Changes to Birth Plans Due to COVID-19: A Survey of Utah Midwives and Doulas.

INTRODUCTION: This study seeks to understand the experiences of Utah midwives and doulas caring for patients during the recent coronavirus disease 2019 (COVID-19) pandemic. Specifically, the goal of the study was to describe the perceived impact on the community birth system and explore differences in the access and use of personal protective equipment (PPE) between in- and out-of-hospital births. METHODS: This study used a cross-sectional, descriptive study design. A 26-item survey developed by the research team was sent via email to Utah birth workers, including nurse-midwives, community midwives, and doulas. Quantitative data were collected during December 2020 and January 2021. Descriptive statistics were used in the analysis. RESULTS: Of the 409 birth workers who were sent a link to the survey, 120 (30%) responded: 38 (32%) CNMs, 30 (25%) direct-entry or community midwives, and 52 (43%) doulas. The majority (79%) reported changes to clinical practice during the COVID-19 pandemic. Community midwives (71%) who responded indicated practice volume increased. Survey participants reported an increased patient preference for home births (53%) and birth center births (43%). Among those with one or more patient transfers to the hospital, 61% experienced a change in the process. One participant reported that it took 43 minutes longer to transfer to the hospital. Community midwives and doulas reported poor access to a regular source of PPE. DISCUSSION: Survey participants reported changes to planned birth locations during the COVID-19 pandemic. When necessary, transfers to hospitals were reported to be slower. Community midwives and doulas reported having insufficient access to PPE and reported limited knowledge about COVID-19 testing resources and resources for educating patients on COVID-19. This study adds an important perspective to the existing literature on COVID-19 by indicating that policymakers should include community birth partners in community planning for natural disasters and future pandemics.

Design and Methodology of the Study of Associated Risks of Stillbirth (SOARS) in Utah.

OBJECTIVES: The Utah Study of Associated Risks of Stillbirth (SOARS) collects data about stillbirths that are not included in medical records or on fetal death certificates. We describe the design, methods, and survey response rate from the first year of SOARS. METHODS: The Utah Department of Health identified all Utah women who experienced a stillbirth from June 1, 2018, through May 31, 2019, via fetal death certificates and invited them to participate in SOARS. The research team based the study protocol on the Pregnancy Risk Assessment Monitoring System surveillance of women with live births and modified it to be sensitive to women's recent experience of a stillbirth. We used fetal death certificates to examine survey response rates overall and by maternal characteristics, gestational age of the fetus, and month in which the loss occurred. RESULTS: Of 288 women invited to participate in the study, 167 (58.0%) completed the survey; 149 (89.2%) responded by mail and 18 (10.8%) by telephone. A higher proportion of women who were non-Hispanic White (vs other races/ethnicities), were married (vs unmarried), and had ≥high school education (vs

Standardized Criteria for Review of Perinatal Suicides and Accidental Drug-Related Deaths.

OBJECTIVE: To estimate the proportion of accidental drug-related deaths and suicides classified as pregnancy-related from 2013 to 2014 (preimplementation of standardized criteria) and 2015 to 2016 (postimplementation). METHODS: Based on Centers for Disease Control and Prevention pregnancy-related death criteria, the Utah Perinatal Mortality Review Committee developed a standardized evaluation tool to assess accidental drug-related death and suicide beginning in 2015. We performed a retrospective case review of all pregnancy-associated deaths (those occurring during pregnancy or 1 year postpartum for any reason) and pregnancy-related deaths (those directly attributable to the pregnancy or postpartum events) evaluated by Utah's Perinatal Mortality Review Committee from 2013 to 2016. We compared the proportion of accidental drug-related deaths and suicides meeting pregnancy-related criteria preimplementation and postimplementation of a standardized criteria checklist tool using Fisher's exact test. We assessed the change in pregnancy-related mortality ratio in Utah from 2013 to 2014 and 2015 to 2016 using test of trend. RESULTS: From 2013 to 2016, there were 80 pregnancy-associated deaths in Utah (2013-2014: n=40; 2015-2016: n=40), and 41 (51%) were pregnancy-related (2013-2014: n=15, 2015-2016: n=26). In 2013-2014 (preimplementation), 12 women died of drug-related deaths or suicides, and only two of these deaths were deemed pregnancy-related (17%). In 2015-2016 (postimplementation), 18 women died of drug-related deaths or suicide, and 94% (n=17/18) of these deaths met one or more of the pregnancy-related criteria on the checklist (P<.001). From 2013 to 2014 to 2015-2016, Utah's overall pregnancy-related mortality ratio more than doubled, from 11.8 of 100,000 to 25.7 of 100,000 (P=.08). CONCLUSION: After application of standardized criteria, the Utah Perinatal Mortality Review Committee determined that pregnancy itself was the inciting event leading to the majority of accidental drug-related deaths or suicides among pregnant and postpartum women. Other maternal mortality review committees may consider a standardized approach to assessing perinatal suicides and accidental drug-related deaths.

