Implementation of a clinically integrated breastfeeding peer counselor program.

OBJECTIVE: Reflecting disparities across the US, in 2015 publicly insured patients of the NorthShore Community Health Center (NSCHC) in Evanston, Illinois had lower breastfeeding rates than commercially insured patients. We used the Replicating Effective Programs framework to describe the design and implementation of a clinically-integrated breastfeeding peer counseling (ci-BPC) program to address these disparities. STUDY DESIGN: Patient focus groups and surveys informed program design, and a multidisciplinary clinical support team developed workflows that integrated the breastfeeding peer counselor (BPC) into the clinic and the postpartum unit. RESULTS: ci-BPC improved breastfeeding intensity and duration by providing every NSCHC patient with (1) prenatal lactation education; (2) hands on lactation care in the hospital; and (3) on-demand postpartum support. Total cost per patient was $297-386. The program was sustained after demonstrating potential cost-savings. CONCLUSION: An evidence-based, multidisciplinary collaboration resulted in a sustainable clinically integrated breastfeeding peer counseling program that improved breastfeeding outcomes.

The role of clinic-based breastfeeding peer counseling on breastfeeding rates among low-income patients.

BACKGROUND: Despite the benefits of breastfeeding (BF), rates remain lower than public health targets, particularly among low-income Black populations. Community-based breastfeeding peer counselor (BPC) programs have been shown to increase BF. We sought to examine whether implementation of a BPC program in an obstetric clinical setting serving low-income patients was associated with improved BF initiation and exclusivity. METHODS: This is a quasi-experimental time series study of pregnant and postpartum patients receiving care before and after implementation of a BPC program in a teaching hospital affiliated prenatal clinic. The role of the BPC staff included BF classes, prenatal counseling and postnatal support, including in-hospital assistance and phone triage after discharge. Records were reviewed at each of 3 time points: immediately before the hire of the BPC staff (2008), 1-year post-implementation (2009), and 5 years post-implementation (2014). The primary outcomes were rates of breastfeeding initiation and exclusivity prior to hospital discharge, secondary outcomes included whether infants received all or mostly breastmilk during inpatient admission and by 6 weeks post-delivery. Bivariable and multivariable analyses were utilized as appropriate. RESULTS: Of 302 patients included, 52.3% identified as non-Hispanic Black and 99% had Medicaid-funded prenatal care. While there was no improvement in rates of BF initiation, exclusive BF during the postpartum hospitalization improved during the 3 distinct time points examined, increasing from 13.7% in 2008 to 32% in 2014 (2009 aOR 2.48, 95%CI 1.13-5.43; 2014 aOR 1.82, 95%CI 1.24-2.65). This finding was driven by improved exclusive BF for patients who identified as Black (9.4% in 2008, 22.9% in 2009, and 37.9% in 2014, p = 0.01). CONCLUSION: Inpatient BF exclusivity significantly increased with the tenure of a BPC program in a low-income clinical setting. These findings demonstrate that a BPC program can be a particularly effective method to address BF disparities among low-income Black populations.

Implementation of perinatal quality collaborative statewide initiative improves obstetrical opioid use disorder care and outcomes.

