Racial Disparities in Breastfeeding Rates in Patients with Heart Disease.

OBJECTIVE: To evaluate racial disparities in breastfeeding rates in patients with heart disease. STUDY DESIGN: Retrospective cohort of pregnant patients with maternal cardiac disease managed by a Cardio-Obstetrics program. Patients self-identifying as Non-Hispanic Black (NHB) and Non-Hispanic White (NHW), who attended ≥ 1 prenatal visit at the Cardio-Obstetrics Program and delivered at the same hospital between March 2015 and June 2019 were included. The primary outcome was breastfeeding rate at discharge from the delivery-associated hospitalization. Secondary outcomes included breastfeeding intent on admission and breastfeeding rates at the postpartum visit among patients who initiated breastfeeding. RESULTS: 138 pregnant patients with cardiac disease were included: 58 (42%) NHB and 80 (58%) NHW patients. Parity, marital status and insurance were statistically different between groups. NHB patients were more likely to have government insurance compared to NHW patients (77.6% vs. 40%; p < 0.001). There was a significant difference in the intent to breastfeed upon admission for the delivery-associated hospitalization (74.2% NHB vs. NHW 91.3%; p = 0.01), but not at hospital discharge (84.5% NHB vs. 93.8% NHW; p = 0.08). However, breastfeeding rates were significantly lower among NHB patients at the postpartum visit among the entire cohort (38.2% in NHB vs. 61.1% in NHW women; p = 0.036) and among those who initiated breastfeeding (35.3% NHB vs. 61.1% NHW, p = 0.018). CONCLUSIONS: Despite similar breastfeeding rates at hospital discharge, NHB patients with maternal cardiac disease were less likely to intend to breastfeed at admission and/or continue breastfeeding by the postpartum visits. Qualitative studies understanding these differences are crucial to improve breastfeeding rates, especially for NHB patients with maternal cardiac disease.

Outcomes in low-risk patients before and after an institutional policy offering 39-week elective induction of labor.

OBJECTIVE: Elective induction of labor versus expectant management at 39 weeks gestation in low-risk nulliparous patients was shown in the ARRIVE randomized trial of over 6000 patients to decrease risks of cesarean delivery without significant change in the composite perinatal outcome. We aimed to pragmatically analyze the effect of offering elective induction of labor (eIOL) to all low-risk patients. METHODS: Retrospective cohort study of low-risk nulliparous and multiparous patients delivering live, non-anomalous singletons at a single center at greater than or equal to 39 0/7 weeks gestational age. Those with prior or planned cesarean delivery, ruptured membranes, medical comorbidities, or contraindications to vaginal delivery were excluded. Patients were categorized as before (pre-eIOL; 1/2012-3/2014) or after (post-eIOL; 3/2019-12/2021) an institution-wide policy offering eIOL at 39 0/7 weeks. Births occurring April 2014 to December 2018 were allocated to a separate cohort (during-eIOL) given increased exposure to eIOL as our center recruited participants for the ARRIVE trial. The primary outcome was cesarean birth. Secondary outcomes included select maternal (e.g. chorioamnionitis, operative delivery, postpartum hemorrhage) and neonatal morbidities (e.g. birthweight, small- and large-for gestational age, hypoglycemia). Characteristics and outcomes were compared between the pre and during-eIOL, and pre and post-eIOL groups; adjusted OR (95% CI) were calculated using multivariable regression. Subgroup analysis by parity was planned. RESULTS: Of 10,758 patients analyzed, 2521 (23.4%) were pre-eIOL, 5410 (50.3%) during-eIOL, and 2827 (26.3%) post-eIOL. Groups differed with respect to labor type, age, race/ethnicity, marital and payor status, and gestational age at care entry. Post-eIOL was associated with lower odds of cesarean compared to pre-eIOL (aOR 0.83 [95% CI 0.72-0.96]), which was even lower among those specifically undergoing labor induction (aOR 0.58 [0.48-0.70]. During-eIOL was also associated with lower odds of cesarean compared to pre-eIOL (aOR 0.79 [0.69-0.90]). Both during and post-eIOL groups were associated with higher odds of chorioamnionitis, operative delivery, and hemorrhage compared to pre-eIOL. However, only among post-eIOL were there fewer neonates weighing ≥4000 g, large-for-gestational age infants, and neonatal hypoglycemia compared to pre-IOL. CONCLUSION: An institutional policy offering eIOL at 39 0/7 to low-risk patients was associated with a lower cesarean birth rate, lower birthweights and lower neonatal hypoglycemia, and an increased risk of chorioamnionitis and hemorrhage.

