Neonatal outcomes of births in freestanding birth centers and hospitals in the United States, 2016-2019.

BACKGROUND: Births in freestanding birth centers have more than doubled between 2007 and 2019. Although birthing centers, which are defined by the American College of Obstetricians and Gynecologists as ". . . freestanding facilities that are not hospitals," are being promoted as offering women fewer interventions than hospitals, there are limited recent data available on neonatal outcomes in these settings. OBJECTIVE: To compare several important measures of neonatal safety between 2 United States birth settings and birth attendants: deliveries in freestanding birth centers and hospital deliveries by midwives and physicians. STUDY DESIGN: This is a retrospective cohort study using the United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, and Division of Vital Statistics natality online database for the years 2016 to 2019. All term, singleton, low-risk births were eligible for inclusion. The study outcomes were several neonatal outcomes including neonatal death, neonatal seizures, 5-minute Apgar scores of <4 and <7, and neonatal death in nulliparous and in multiparous women. Outcomes were compared between the following 3 groups: births in freestanding birth centers, in-hospital births by a physician, and in-hospital births by a midwife. The prevalence of each neonatal outcome among the different groups was compared using Pearson chi-squared test, with the in-hospital midwife births being the reference group. Multivariate logistic regression models were performed to account for several potential confounding factors such as maternal prepregnancy body mass index, maternal weight gain, parity, gestational weeks, and neonatal birthweight and calculated as adjusted odds ratio. RESULTS: The study population consisted of 9,894,978 births; 8,689,467 births (87.82%) were in-hospital births by MDs and DOs, 1,131,398 (11.43%) were in-hospital births by midwives, and 74,113 (0.75%) were births in freestanding birth centers. Freestanding birth center deliveries were less likely to be to non-Hispanic Black or Hispanic, less likely to women with public insurance, less likely to be women with their first pregnancy, and more likely to be women with advanced education and to have pregnancies at ≥40 weeks' gestation. Births in freestanding birth center had a 4-fold increase in neonatal deaths (3.64 vs 0.95 per 10,000 births: adjusted odds ratio, 4.00; 95% confidence interval, 2.62-6.1), a more than 7-fold increase in neonatal deaths for nulliparous patients (6.8 vs 0.92 per 10,000 births: adjusted odds ratio, 7.7; 95% confidence interval, 4.42-13.76), a more than 2-fold increase in neonatal seizures (3.91 vs 1.94 per 10,000 births: adjusted odds ratio, 2.19; 95% confidence interval, 1.48-3.22), and a more than 7-fold increase of a 5-minute Apgar score of <4 (194.84 vs 28.5 per 10,000 births: adjusted odds ratio, 7.46; 95% confidence interval, 7-7.95). Compared with hospital midwife deliveries, hospital physician deliveries had significantly higher adverse neonatal outcomes (P<0.001). CONCLUSION: Births in United States freestanding birth centers are associated with an increased risk of adverse neonatal outcomes such as neonatal deaths, seizures, and low 5-minute Apgar scores. Therefore, when counseling women about the location of birth, it should be conveyed that births in freestanding birth centers are not among the safest birth settings for neonates compared with hospital births attended by either midwives or physicians.

Mommy Meltdown: Understanding Racial Differences Between Black and White Women in Attitudes About Postpartum Depression and Treatment Modalities.