Pregnancy-Associated Death in Utah: Contribution of Drug-Induced Deaths.

OBJECTIVE: Drug-induced deaths, defined as intentional or unintentional consumption of illicit substances or diverted medications leading to death, are the leading cause of death for reproductive-age women in the United States. Our objective was to describe pregnancy-associated deaths attributed to drug-induced causes to identify opportunities for intervention. METHODS: Using the Utah Perinatal Morality Review Committee database, we performed a retrospective cohort study of all pregnancy-associated deaths-death of a woman during pregnancy or within 1 year from the end of pregnancy-from 2005 to 2014. We performed a detailed descriptive analysis of women with drug-induced deaths. We compared characteristics of women with drug-induced and other pregnancy-associated deaths. RESULTS: From 2005 to 2014, 136 pregnancy-associated deaths were identified. Drug-induced death was the leading cause of pregnancy-associated death (n=35, 26%) and 89% occurred in the postpartum period. More specifically, those with a drug-induced death were more likely to die in the late postpartum period, defined as death occurring within 43 days to 1 year of the end of the pregnancy, (n=28/35, 80%) compared with women whose deaths were from other pregnancy-associated causes (n=34/101, 34%) (P<.001). The majority of drug-induced deaths were attributed to opioids (n=27/35, 77%), prescription opioids (n=21/35, 60%), and polysubstance use (n=29/35, 83%). From 2005 to 2014, the pregnancy-associated mortality ratio increased 76%, from 23.3 in 2005 to 41.0 in 2014. During this same time period, the drug-induced pregnancy-associated mortality ratio increased 200%, from 3.9 in 2005 to 11.7 in 2014. CONCLUSION: Drug-induced death is the leading cause of pregnancy-associated death in Utah and occurs primarily in the late postpartum period. Interventional studies focused on identifying and treating women at risk of drug-induced death are urgently needed.

Duration of Maternal Stress and Depression: Predictors of Newborn Admission to Neonatal Intensive Care Unit and Postpartum Depression.

BACKGROUND: Maternal psychosocial factors contribute to adverse pregnancy outcome, but very few studies have assessed associations of duration and experiences of stress, depression, and intimate partner violence (IPV) with maternal and newborn outcomes. OBJECTIVES: It was hypothesized that duration and level of maternal stress, depression, and IPV would predict increased risk of adverse maternal/newborn outcomes. METHODS: A secondary data analysis of a population-based data set collected by the Utah Department of Health Pregnancy Risk Assessment and Monitoring System and birth certificates for 4682 live births was conducted, reflecting a total population size of 143,373 live births in 2009-2011. Exposures of interest were experiences and duration of maternal stress, depression, and IPV before and during pregnancy. Outcomes were gestational age, birth weight, newborn admission to the neonatal intensive care unit (NICU), and postpartum depression (PPD) symptoms and diagnosis. RESULTS: After controlling for maternal demographics, body mass index, and smoking, women with greater duration of depression before and during pregnancy showed an increase in admission of their newborn to NICU (adjusted odds ratios [aORs] = 1.66-2.48, p < .001), PPD symptoms (aORs = 3.94-9.13, p < .001), and diagnosis of PPD (aORs = 7.72-59.60, p < .001). More kinds of experiences of maternal stress were associated with higher odds of PPD symptoms (aORs = 1.34-5.51, p < .001), but not PPD diagnosis or NICU admissions. DISCUSSION: Longer lasting maternal depression and stress are associated with poorer outcomes for mothers and newborns. Future prospective studies should evaluate the usefulness of preconception and continuous prenatal risk identification of maternal depression and stress. This would facilitate timely psychosocial interventions as an approach to improving maternal/newborn outcomes for these higher risk women.

Exploring the Psychosocial Predictors of Gestational Diabetes and Birth Weight.