Racial disparities in reliable contraceptive use in women with heart disease.

OBJECTIVE: The aim of the study was to investigate the differences in reliable contraceptive use between black women and white women with maternal cardiac disease. METHODS: The study comprised a retrospective cohort of women with maternal cardiac disease managed by the University of Alabama at Birmingham (UAB) Comprehensive Pregnancy and Heart Program (CPHP). Women were included if they had attended one or more prenatal visits at the UAB CPHP and delivered at the UAB hospital between March 2015 and June 2019. The primary outcome was reliable contraceptive use within 2 months postpartum, defined by receipt of long-acting reversible contraception (i.e., an intrauterine contraceptive device or an etonogestrel implant) or female sterilisation. All outcomes were compared based on self-reported race. RESULTS: One hundred and forty-nine women met the inclusion criteria. Black women (n = 63) were more likely than white women (n = 86) to use reliable contraception (65% vs 43%; p = 0.008). Black women were less likely than white women to be undecided or decline contraception at the time of admission (13% vs 27%; p = 0.037). There was no difference in reliable contraceptive use between black women (n = 20, 63%) and white women (n = 23, 72%) with modified World Health Organisation (WHO) class III/IV lesions (p = 0.42). CONCLUSION: Black women with maternal cardiac disease were more likely than white women to receive reliable contraception. Interventions to prevent unintended pregnancy in women with maternal cardiac disease should focus on improving reliable contraceptive use, especially for women with modified WHO class III/IV lesions.

A systematic review of biomarkers associated with maternal infection in pregnant and postpartum women.

BACKGROUND: Serum biomarkers are commonly used to support the diagnosis of infection in non-pregnant patients whose clinical presentation suggests infection. The utility of serum biomarkers for infection in pregnant and postpartum women is uncertain. SEARCH STRATEGY: PubMed, CINAHL, EMBASE, ClinicalTrials.gov, Cochrane Library, CINAHL, and SCOPUS were searched from inception to February 2020. SELECTION CRITERIA: Full-text manuscripts in English were included if they reported the measurement of maternal serum biomarkers-and included a control group-to identify infection in pregnant and postpartum women. DATA COLLECTION AND ANALYSIS: two authors independently screened manuscripts, extracted data, and assessed methodologic quality. MAIN RESULTS: Interleukin-6 (IL-6), C-reactive protein, procalcitonin, insulin-like growth factor binding protein 1, tumor necrosis factor-α, calgranulin B, neopterin, and interferon-γ inducible protein 10 reliably indicated infection. Intercellular adhesion molecule 1, monocyte chemotactic and activating factor, soluble IL-6 receptor, and IL-8 were not useful markers in pregnant and postpartum women. CONCLUSIONS: Findings suggest that certain biomarkers have diagnostic value when maternal infection is suspected, but also confirms limitations in this population.

Identifying Risk Factors for Cesarean Delivery in a Predominantly Hispanic Teenage Population: A 5-Year Retrospective Study.

STUDY OBJECTIVE: To identify risk factors for primary nonelective cesarean delivery, in a predominantly Hispanic teen population of an urban tertiary care center. DESIGN: Retrospective descriptive study. SETTING: A tertiary academic center with approximately 3000 deliveries per year. PARTICIPANTS: Our study population comprised all women (ages 13-19 years at time of delivery) who gave birth at our tertiary university hospital between July 2011 and July 2016. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Our main outcome of interest was primary nonelective cesarean delivery. RESULTS: Of the 958 included deliveries, 9.6% (92/958) were delivered via nonelective cesarean section. The population was 89% Hispanic with a mean age of 17.7 years. Age, body mass index at delivery, and neonatal birth weight were significantly associated with delivery via cesarean section. Mothers of neonates with extremes of birth weights (<2500 g, >4000 g) had higher odds of having a cesarean delivery, compared with neonates with normal birth weight (odds ratio, 3.27; 95% confidence interval, 1.90-5.63 and odds ratio, 4.43; 95% confidence interval, 1.33-14.72). CONCLUSION: Among adolescent patients, age, body mass index at delivery, and birth weight of the neonate were found to be risk factors that place the gravid teen at increased risk for cesarean delivery.