BACKGROUND: Maternal deaths resulting from opioid use disorder have been increasing across the United States. Opioid use disorder among pregnant persons is associated with adverse pregnancy outcomes, including preterm birth, along with racial disparities in optimal opioid use disorder care. OBJECTIVE: This study aimed to evaluate whether the Illinois Perinatal Quality Collaborative implementation of the Mothers and Newborns affected by Opioids - Obstetric quality improvement initiative was associated with improvement in opioid use disorder identification, provision of optimal opioid use disorder care for birthing patients, and reduction in racial gaps in optimal opioid use disorder care. STUDY DESIGN: Using a prospective cohort design, hospitals reported monthly key measures for all patients with opioid use disorder at delivery between July 2018 and December 2020. The Illinois Perinatal Quality Collaborative facilitates collaborative learning opportunities, rapid response data, and quality improvement support. Generalized linear mixed-effects regression models were used to evaluate improvement in optimal opioid use disorder care, including increases in linkages to medication-assisted treatment, recovery treatment services, and naloxone counseling across time, and to determine whether optimal opioid use disorder care was associated with positive outcomes, such as lower odds of preterm birth. RESULTS: A total of 91 hospitals submitted data on 2095 pregnant persons with opioid use disorder. For the primary outcomes, the rates of patients receiving medication-assisted treatment and recovery treatment services improved across the initiative from 41% to 78% and 48% to 67%, respectively. For the secondary outcomes, the receipt of recovery treatment services and both recovery treatment services and medication-assisted treatment provided prenatally before delivery admission was associated with lower odds of preterm birth (adjusted odds ratio: 0.67 [95% confidence interval, 0.50-0.91] and 0.49 [95% confidence interval, 0.31-0.75], respectively). During the first quarter of the initiative, Black patients with opioid use disorder were less likely to be linked to medication-assisted treatment than White patients (23% vs 48%, respectively); however, an increase in medication-assisted treatment rates across the initiative occurred for all patients, with the greatest improvement for Black patients with an associated reduction in this disparity gap with >70% of both Black and White patients linked to medication-assisted treatment. CONCLUSION: The Mothers and Newborns affected by Opioids - Obstetric initiative was associated with improvement in optimal opioid use disorder care for pregnant patients across Illinois hospitals, additionally racial disparities in opioid use disorder care was reduced across the initiative. Our findings implicate how optimal opioid use disorder care can improve pregnancy outcomes and close persistent racial gaps for pregnant individuals with opioid use disorder.

Clinically Integrated Breastfeeding Peer Counseling to Promote Breastfeeding Equity.

OBJECTIVE: This study aimed to determine whether clinically integrated Breastfeeding Peer Counseling (ci-BPC) added to usual lactation care reduces disparities in breastfeeding intensity and duration for Black and Hispanic/Latine participants. STUDY DESIGN: This study is a pragmatic, randomized control trial (RCT) of ci-BPC care at two ci-BPC-naïve obstetrical hospital facilities in the greater Chicago area. Participants will include 720 patients delivering at Hospital Site 1 and Hospital Site 2 who will be recruited from eight prenatal care sites during midpregnancy. Participants must be English or Spanish speaking, planning to parent their child, and have no exposure to ci-BPC care prior to enrollment. Randomization will be stratified by race and ethnicity to create three analytic groups: Black, Hispanic/Latine, and other races. RESULTS: The primary outcome will be breastfeeding duration. Additional outcomes will include the proportion of breastmilk feeds during the delivery admission, at 6-week postdelivery, and at 6-month postdelivery. A process evaluation will be conducted to understand implementation outcomes, facilitators, and barriers to inform replication and scaling of the innovative ci-BPC model. CONCLUSION: This research will produce findings of relevance to perinatal patients and their families, the vast majority of whom desire to provide breastmilk to their infants and require support to succeed with their feeding goals. As the largest RCT of ci-BPC in the United States to date, this research will improve the quality of evidence available regarding the effectiveness of ci-BPC at reducing disparities. These findings will help patients and stakeholders determine the benefits of accepting and adopting the program and inform policies focused on improving perinatal care and reducing maternal/child health disparities. This study is registered with Clinical Trial (identifier: NCT05441709). KEY POINTS: · Ci-BPC can promote racial breastfeeding equity.. · Ci-BPC has not been tested as a generalized lactation strategy in prior trials and is underused.. · This RCT will identify if ci-BPC can reduce breastfeeding disparities for Black and Hispanic patients..

Adaptation of Screening Tools for Social Determinants of Health in Pregnancy: A Pilot Project.

