sites on TNFAIP8 and PON1 genes (corresponding to: cg23917399; cg07086380; and cg07404485, respectively) were significantly differentially methylated between black and non-black individuals. The three CpG sites showed lower methylation status among infants of black women. Bootstrapping validated and replicated results. Conclusion for Practice Our study identified significant differences in levels of methylation on specific genes between black and non-black individuals. Understanding the genetic/epigenetic mechanisms that lead to preterm birth may lead to enhanced prevention strategies to reduce morbidity and mortality by eventually providing a means to identify individuals with a genetic predisposition to preterm labor.     

Cost Implications for Subsequent Perinatal Outcomes After IVF Stratified by Number of Embryos Transferred: A Five Year Analysis of Vermont Data

Background

In states in the USA without in vitro fertilzation coverage (IVF) insurance coverage, more embryos are transferred per cycle leading to higher risks of multi-fetal pregnancies and adverse pregnancy outcomes.

Objective

To determine frequency and cost of selected adverse perinatal complications based on number of embryos transferred during IVF, and calculate incremental cost per IVF live birth.

Methods

Medical records of patients who conceived with IVF (n = 116) and delivered at >20 weeks gestational age between 2007 and 2011 were evaluated. Gestational age at delivery, low birth weight (LBW) term births, and delivery mode were tabulated. Healthcare costs per cohort, extrapolated costs assuming 100 patients per cohort, and incremental costs per infant delivered were calculated.

Results

The highest prematurity and cesarean section rates were recorded after double embryo transfers (DET), while the lowest rates were found in single embryo transfers (SET). Premature singleton deliveries increased directly with number of transferred embryos [6.3 % (SET), 9.1 % (DET) and 10.0 % for ≥3 embryos transferred]. This trend was also noted for rate of cesarean delivery [26.7 % (SET), 36.6 % (DET), and 47.1 % for ≥3 embryos transferred]. The proportion of LBW infants among deliveries after DET and for ≥3 embryos transferred was 3.9 and 9.1 %, respectively. Extrapolated costs per cohort were US$718,616, US$1,713,470 and US$1,227,396 for SET, DET, and ≥3 embryos transferred, respectively.

Conclusion

Attempting to improve IVF pregnancy rates by permitting multiple embryo transfers results in sharply increased rates of multiple gestation and preterm delivery. This practice yields a greater frequency of adverse perinatal outcomes and substantially increased healthcare spending. Better efforts to encourage SET are necessary to normalize healthcare expenditures considering the frequency of very high cost sequela associated with IVF where multiple embryo transfers occur.

     

Obesity,Diabetes, and Birth Outcomes Among American Indians and Alaska Natives

Objectives To examine the relationships between prepregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), and prepregnancy body mass index, with several adverse birth outcomes: preterm delivery (PTB), low birthweight (LBW), and macrosomia, comparing American Indians and Alaska Natives (AI/AN) with other race/ethnic groups. Methods The sample includes 5,193,386 singleton US first births from 2009–2013. Logistic regression is used to calculate adjusted odds ratios controlling for calendar year, maternal age, education, marital status, Kotelchuck prenatal care index, and child’s sex. Results AI/AN have higher rates of diabetes than all other groups, and higher rates of overweight and obesity than whites or Hispanics. Neither overweight nor obesity predict PTB for AI/AN, in contrast to other groups, while diabetes predicts increased odds of PTB for all groups. Being overweight predicts reduced odds of LBW for all groups, but obesity is not predictive of LBW for AI/AN. Diabetes status also does not predict LBW for AI/AN; for other groups, LBW is more likely for women with DM or GDM. Overweight, obesity, DM, and GDM all predict higher odds of macrosomia for all race/ethnic groups. Conclusions for Practice Controlling diabetes in pregnancy, as well as prepregnancy weight gain, may help decrease preterm birth and macrosomia among AI/AN.     