BACKGROUND: Postpartum depression is a major public health problem, but limited information is available about risk factors and attitudes of minority women about postpartum depression. The objective of this study is to determine attitudes of minority women toward postpartum depression and treatment. METHODS: In this prospective study at an academic resident and faculty clinic, 39 women (19 black and 20 white) at the 6-week postpartum visit completed a survey that was developed for this study to assess personal and family attitudes about postpartum depression in addition to the routinely distributed Edinburgh postnatal depression scale. The primary outcome variable was the presence of postpartum depression amongst minority women compared to other races. The secondary outcome looked at descriptors of attitudes about depression and treatment. Data were analyzed with Chi-square test for categorical data and Student's t-test for continuous data. RESULTS: Black and white participants were comparable in age, distribution of gestational age at birth, delivery type and pregnancy complications. The diagnosis of postpartum depression was not different in either population (two black and three white women; P = 0.667). Black participants were referred less frequently to counseling as treatment (5% vs. 30%; P = 0.052) but both black and white study participants viewed counseling as helpful (84% vs. 80%; P = 0.345). Black participants had a lower frequency of family history of depression (11% vs. 40%; P = 0.052) but both study groups were comfortable discussing the topic with their families, felt that their families were not ashamed of any social stigma about depression, and would be supportive of either counseling or medications as a treatment modality. CONCLUSIONS: Postpartum depression was common among our patients regardless of race. Most black and white women were willing to discuss depression with their families and accept treatment. Despite previous evidence to the contrary, black women stated that they were open to counseling as treatment for depression.

Disparity in the persistence of high-risk human papillomavirus genotypes between African American and European American women of college age.

BACKGROUND: Cervical cancer incidence and mortality rates are higher in African Americans than in European Americans (white, non-Hispanic of European ancestry). The reasons for this disparity are not known. METHODS: We recruited a population-based longitudinal cohort of 326 European American and 113 African American female college freshmen in Columbia, South Carolina, to compare clearance of high-risk human papillomavirus (HR-HPV) infection between ethnicities. HPV testing and typing from samples obtained for Papanicolaou testing occurred every 6 months. RESULTS: African American participants had an increased risk of testing positive for HR-HPV, compared with European American participants, but the frequency of incident HPV infection was the same in African American and European American women. Thus, exposure to HPV could not explain the higher rate of HPV positivity among African American women. The time required for 50% of participants to clear HR-HPV infection was 601 days for African American women (n = 63) and 316 days for European American women (n = 178; odds ratio [OR], 1.61; 95% confidence interval [CI], 1.08-2.53). African American women were more likely than European American women to have an abnormal result of a Papanicolaou test (OR, 1.58; 95% CI, 1.05-2.39). CONCLUSIONS: We propose that the longer time to clearance of HR-HPV among African American women leads to increased rates of abnormal results of Papanicolaou tests and contributes to the increased rates of cervical cancer observed in African American women.

Selection of contraceptive therapy for patients with thrombophilia: a review of the evidence.

BACKGROUND: Awareness of the contributions of thrombophilia to thrombosis-related morbidity and mortality has been growing in the last few decades. Thrombophilia is especially concerning in females seeking contraception because some types of hormonal contraception have been associated with venous thromboembolism (VTE). Clinicians face a growing need for awareness of evidence-based contraception selection for this population. METHODS: PubMed literature searches were conducted to provide a review of the literature describing contraceptive use in patients with thrombophilia. This review also describes contraceptive selection and counseling for this population. RESULTS: Studies of combined hormonal contraceptive (CHC) use demonstrate a 2- to 50-fold increase in VTE in individuals with thrombophilia, depending on the type of thrombophilia and the reference group identified. Two small studies describing VTE incidence in progesterone-only contraceptive (POC) users with thrombophilia were identified but they did not provide conclusive information regarding VTE risk in this population. CONCLUSIONS: POC may be recommended for contraception in patients with most thrombophilias, but studies should be undertaken to further define the safety of POC use in this population.

HPV prevalence at enrollment and baseline results from the Carolina Women's Care Study, a longitudinal study of HPV persistence in women of college age.