OBJECTIVES: Social determinants of health (SDOH) and stress during pregnancy may contribute to adverse pregnancy outcomes. The objective of this in the field pilot project was to develop a comprehensive screening tool by combining existing validated screeners. Additionally, implement use of this tool within routine prenatal visits and assess feasibility. METHODS: Pregnant patients accessing prenatal care at a single site of an urban Federally Qualified Health Center were recruited during prenatal visits to complete a Social Determinants of Health in Pregnancy Tool (SIPT). SIPT combines a series of questions from existing and well-validated tools and consists of five domains: (1) perceived stress, (2) relationship and family stress, (3) domestic violence, (4) substance abuse, and (5) financial stress. RESULTS: Between April 2018 and March 2019, 135 pregnant participants completed SIPT. Ninety-one percent of patients scored positive on at least one screener, 54% to three or more screeners. CONCLUSIONS: Despite guidelines to screen for SDOH during pregnancy there is no universal tool. Our pilot project demonstrated the concurrent use of adapted screening tools where participants reported at least one area of potential stress, and that linking to resources at the time of a visit is plausible. Future work should examine if screening and point of care linkages of services improves maternal child outcomes.

Maternal exposure to childhood maltreatment and adverse birth outcomes.

Exposure to traumatic events during pregnancy may influence pregnancy and birth outcomes. Growing evidence suggests that exposure to traumatic events well before pregnancy, such as childhood maltreatment (CM), also may influence the course of pregnancy and risk of adverse birth outcomes. We aimed to estimate associations between maternal CM exposure and small-for-gestational-age birth (SGA) and preterm birth (PTB) in a diverse US sample, and to examine whether common CM-associated health and behavioral sequelae either moderate or mediate these associations. The Measurement of Maternal Stress (MOMS) Study was a prospective cohort study that enrolled 744 healthy English-speaking participants ≥ 18 years with a singleton pregnancy, who were < 21 weeks at enrollment, between 2013 and 2015. CM was measured via the Childhood Trauma Questionnaire (CTQ) and participants above the moderate/severe cut-off for any of the five childhood abuse and neglect scales were assigned to the CM-exposed group. Common CM-associated health (obesity, depressive symptoms, hypertensive disorders) and behavioral (substance use) sequelae were obtained from standardized questionnaires and medical records. The main outcomes included PTB (gestational age < 37 weeks at birth) and SGA (birthweight < 10%ile for gestational age) abstracted from the medical record. Multivariable logisitic regression was used to test associations between CM, sequeale, and birth outcomes, and both moderation and mediation by CM-related sequelae were tested. Data were available for 657/744 participants. Any CM exposure was reported by 32% of participants. Risk for SGA birth was 61% higher among those in the CM group compared to the non-CM group (14.1% vs. 7.6%), and each subsequent form of CM that an individual was exposed to corresponded with a 27% increased risk for SGA (aOR 1.27, 95% CI 1.05, 1.53). There was no significant association between CM and PTB (9.3% vs. 13.0%, aOR 1.07, 95% CI 0.58, 1.97). Of these sequelae only hypertensive disorders were associated with both CM and SGA and hypertensive disorders of pregnancy did not mediate the association between CM and SGA. Our findings indicate that maternal CM exposure is associated with increased risk for SGA birth and highlight the importance of investigating the mechanisms whereby childhood adversity sets the trajectory for long-term and intergenerational health issues.

The intersection of race and socioeconomic status is associated with inflammation patterns during pregnancy and adverse pregnancy outcomes.