Cost effects of preterm birth: a comparison of health care costs associated with early preterm,late preterm,and full-term birth in the first 3 years after birth

Preterm birth is one of the main causes for infant morbidity and mortality. Apart from negative health outcomes, preterm birth also produces significant health care expenditures. This study evaluates the costs associated with preterm birth in different health sectors during the first 3 years of infants’ lives. In a retrospective observational study based on claims data from a German statutory health insurance company, average costs for medication, hospital treatment, ambulatory treatment, and non-medical remedies during the first 3 years after birth were analyzed for early preterm, late preterm, and full-term births. Costs associated with preterm births were generally higher than for full-term births, with the highest costs for the hospital treatment of early preterm births. Cost differences tended to decrease in the second and third year after birth except for ambulatory treatment costs, which decreased for late preterm and full-term births but not for early preterm births. The study shows that preterm birth is associated with increased health care costs, particularly during the first year after birth, indicating that the implementation of adequate programs and policies for preventing preterm birth is not only desirable from a medical but also from a health economic perspective.     

Relationship Between Common Mental Disorder Symptoms During Pregnancy and Preterm Birth Among Chinese Women in Wuhan

Objectives Few studies focus on the symptoms of common mental disorders during pregnancy (CMDP) and risk of preterm birth subtypes (PTB). The purpose of this study was to estimate the association between CMDP and PTB, and to examine whether or not the association between CMDP and PTB varies with the subtype of PTB in Chinese. Methods This population-based case control study, conducted in Wuhan, China, defined cases as every pregnant woman who had a PTB among all births in Wuhan, from June 10, 2011, to June 9, 2013. The same number of pregnant women who had term births was randomly selected as controls. The Electronic Perinatal Health Care Information System, a questionnaire designed for the study, provided data about the participants. Logistic regression analyses were used to model associations betweenCMDP and PTB, and to test associations between CMDP and two subtypes of PTB. Results The study recruited 8616 cases and an equal number of controls. We successfully collected maternal information on 6656 cases and controls for a response rate of 77.3 %. The incidence of PTB in Wuhan was 4.5 %. Spontaneous preterm births (SPTB) accounted for 60.1 %, and medically induced preterm births (IPTB) accounted for 39.9 % of preterm births. The prevalence rate of CMDP was 15.8 %. CMDP was slightly associated with PTB (crude OR 1.16, 95 % CI 1.01–1.32; adjusted OR 1.15, 95 % CI 1.00–1.32), further analyses showed CMDP was associated with IPTB (aOR 1.25, 95 % CI 1.04–1.50), but not with SPTB. Conclusion Our data suggest that CMDP is related to an increased risk of PTB, and that this association is primarily due to IPTB rather than SPTB.     

Estimated Number of Preterm Births and Low Birth Weight Children Born in the United States Due to Maternal Binge Drinking

The objective of this study was to estimate the aggregate burden of maternal binge drinking on preterm birth (PTB) and low birth weight (LBW) across American sociodemographic groups in 2008. To estimate the aggregate burden of maternal binge drinking on preterm birth (PTB) and low birth weight (LBW) across American sociodemographic groups in 2008. A simulation model was developed to estimate the number of PTB and LBW cases due to maternal binge drinking. Data inputs for the model included number of births and rates of preterm and LBW from the National Center for Health Statistics; female population by childbearing age groups from the U.S. Census; increased relative risks of preterm and LBW deliveries due to maternal binge drinking extracted from the literature; and adjusted prevalence of binge drinking among pregnant women estimated in a multivariate logistic regression model using Behavioral Risk Factor Surveillance System survey. The most conservative estimates attributed maternal binge drinking to 8,701 (95 % CI: 7,804–9,598) PTBs (1.75 % of all PTBs) and 5,627 (95 % CI 5,121–6,133) LBW deliveries in 2008, with 3,708 (95 % CI: 3,375–4,041) cases of both PTB and LBW. The estimated rate of PTB due to maternal binge drinking was 1.57 % among all PTBs to White women, 0.69 % among Black women, 3.31 % among Hispanic women, and 2.35 % among other races. Compared to other age groups, women ages 40–44 had the highest adjusted binge drinking rate and highest PTB rate due to maternal binge drinking (4.33 %). Maternal binge drinking contributed significantly to PTB and LBW differentially across sociodemographic groups.     