OBJECTIVE: To determine the best sociodemographic and behavioral predictors for gestational diabetes mellitus (GDM) and birth weight (BW) and whether stress, depression, or abuse influences GDM and BW after controlling for sociodemographic variables. DESIGN: Retrospective correlational. SETTING: Utah Pregnancy Risk Monitoring System and birth certificate data. PARTICIPANTS: We analyzed data from the birth certificates of 4,682 women with live births between 2009 and 2011 in Utah. During that time, a total of 143,373 live births occurred in the state. Data were predominantly from non-Hispanic White, married, or partnered women with average age of 27.5 years and average body mass index (BMI) of 25.1. METHODS: Stress, cumulative depression, and abuse were operationalized based on previous analysis, and control and covariate data (e.g., age, BMI, race, ethnicity, education, marital status) were collected. Bivariate analysis was used to identify associations between variables, and a hierarchical stepwise logistical regression was conducted to identify best predictors of GDM and BW. RESULTS: We did not find that cumulative depression, stress, or abuse was a predictor of GDM, and only cumulative stress was a predictor of BW. More incidences of GDM were observed in women who were poor, older, less educated, non-White, obese, or experienced depression during pregnancy. CONCLUSION: Unlike depression or abuse, stress is often overlooked by providers. This finding represents an unmet opportunity for nurses to screen for and assist women with stressors to positively affect birth weight.

Use of fertility treatments in relation to the duration of pregnancy attempt among women who were trying to become pregnant and experienced a live birth.

The purpose of this study was to compare the utilization of medical help for fertility among women who reported up to a year versus more than a year of trying to become pregnant and to describe the characteristics of those women seeking early treatment. Data from the 2004-2008 Pregnancy Risk Assessment Monitoring System (PRAMS) survey were used to assess attempt duration and use of fertility treatments in a sample of 9,517 women who had a recent live birth in Utah. PRAMS respondents who were trying to become pregnant at the time of conception were asked questions about fertility treatments (sampling n = 5,238; representative n = 153,036). Univariate and bivariate analyses were used to describe and compare characteristics of women who sought treatment after attempting pregnancy for a year or less and women who waited at least a year to seek treatment. Among women who were trying to become pregnant, 9.5 % reported using some medical assistance to conceive. Among the women trying to become pregnant, 89.3 % had been trying for ≤12 months and 10.7 % reported having tried >12 months. 5.2 % of those trying to become pregnant for up to a year reported use of fertility treatment, compared with 45.8 % of those trying for a year or more. Women who had previous live births were significantly more likely to use early treatment than nulliparous women (aOR = 2.4, 95 % CI = 1.5, 3.9). The use of fertility drugs and other treatments were more common than ART among recipients of early treatment (aOR = 3.7, 95 % CI = 1.7, 7.9). Some women may be receiving fertility treatment before it is clinically indicated. Instead of invasive treatment, these women may benefit from preconception counseling on folic acid, healthy prepregnancy weight and use of ovulation monitoring to time intercourse.

Infertility treatment in a population-based sample: 2004-2005.

To describe the characteristics of women seeking infertility treatment and the types of fertility treatment sought within a population-based sample. We analyzed data from the cross-sectional Pregnancy Risk Assessment Monitoring System (PRAMS) of women with a live birth using data from seven states. Logistic regression was used to determine factors associated with infertility treatment utilization. Infertility treatment was reported by 10.5% of women who were trying to become pregnant. The most common treatment reported was fertility enhancing drugs (29%), followed by assisted reproductive technology including in vitro fertilization (21%), and artificial insemination together with fertility enhancing drugs (15%). Some women reported using other types of treatment (23%). The PRAMS data provide insights into the use of infertility treatment among women giving birth in the United States. Further research is needed to understand the true prevalence of infertility, factors that influence treatment choices, and the longitudinal impact of infertility treatment on outcomes.

Health behaviors and infant health outcomes in homeless pregnant women in the United States.

OBJECTIVE: To describe selected demographics; maternal health behaviors before, during, and after pregnancy; and infant health outcomes among homeless women in the United States. PATIENTS AND METHODS: Analyses are based on Pregnancy Risk Assessment Monitoring System data from 31 participating states from 2000 to 2007 that were linked to birth certificate data, which contain demographic and medical information collected through the state's vital records system. Responses were then weighted to be representative of all women who gave birth in each state during that year. Assessment of these data takes into account the complex sampling designs employed by the states. RESULTS: Four percent of women reported homelessness within 12 months before pregnancy, with the highest percentage in Illinois, followed by Oregon and Washington. Homeless women were younger, unmarried, uninsured, less educated, less likely to initiate and sustain breastfeeding, and had less prenatal care and well-visits. They were also more likely to be black, Hispanic, smoke cigarettes, be underweight or have class III obesity, and not take preconception multivitamins. Infants had lower birth weights, a longer hospital stay, and were more likely to receive neonatal intensive care. CONCLUSIONS: In this study we provide additional insight into homelessness in the perinatal period and provide information on ways to direct interventions aimed at improving the health of homeless mothers and infants. Additional research is needed to determine factors that influence pregnancy weight gain and infant feeding practices among homeless women and how this affects infant health.