BACKGROUND: Preterm birth rates are higher among individuals of lower socioeconomic status and non-White race, which is possibly related to life-course stressors. It is important to understand the underlying mechanisms of these health disparities, and inflammation is a possible pathway to explain the disparities in birth outcomes. OBJECTIVE: In this study, we aimed to determine whether patterns of inflammation differed by maternal race and socioeconomic status. STUDY DESIGN: Seven hundred and forty-four participants in a multi-site, prospective study of pregnancy and birth outcomes provided biological and psychological data between 12'0-20'6 weeks gestation. Participants with recent infection, fever, antibiotics or steroid treatment were excluded. Cytokines including INFÉ£, IL-10, IL-13, IL-6, IL-8, and TNFα, and the acute phase protein CRP were measured in serum and values and were log-transformed for normality when appropriate, and a non-orthogonal rotation (Oblimid) was performed to allow the extracted factor to inter-correlate. IFNγ, IL-8, IL-10, IL-6, TNF-a, and IL-13 loaded onto Inflammatory Factor 1 (IF-1), while CRP and IL-6 loaded onto Inflammatory Factor 2 (IF-2). Race and education were collected via self-report during an in-person study visit. Multivariable models were used to determine the association of race and SES with IF-1 and IF-2 during the second trimester, and a mediation model was used to examine if inflammation is on the causal pathway. Models were adjusted for study site, prenatal age, pre-pregnancy BMI, smoking during pregnancy, and gestational age at the time of blood collection. RESULTS: Six hundred and five participants were included in our final analysis, with 61.2% of low or moderate SES, and 35.5% identifying as a person of color (POC). Identifying as a POC, being of low and moderate SES, and being both low-SES and POC or moderate-SES and POC were associated with higher odds of preterm birth and lower birth weight percentile infants. Low SES POC participants had significantly higher IF-1 and IF-2 scores when compared to high-SES White participants. Additionally, higher IF-1 and IF-2 were associated with shorter gestation. In the mediation analysis, we observed a significant direct effect of race/SES on preterm birth; however, the results did not support an indirect pathway where IF-1 or IF-2 acted as mediators. CONCLUSION: Maternal race and SES are significantly associated with inflammatory biomarkers during pregnancy, and when race and SES are considered in combination, they are stronger predictors of adverse pregnancy outcomes than when evaluated separately.

Using principal component analysis to examine associations of early pregnancy inflammatory biomarker profiles and adverse birth outcomes.

OBJECTIVE: Inflammation as a risk factor for preterm birth is well-established. The primary objective of this analysis was to examine whether individual cytokines versus a composite indicator of mid-pregnancy inflammation are significantly associated with risk for adverse birth outcomes. STUDY DESIGN: A multi-site prospective study was conducted in a socio-demographically diverse cohort of 610 pregnant participants. At a study visit between 12 and 20 6/7 weeks' gestation, low-grade inflammation was measured via log-transformed serum concentrations of the biomarkers IFN-γ, IL-10, IL-13, IL-6, IL-8, TNF-α, and CRP. Principal component analysis (PCA) was used to identify underlying dimensions of inflammatory activity from the seven biomarkers measured. Gestational age and birth weight at delivery were obtained from medical chart review. The associations between inflammatory profiles and birth outcomes were assessed via linear and logistic regression models. Results were compared with those from individual inflammatory biomarkers, and model fit was assessed using Akaike's Information Criterion (AIC). RESULTS: Principal component analysis analysis yielded a two-factor solution, with the first factor (IF1) composed of IL-8, IL-10, IL-13, IFN-É£, and TNF-α, and the second factor (IF2) containing IL-6 and CRP. When adjusted for race, education, BMI, smoking status, gestational age at time of blood draw, and study site, a one standard deviation (SD) increase in IF1 remained significantly associated with a decrease in standardized gestational age (ß = -.13, 95% CI: -.21, -.05) and an increase in odds of preterm delivery (OR = 1.46, 95% CI: 1.13, 1.88) (Table 3). A one SD increase in IF2 was similarly associated with a decrease in standardized gestational age at delivery (ß = -.13, 95% CI: -.23, -.04) and an increase in odds of preterm delivery (OR: 1.46, 95% CI: 1.04, 2.05). Neither IF1 nor IF2 was associated with measures of fetal growth. AIC identified that IL-6 was a slightly better fit for length of gestation compared to either composite measure, though all performed similarly. CONCLUSION: Independent of known sociodemographic risk factors, an elevated mid-pregnancy inflammatory profile was associated with a nearly 50% increase in odds of preterm delivery. The composite performed similarly to IL-6. These results suggest that maternal low-grade inflammation is a risk factor for preterm delivery, and that mid-pregnancy inflammatory biomarkers may be useful in predicting risk for preterm delivery.