Birth Settings and the Validation of Neonatal Seizures Recorded in Birth Certificates Compared to Medicaid Claims and Hospital Discharge Abstracts Among Live Births in South Carolina, 1996–2013

Objective Neonatal seizures in the first 28 days of life often reflect underlying brain injury or abnormalities, and measure the quality of perinatal care in out-of-hospital births. Using the 2003 revision of birth certificates only, three studies reported more neonatal seizures recorded among home births ?or planned out-of-hospital births compared to hospital births. However, the validity of recording neonatal seizures or serious neurologic dysfunction across birth settings in birth certificates has not been evaluated. We aimed to validate seizure recording in birth certificates across birth settings using multiple datasets. Methods We examined checkbox items “seizures” and “seizure or serious neurologic dysfunction” in the 1989 and 2003 revisions of birth certificates in South Carolina from 1996 to 2013. Gold standards were ICD-9-CM codes 779.0, 345.X, and 780.3 in either hospital discharge abstracts or Medicaid encounters jointly. Results Sensitivity, positive predictive value, false positive rate, and the kappa statistic of neonatal seizures recording were 7%, 66%, 34%, and 0.12 for the 2003 revision of birth certificates in 547,177 hospital births from 2004 to 2013 and 5%, 33%, 67%, and 0.09 for the 1998 revision in 396,776 hospital births from 1996 to 2003, and 0, 0, 100%, ?0.002 among 660 intended home births from 2004 to 2013 and 920 home births from 1996 to 2003, respectively. Conclusions for Practice Despite slight improvement across revisions, South Carolina birth certificates under-reported or falsely reported seizures among hospital births and especially home births. Birth certificates alone should not be used to measure neonatal seizures or serious neurologic dysfunction.     

Electronic Medical Record Use and Maternal and Child Care and Health

Objectives To evaluate effects of EHR adoption and use during pregnancy on maternal and child health care utilization and health among pregnant mothers and their infants. Methods The study population was comprised of all Medicaid-insured pregnant women who delivered a singleton birth in Michigan between 1/1/2009 and 12/31/2012 and their infants (N = 226,558). Linked data included birth records, maternal and infant medical claims, and EHR adoption, implementation, upgrading and meaningful use data. Pre-post comparisons with a control group (difference-in-difference) took advantage of a natural experiment of EHR adoption and use among providers in Michigan. Women and infants who received care from providers who adopted and used EHR were compared with those who received care from other providers, in a quasi-experimental framework. Results Over 34 % of all women in the analytic sample received perinatal care from providers who adopted and used EHR. Multivariate regressions indicate that women who received prenatal care mainly from a provider who adopted and used EHR were more likely to have any well-child visits (0.05, p = 0.04), and the appropriate number of well-child visits during the first year of life (0.03, p < 0.01). Conclusions The findings of this study are consistent with EHR adoption and use supporting improved child health care utilization. The findings have the potential to provide Medicaid and other healthcare program officials with evidence of the potential gains to be derived from EHRs for vulnerable low-income women and infants.     

Effect of Modifiable Risk Factors on Preterm Birth: A Population Based-Cohort

Objectives The purpose of this study is to evaluate the prevalence, impact, and interaction of short interpregnancy interval (IPI), pre-pregnancy body mass index (BMI) category, and pregnancy weight gain (PWG) on the rate of preterm birth. Methods This is a population-based retrospective cohort study using vital statistics birth records from 2006 to 2011 in OH, US, analyzing singleton live births to multiparous mothers with recorded IPI (n?=?393,441). Preterm birth rate at <37 weeks gestational age was compared between the referent pregnancy (defined as normal pre-pregnancy maternal BMI, IPI of 12–24 months, and Institute of Medicine (IOM) recommended PWG) and those with short or long IPI, abnormal BMI (underweight, overweight, and obese), and high or low PWG (under or exceeding IOM recommendations). Results Only 6?% of the women in this study had a referent pregnancy, with a preterm birth rate of 7.6?% for this group. Short IPIs of <6 and 6–12 months were associated with increased rates of preterm birth rate to 12.9 and 10.4?%, respectively. Low PWG compared to IOM recommendations for pre-pregnancy BMI class was also associated with increased preterm birth rate of 13.2?% for all BMI classes combined. However, the highest rate of preterm birth of 25.2?% occurred in underweight women with short IPI and inadequate weight gain with _adjOR 3.44 (95?% CI 2.80, 4.23). The fraction of preterm births observed in this cohort that can be attributed to short IPIs is 5.9?%, long IPIs is 8.3?%, inadequate PWG is 7.5?%, and low pre-pregnancy BMI is 2.2?%. Conclusions Our analysis indicates that a significant proportion of preterm births in Ohio are associated with potentially modifiable risk factors. These data suggest public health initiatives focused on preterm birth prevention could include counseling and interventions to optimize preconception health and prenatal nutrition.     