Maternal health behaviors and infant health outcomes among homeless mothers: U.S. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2000-2007.

OBJECTIVE: To determine whether participation in the Women, Infants, and Children Program is associated with improved maternal and infant health outcomes among homeless women in the Pregnancy Risk Assessment Monitoring System. METHOD: Analyses were based on Pregnancy Risk Assessment Monitoring System participants from 31 states/cities in the United States, 2000-2007 (n=272,859). Overall, 4% of women completing the Pregnancy Risk Assessment Monitoring System survey were homeless, with 76% participating in the Women, Infants, and Children Program, a federally-funded supplemental nutrition program for low-income women and children less than 5 years old. RESULTS: Among women in the Pregnancy Risk Assessment Monitoring System survey who reported using the Women, Infants, and Children Program, those experiencing homelessness were older, less educated, less likely to have private health insurance, and more likely to receive government assistance. Homeless women in the Women, Infants, and Children Program compared with those not in the program were significantly more likely to have a higher body mass index, to initiate breastfeeding after delivery, have prenatal care visits, have a longer gestational age, and have a greater infant birth weight. CONCLUSION: Characteristics of homeless pregnant women choosing to participate in the Women, Infants, and Children Program are consistent with the requirements for program participation for women in general. Homeless women accessing the Women, Infants, and Children Program had better maternal and infant health outcomes.

Postpartum depression and help-seeking behavior.

The objective of this analysis was to investigate the demographic differences between women who report postpartum depression symptoms (PPDS) and seek help versus those who report symptoms but who do not seek help, using data from the Utah Pregnancy Risk Assessment Monitoring System (PRAMS) 2004 dataset. Overall, 14.7% of Utah women reported experiencing PPDS in 2004. Sixty percent of the women who reported having PPDS did not seek help. Seeking help for depression during pregnancy was associated with help-seeking behavior postpartum (adjusted odds ratio [aOR] = 0.1; 95% confidence interval [CI], 0.04-0.2). Other factors associated with seeking help included having an infant admitted to the intensive care unit (aOR = 0.4; 95% CI, 0.2-0.9) and rural residency (aOR = 0.3; 95% CI, 0.2-0.7). Nonwhite women were 12.1 times (95% CI, 3.0-48.5) more likely to not seek help for depression compared to white women. Further, Hispanic women (aOR = 3.2; 95% CI, 1.3-8.1) and women who experienced emotional abuse had increased odds of not seeking help (aOR = 2.9; 95% CI, 1.3-6.2). Nearly 15% of Utah women in this study reported PPDS, yet fewer than half sought help. Target populations, such as nonwhite, Hispanic, emotionally abused, and urban women, have been identified for public health interventions.

Maternal body mass index and self-reported postpartum depressive symptoms.

OBJECTIVES: The association between extremes of body mass index (BMI) and depression in women has been documented, yet little is known about the relationship between obesity and postpartum depression (PPD). This study seeks to characterize the association between BMI and PPD. METHODS: The 2000-2001 Utah data from Pregnancy Risk Assessment Monitoring System (PRAMS) were used to determine the proportion of women, stratified by prepregnancy body mass index, reporting postpartum depressed mood and stressors during pregnancy. RESULTS: The prevalence of self-reported moderate or greater depressive symptoms was 27.7% (S.E. +/-2.2) in underweight, 22.8% (+/-1.2) in normal weight, 24.8% (+/-2.9) in overweight and 30.8% (+/-2.5) in obese women. After controlling for marital status and income, normal BMI (19.8-25.9) was associated with the lowest rate of self-reported postpartum depressive symptoms. There was a two-fold increase in self-reported depressive symptoms requiring assistance among overweight and obese women compared to normal weight women (1.53% normal, 2.99% overweight, and 3.10% obese [p < 0.001]). Obese women were significantly more likely to report emotional and traumatic stressors during pregnancy than normal weight women. CONCLUSION: This population-based survey suggests a potential association between prepregnancy body mass index and self-reported postpartum depressive symptoms. Prospective studies of association between obesity and PPD, with improved diagnostic precision are warranted.