Clinically integrated breastfeeding peer counseling and breastfeeding outcomes.

OBJECTIVE: To evaluate whether clinically integrated breastfeeding peer counseling (ci-BPC) improved breastfeeding outcomes for a diverse cohort of Medicaid-enrolled patients. STUDY DESIGN: Medical records were reviewed for a random subset of patients delivering 2014-2015 (baseline, N = 147) and 2017-2019 (post-implementation, N = 281). Chi-squared and logistic regression evaluated differences in breastfeeding initiation, exclusivity, and duration, and results were stratified by race/ethnicity. RESULTS: Post-implementation, 90.4% of patients received ci-BPC. Compared to baseline, documented prenatal breastfeeding counseling increased from 5 to 84% (<0.001), and inpatient counseling increased from 12 to 55% (p < 0.001). Breastfeeding initiation was similar (86 to 89%, p = 0.28), while exclusivity increased from 21 to 31% (p = 0.03). Any breastfeeding ≥6 weeks increased from 29 to 65% (p < 0.001) and was most improved for Black (32 to 50%, p < 0.01) and Latinx patients (37 to 71%, p < 0.01). CONCLUSIONS: ci-BPC was associated with significant improvement in breastfeeding exclusivity and duration, and may address breastfeeding disparities.

Improving the Timely Delivery of Antihypertensive Medication for Severe Perinatal Hypertension in Pregnancy and Postpartum.

OBJECTIVE: Sustained blood pressures ≥160/110 during pregnancy and the postpartum period require timely antihypertensive therapy. Hospital-level experiences outlining the efforts to improve timely delivery of care within 60 minutes have not been described. The objective of this analysis was to assess changes in care practices of an inpatient obstetrical health care team following the implementation of a quality improvement initiative for severe perinatal hypertension during pregnancy and the postpartum period. STUDY DESIGN: In January 2016, NorthShore University HealthSystem Evanston Hospital launched a quality improvement initiative focusing on perinatal hypertension, as part of a larger, statewide quality initiative via the Illinois Perinatal Quality Collaborative. We performed a retrospective cohort study of all pregnant and postpartum patients with sustained severely elevated blood pressure (two severely elevated blood pressures ≤15 minutes apart) with baseline data from 2015 and data collected during the project from 2016 through 2017. Changes in clinical practice and outcomes were compared before and after the start of the project. Statistical process control charts were used to demonstrate process-behavior changes over time. RESULTS: Comparing the baseline to the last quarter of 2017, there was a significant increase in the administration of medication within 60 minutes for severe perinatal hypertension (p <0.001). Implementation of a protocol for event-specific debriefing for each severe perinatal hypertension episode was associated with increased odds of the care team administering medication within 60 minutes of the diagnosis of severe perinatal hypertension (adjusted odds ratio 3.20, 95% confidence interval 1.73-5.91, p < 0.01). CONCLUSION: Implementation of a quality improvement initiative for perinatal hypertension associated with pregnancy and postpartum improved the delivery of appropriate and timely therapy for severely elevated blood pressures and demonstrated the impact of interdisciplinary communication in the process. KEY POINTS: · Process of hospital-level implementation of a state quality improvement initiative.. · Evidence of improvement in care delivery for severe perinatal hypertension (HTN).. · Episode related debriefing by the clinical team improved perinatal HTN care..

A highly sensitive multiplex immunoassay for inflammatory cytokines in dried blood spots.