BACKGROUND: Cervical cancer, a rare outcome of high-risk human papillomavirus (HPV) infection, disproportionately affects African American women, who are about twice more likely than European American women to die of the disease. Most cervical HPV infections clear in about one year. However, in some women HPV persists, posing a greater risk for cervical dysplasia and cancer. The Carolina Women's Care Study (CWCS) was conducted to explore the biological, genetic, and lifestyle determinants of persistent HPV infection in college-aged European American and African American women. This paper presents the initial results of the CWCS, based upon data obtained at enrollment. METHODS: Freshman female students attending the University of South Carolina were enrolled in the CWCS and followed until graduation with biannual visits, including two Papanicolaou tests, cervical mucus collection, and a questionnaire assessing lifestyle factors. We recruited 467 women, 293 of whom completed four or more visits for a total of 2274 visits. RESULTS AND CONCLUSION: CWCS participants were 70% European American, 24% African American, 3% Latina/Hispanic, and 3% Asian. At enrollment, 32% tested positive for any HPV. HPV16 infection was the most common (18% of infections). Together, HPV16, 66, 51, 52, and 18 accounted for 58% of all HPV infections. Sixty-four percent of all HPV-positive samples contained more than one HPV type, with an average of 2.2 HPV types per HPV-positive participant. We found differences between African American and European American women in the prevalence of HPV infection (38.1% African American, 30.7% European American) and abnormal Papanicolaou test results (9.8% African-American, 5.8% European American). While these differences did not reach statistical significance at enrollment, as the longitudinal data of this cohort are analyzed, the sample size will allow us to confirm these results and compare the natural history of HPV infection in college-aged African American and European American women.

Graft-versus-host disease of the vulva and/or vagina: diagnosis and treatment.

We describe a series of women after allogeneic stem cell transplantation with vaginal graft-versus-host disease (GVHD) who were treated with topical cyclosporine, surgery, or both. We reviewed the medical charts of 11 women who presented with vaginal pain, discomfort, and vaginal scarring (inability to perform a Papanicolaou test or have vaginal intercourse because of pain). Vaginal symptoms develop an average of 10 months from bone marrow transplantation. Symptoms and physical findings include excoriated and ulcerated mucosa, thickened mucosa, narrowed introitus, and obliterated introitus from dense scar tissue that does not resolve with systemic or topical estrogens. The severity of symptoms and the physical findings in our study population did not correlate with age, type of leukemia, type of transplant, or severity or acute or chronic GVHD. Excoriated mucosa and moderately thickened mucosa were successfully treated with topical cyclosporine. Extensive synechiae and complete obliteration of the vaginal canal required surgical lysis with postoperative topical cyclosporine. Vaginal GVHD can successfully be treated with topical cyclosporine when mild to moderate disease is present. Surgical lysis with topical cyclosporine is required when more severe disease ensues.

Direct binding of AP-1 (Fos/Jun) proteins to a SMAD binding element facilitates both gonadotropin-releasing hormone (GnRH)- and activin-mediated transcriptional activation of the mouse GnRH receptor gene.

The response of pituitary gonadotropes to gonadotropin-releasing hormone (GnRH) correlates directly with the concentration of GnRH receptors (GnRHR) on the cell surface, which is mediated in part at the level of gene expression. Several factors are known to affect expression of the mouse GnRHR (mGnRHR) gene, including GnRH and activin. We have previously shown that activin augments GnRH-mediated transcriptional activation of mGnRHR gene, and that region -387/-308 appears to be necessary to mediate this effect. This region contains two overlapping cis-regulatory elements of interest: GnRHR activating sequence (GRAS) and a putative SMAD-binding element (SBE). This study investigates the role of these elements and their cognate transcription factors in transactivation of the mGnRHR gene. Transfection studies confirm the presence of GnRH- and activin-response elements within -387/-308 of mGnRHR gene promoter. Competition electrophoretic mobility shift assay experiments using -335/-312 as probe and alphaT3-1 nuclear extract or SMAD, Jun, and Fos proteins demonstrate direct binding of AP-1 (Fos/Jun) protein complexes to -327/-322 and SMAD proteins to -329/-328. Further transfection studies using mutant constructs of these cis-regulatory elements confirm that both are functionally important. These data define a novel cis-regulatory element comprised of an overlapping SBE and newly characterized non-consensus AP-1 binding sequence that integrates the stimulatory transcriptional effects of both GnRH and activin on the mGnRHR gene.