An Analysis of Payment Mix Patterns of Preterm Births in a Post-Affordable Care Act Insurance Market: Implications for the Medicaid Program

BackgroundThe United States has a relatively high preterm birth rate compared with other developed nations. Before the enactment of the Affordable Care Act in 2010, many women at risk of a preterm birth were not able to access affordable health insurance or a wide array of preventive and maternity care services needed before, during, and after pregnancy. The various health insurance market reforms and coverage expansions contained in the Affordable Care Act sought in part to address these problems. This analysis aims to describe changes in the patterns of payer mix of preterm births in the context of a post-Affordable Care Act insurance market, explore possible factors for the observed changes, and discuss some of the implications for the Medicaid program.MethodsWe applied a repeated cross-sectional study design to explore payment mix patterns of all births and preterm births between 2011 and 2016, using publicly available National Vital Statistics Birth Data. We included an equal number of years with payment source available in the dataset before and after January 1, 2014, when the coverage expansions became effective.ResultsWe found a small relative change in payment mix during the study period. Private health insurance (PHI) paid for a higher percentage of all births and this rate increased steadily between 2011 and 2016. Preterm births paid by PHI increased by 1.4 percentage points between 2011 and 2016 and self-pay/uninsured preterm births decreased by 0.3 percentage points over the same time period. Medicaid had the highest, and a relatively stable, preterm birth coverage percentage (48.9% in 2011, 49.2% in 2014, and 48.9% in 2016). Medicaid was also more likely to pay for preterm births than PHI, but this likelihood decreased by more than one-half after 2014 (8.2% in 2013 vs. 3.8% in 2014).ConclusionsAfter the 2010 reforms, Medicaid remained a constant source of coverage for the most vulnerable women in society when faced with the high cost of a preterm birth. Nationwide, of the 64 million women ages 15 to 44, 4% gained PHI (directly purchased or employer sponsored) and another 4% Medicaid, with a concomitant 8% decrease in uninsured women of reproductive age between 2013 and 2017. More research is needed to conclude with certainty that the reforms worked as intended, but the important role of Medicaid as a financial safety net is undeniable.     

Association Between Maternal Multivitamin Use and Preterm Birth in 24 States,Pregnancy Risk Assessment Monitoring System, 2009–2010

Objectives The study objective was to examine the prevalence of maternal multivitamin use and associations with preterm birth (<37 weeks gestation) in the United States. We additionally examined whether associations differed by race/ethnicity. Methods Using the Pregnancy Risk Assessment Monitoring System, we analyzed 2009–2010 data among women aged ≥18 years with a singleton live birth who completed questions on multivitamin use 1 month prior to pregnancy (24 states; n = 57,348) or in the last 3 months of pregnancy (3 states, n = 5095). Results In the month prior to pregnancy, multivitamin use ≥4 times/week continued to remain low (36.8 %). In the last 3 months of pregnancy, 79.6 % of women reported using multivitamins ≥4 times/week. Adjusting for confounders, multivitamin use 1–3 times/week or ≥4 times/week prior to pregnancy was not associated with preterm birth overall. Though there was no evidence of dose response, any multivitamin use in the last 3 months of pregnancy was associated with a significant reduction in preterm birth among non-Hispanic black women. Conclusions for Practice Multivitamin use during pregnancy may help reduce preterm birth, particularly among populations with the highest burden, though further investigations are warranted.