OBJECTIVES: Inflammatory cytokines are key regulators of inflammation, but current measurement approaches require venous blood to quantify low circulating concentrations associated with chronic, low-grade inflammation. This article describes a highly sensitive multiplex immunoassay protocol for the measurement of IL6, IL8, IL10, and TNFα in finger stick dried blood spot (DBS) samples. METHODS: The protocol uses a multiplex electrochemiluminescent immunoassay platform. The following measures of assay performance were evaluated: reliability (inter-assay percent coefficient of variation; %CV), precision (intra-assay %CV), lower limit of detection (LLD), linearity of dilution, and agreement with results from matched plasma samples. RESULTS: Analysis of three control samples across the assay range indicated an acceptable level of precision and reliability for each cytokine. Linearity of dilution returned average values that ranged from 104.1 to 127.6% of expected. Lower limits of detection for IL6, IL8, and IL10 were <0.5, and <1.0 pg/ml for TNFα. Level of agreement in results between matched DBS and plasma samples was high for all cytokines except for IL8. CONCLUSIONS: Finger stick DBS sampling provides a viable alternative to venipuncture for the quantification of IL6, IL10, and TNFα at low concentrations associated with chronic inflammation. The presence of red blood cells may interfere with the quantification of IL8 in DBS. In facilitating blood collection in nonclinical settings this method can advance scientific understandings of how social and ecological contexts shape immune function and health over the life course.

Lifetime Psychosocial Stress Exposure Associated with Hypertensive Disorders of Pregnancy.

OBJECTIVE: Hypertensive disorders of pregnancy (HDP) complicate 5 to 10% of all pregnancies and are a major cause of pregnancy-related morbidity. Exposure to psychosocial stress has been associated with systemic inflammation and adverse birth outcomes in pregnant women. Thus, it is probable that psychosocial stress and inflammation play a role in the development of HDP. The primary objective of this analysis was to determine if a woman's lifetime psychosocial stress exposure was associated with an increased risk of HDP. Additionally, we examined whether serum inflammation was an underlying biological mediator for this relationship. STUDY DESIGN: A multisite prospective study was conducted in a sociodemographically diverse cohort of 647 pregnant women. At a study visit between 12 and 206/7 weeks' gestation, maternal psychosocial stress was assessed with six validated assessments and inflammation was measured via log-transformed serum concentrations of interferon-γ, interleukin (IL)-10, IL-13, IL-6, IL-8, and tumor necrosis factor-α. A composite stress score was calculated for each participant from the six stress assessments. The diagnosis of HDP was abstracted from the medical record and was defined as the presence of gestational hypertension after 20 weeks of pregnancy and/or preeclampsia. The association between composite stress and HDP was determined using binary logistic regression. Inflammation, using the six inflammatory biomarkers, was tested as a potential mediator between stress and HDP. RESULTS: Participants with higher composite stress scores were more likely to develop HDP (odds ratio [OR]: 1.50, 95% confidence interval [CI]: 1.06-2.12). When adjusted for known risk modifiers, including maternal age, race/ethnicity, parity, pre-pregnancy body mass index, diabetes, chronic hypertension, and smoking during pregnancy, the risk remained unchanged (OR: 1.50, 95% CI: 1.03-2.20). No mediation effect by inflammation was observed. CONCLUSION: Independent of known risk factors, women exposed to greater composite stress burden across the life course are at increased risk of developing HDP. KEY POINTS: · This study was conducted to determine if women with high levels of psychosocial stress have differences in risk for hypertensive disorders of pregnancy (HDP).. · Independent of known risk factors, women with increased lifetime psychosocial burden are at higher risk for HDP.. · A model that captures multiple domains of life stress may better predict HDP than a unimodal stress assessment..

Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes.

State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.

Maternal Glucocorticoid Metabolism Across Pregnancy: A Potential Mechanism Underlying Fetal Glucocorticoid Exposure.

CONTEXT: Across pregnancy, maternal serum cortisol levels increase up to 3-fold. It is not known whether maternal peripheral cortisol metabolism and clearance change across pregnancy or influence fetal cortisol exposure and development. OBJECTIVES: The primary study objective was to compare maternal urinary glucocorticoid metabolites, as markers of cortisol metabolism and clearance, between the second and third trimester of pregnancy. Secondary objectives were to test associations of total maternal urinary glucocorticoid excretion, with maternal serum cortisol levels and offspring birth weight z score. DESIGN, PARTICIPANTS, AND SETTING: A total of 151 women with singleton pregnancies, recruited from prenatal clinic at the Pittsburgh site of the Measurement of Maternal Stress (MOMS) study, had 24-hour urine collections during both the second and third trimesters. RESULTS: Between the second and third trimester, total urinary glucocorticoid excretion increased (ratio of geometric means [RGM] 1.37, 95% CI 1.22-1.52, P < .001), and there was an increase in calculated 5ß-reductase compared to 5α-reductase activity (RGM 3.41, 95% CI 3.04-3.83, P < .001). During the third trimester total urinary glucocorticoid excretion and serum cortisol were negatively correlated (r = -0.179, P = .029). Mean total urinary glucocorticoid excretion across both trimesters and offspring birth weight z score were positively associated (ß = 0.314, P = .001). CONCLUSIONS: The estimated activity of maternal enzymes responsible for cortisol metabolism change between the second and third trimester of pregnancy. Additionally, maternal peripheral metabolism and clearance of cortisol may serve as a novel mechanism affecting fetal cortisol exposure and growth.

Early Term Delivery and Breastfeeding Outcomes.

OBJECTIVE: Higher rates of adverse outcomes have been reported for early term (37 0 to 38 6 weeks) versus full term (≥ 39 0 weeks) infants, but differences in breastfeeding outcomes have not been systematically evaluated. This study examined breastfeeding initiation and exclusivity in early and full term infants in a large US based sample. METHODS: This secondary analysis included 743 geographically- and racially-diverse women from the Measurement of Maternal Stress Study cohort, and 295 women from a quality assessment at a hospital-based clinic in Evanston, IL. Only subjects delivering ≥ 37 weeks were included. Initiation of breastfeeding (IBF) and exclusive breastfeeding (EBF) were assessed via electronic medical record review after discharge. Associations of IBF and EBF with early and full term delivery were assessed via univariate and multivariate logistic regression. RESULTS: Among 872 women eligible for inclusion, 85.7% IBF and 44.0% EBF. Early term delivery was not associated with any difference in frequency of IBF (p = 0.43), but was associated with significantly lower odds of EBF (unadjusted OR 0.61, 95% CI 0.466, 0.803, p < 0.001). This association remained significant (adjusted OR 0.694, 95% CI 0.515, 0.935, p = 0.016) after adjusting for maternal diabetes, hypertensive disorders of pregnancy, cesarean delivery, maternal age, race/ethnicity, parity, Medicaid status, NICU admission, current smoking, and delivery hospital. CONCLUSIONS FOR PRACTICE: Despite comparable breastfeeding initiation frequencies, early term infants were significantly less likely to be exclusively breastfed compared to full term infants. These data suggest that women with early term infants may benefit from counseling regarding the potential for breastfeeding difficulties as well as additional breastfeeding support after delivery.

A Framework to Harness the Power of Quality Collaboratives to Improve Perinatal Outcomes.

The Illinois Perinatal Quality Collaborative developed a framework for successfully engaging teams and implementing statewide obstetric and neonatal quality improvement (QI) initiatives. This framework includes: (1) engaging hospitals to create an environment of improvement; (2) motivating hospital teams to facilitate change at their hospital; and (3) supporting hospital teams through the 3 pillars of QI-collaborative learning opportunities, rapid-response data, and QI support-to achieve initiative goals and improve outcomes for mothers and newborns. Utilizing this framework, the Illinois Perinatal Quality Collaborative Severe Maternal Hypertension Initiative engaged teams and achieved initiative goals.

The Hard Work of Improving Outcomes for Mothers and Babies: Obstetric and Perinatal Quality Improvement Initiatives Make a Difference at the Hospital, State, and National Levels.

Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives.

Using item response theory to optimize measurement of chronic stress in pregnancy.

OBJECTIVE: Utilize Rasch analysis to develop an optimized self-reported measure of stress in pregnancy and examine the association with patient demographics and biologic measures of stress. STUDY DESIGN: Measured self-reported stress in pregnant women using 12 existing scales. Collected blood for biologic measures of stress (Epstein Barr Virus [EBV], C-Reactive Protein [CRP], Corticotropin Reactive Hormone [pCRH], and Adenocorticotropin Hormone [ACTH]). Used multidimensional scaling and Rasch analysis to produce an item reduced self-report measure. RESULTS: Enrolled 112 women. Survey items reduced to two factors: perceived stressors and buffers of stress. Women with a domestic partner had lower perceived stress (p = 0.003). Caucasian women reported higher buffers of stress (p = 0.045), as did women with private insurance (p < 0.001), a planned pregnancy (p < 0.01), and a domestic partner (p < 0.001). Women with higher buffers of stress had lower levels of pCRH (adjusted p = 0.01). CONCLUSION: Item reduced, optimized measures of stress were associated with significant differences in patient demographics and biologic measures of stress.

Maternal Income during Pregnancy is Associated with Chronic Placental Inflammation at Birth.

Objective This study aims to examine whether maternal household income is associated with histological evidence of chronic placental inflammation. Study Design A total of 152 participants completed surveys of household income and consented to placenta collection at delivery and postpartum chart review for birth outcomes. Placental inflammatory lesions were evaluated via histological examination of the membranes, basal plate, and villous parenchyma by a single, experienced pathologist. Associations between household income and the presence of inflammatory lesions were adjusted for known perinatal risk factors. Results Overall, 45% of participants reporting household income below $30,000/y had chronic placental inflammation, compared with 25% of participants reporting income above $100,000 annually (odds ratio [OR] = 4.23, 95% confidence interval [CI] = 1.25, 14.28; p = 0.02). Middle-income groups showed intermediate rates of chronic inflammatory lesions, at 40% for those reporting $30,000 and 50,000 (OR = 3.60, 95% CI = 1.05, 12.53; p = 0.04) and 38% for those reporting $50,000 to 100,000 (OR = 1.57, 95% CI = 0.60, 4.14; p = 0.36). Results remained significant after adjustment for maternal age, race, and marital status. Conclusion Chronic placental inflammation is associated with maternal household income. Greater occurrence of placental lesions in low-income mothers may arise from a systemic inflammatory response to social and physical environmental factors.

Prenatal Stress and the Cortisol Awakening Response in African-American and Caucasian Women in the Third Trimester of Pregnancy.

Objectives Prior studies have shown significant racial disparities in psychosocial stressors for pregnant women. One physiological mechanism by which prenatal stress is expressed is via the stress-sensitive hormone cortisol, which itself differs by race. In this study, we examine differences in cortisol awakening response (CAR) for African-American and Caucasian pregnant women during late pregnancy, particularly whether racial disparities are evident after accounting for measures of psychosocial stress. Methods During their third trimester of pregnancy (32-40 weeks of gestation), we asked women to self-collect salivary samples at home over 2 days. We then measured salivary cortisol across the day for 30 pregnant women (18 Caucasian; 12 African-American) to examine the CAR by race and by multiple measures of self-reported psychosocial stress, including perceived discrimination. Results Although the women in our sample showed normative cortisol diurnal rhythms (high on waking, peak 30 min post-waking, lowest at bedtime), we found that African-American women had blunted (smaller) awakening responses compared to Caucasian women (p < 0.05). The CAR was significantly larger in Caucasian women compared to African-American women even after accounting for covariates in a multivariate equation. However, when we added measures of psychosocial stress to the multivariate equation, higher levels of stress were significantly associated with a smaller CAR (p < 0.05), and the association between maternal race and CAR was no longer significant. Conclusions Our results add to a growing body of evidence that racial differences in the activity of the hypothalamic-pituitary-adrenal axis are associated with psychosocial stress during pregnancy.