A randomized comparative-effectiveness study of two enhanced prenatal care models for low-income pregnant people: Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE).

BACKGROUND: Improving perinatal mental health and care experiences and preventing adverse maternal and infant outcomes are essential prenatal care components, yet existing services often miss the mark, particularly for low-income populations. An enhanced group prenatal care program, "Glow! Group Prenatal Care and Support," was developed in California's Central Valley in response to poor perinatal mental health, disrespectful care experiences, and high rates of adverse birth outcomes among families with low incomes. METHODS: Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) is a pragmatic, two-arm, randomized, comparative-effectiveness study designed to assess depression (primary outcome), the experience of care (secondary outcome), and preterm birth (exploratory outcome) among Medi-Cal (California's Medicaid program)-eligible pregnant and birthing people, comparing those assigned to Glow! Group Prenatal Care and Support (Glow/GC) with those assigned to enhanced, individual prenatal care through the California Department of Public Health's Comprehensive Perinatal Services Program (CPSP/IC). Participating clinical practices offer the two comparators, alternating between comparators every 6 weeks, with the starting comparator randomized at the practice level. Participant-reported outcomes are assessed through interviewer-administered surveys at study entry, during the participant's third trimester, and at 3 months postpartum; preterm birth and other clinical outcomes are abstracted from labor and delivery records. Patient care experiences are further assessed in qualitative interviews. The protocol complies with the Standard Protocol Items for Randomized Trials. CONCLUSIONS: This comparative-effectiveness study will be used to determine which of two forms of enhanced prenatal care is more effective, informing future decisions regarding their use. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04154423.

Endorsement of a single-item measure of sleep disturbance during pregnancy and risk for postpartum depression: a retrospective cohort study.

Poor prenatal sleep quality is associated with increased risk for depressive symptoms but may go undetected in brief, busy prenatal care visits. Among non-depressed pregnant participants, we evaluated whether 1) the endorsement of sleep disturbance on a depression questionnaire predicted postpartum depressive symptoms, 2) the strength of these associations was higher than other somatic symptoms of pregnancy and depression (i.e., fatigue, appetite disturbance), and 3) the endorsement of prenatal sleep disturbance varied by participant characteristics. In this retrospective cohort study, participants had a live birth and completed Patient Health Questionnaire (PHQ-9) during pregnancy and within 8 weeks postpartum between 2012 and 2017. Participants who were non-depressed during pregnancy (PHQ-9 < 10) were included (n = 3619). We operationalized sleep disturbance, fatigue, and appetite disturbance as endorsement of item 3, 4, and 5 on the PHQ-9, respectively, and postpartum depressive symptoms as PHQ-9 total score ≥ 10. Participant characteristic variables included age, race, ethnicity, parity, gestational age at delivery, and preterm birth. Prenatal sleep disturbance was associated with higher odds of postpartum depressive symptoms (aORs 1.9, 95% CI 1.2-3.1 for first trimester; 3.7, 95% CI 1.5-11.5 for second trimester; 3.4, 95% CI 1.9-6.8 for third trimester). Fatigue and appetite disturbance in the first and third trimesters were associated with higher odds of postpartum depressive symptoms. Sleep disturbance varied by race during the first and second trimesters (p < 0.05) and was highest among Black or African American participants (61.8-65.1%). A routinely administered single-item measure of sleep disturbance could identify otherwise lower-risk pregnant individuals who may benefit from depression prevention efforts.

Pregnancy-related COVID worry, depressive symptom severity, and mediation through sleep disturbance in a low-income, primarily Latinx population in California's Central valley.

PURPOSE: This study (1) assessed the psychometric properties of a pregnancy-related COVID worry scale, (2) explored variations in pregnancy-related COVID worry over the course of the pandemic, and (3) examined associations between pregnancy-related COVID worry and depressive symptom severity, and evaluated sleep disturbance as a mediator. METHODS: Data were drawn from an ongoing randomized trial comparing the effectiveness of two enhanced forms of prenatal care. The current analysis includes baseline pre-randomization data collected from participants who enrolled November 2020-November 2021 (n = 201). Participants were pregnant individuals with low income and primarily Latinx. RESULTS: Our 7-item scale was valid and reliable for assessing pregnancy-related COVID worry. Pregnancy-related COVID worry did not vary significantly by any participant characteristic or pandemic stage. Pregnancy-related COVID worry was significantly associated with depressive symptom severity in multivariate analysis (p = .002). For each unit increase on the 10-point pregnancy-related COVID worry scale, the odds of mild-to-severe depression increased by 16% (odds ratio = 1.16, 95% confidence interval 1.02-1.32, p = .02), holding all other variables constant. Sleep disturbance mediated the pregnancy-related COVID worry-depressive symptom relationship (48% of the total effect mediated). CONCLUSIONS: Worry about how COVID may impact their baby, birth, and postpartum experiences was associated with higher depressive symptom severity, partly through its effect on sleep. These findings suggest that interventions related to improving sleep quality among perinatal populations may reduce depressive symptoms. TRIAL REGISTRATION: ClinicalTrials.gov NCT04154423, "Engaging Mothers & Babies; Reimagining Antenatal Care for Everyone (EMBRACE) Study".

Adverse infant outcomes among women with sleep apnea or insomnia during pregnancy: A retrospective cohort study.

OBJECTIVE: To evaluate whether sleep apnea or insomnia among pregnant people is associated with increased risk for adverse infant outcomes. DESIGN: Retrospective cohort study SETTING: California PARTICIPANTS: The sample included singleton live births. Sleep apnea and insomnia were defined based on ICD-9 and -10 codes. A referent group was selected using exact propensity score matching on maternal characteristics, obstetric factors, and infant factors among individuals without a sleep disorder. MEASUREMENTS: Adverse infant outcomes were obtained from birth certificate, hospital discharge, and death records (eg, Apgar scores, neonatal intensive care unit (NICU) stay, infant death, long birth stay, etc.). Logistic regression was used to calculate odds of an adverse infant outcome by sleep disorder type. RESULTS: Propensity-score matched controls were identified for 69.9% of the 3371 sleep apnea cases and 68.8% of the 3213 insomnia cases. Compared to the propensity-matched referent group, individuals with a diagnosis of sleep apnea (n = 2357) had infants who were more likely to have any adverse outcome, low 1-min Apgar scores, NICU stay, and an emergency room visit in the first year of life. Infants born to mothers with a diagnosis of insomnia (n = 2212) were at increased risk of few negative outcomes relative to the propensity matched referent group, with the exception of an emergency room visit. CONCLUSIONS: In unadjusted analyses, infants born to individuals with a diagnosis of sleep apnea or insomnia were at increased risk of several adverse outcomes. These were attenuated when using propensity score matching, suggesting these associations were driven by other comorbidities.

Uptake of USPSTF recommendation to refer pregnant individuals for therapy or counseling to prevent perinatal depression.

PURPOSE: Perinatal depression is the most common complication of pregnancy and childbirth, and it is associated with adverse consequences. The United States Preventive Services Task Force (USPSTF) recommends that pregnant and postpartum (i.e., perinatal) individuals at risk for depression be referred for therapy or counseling interventions; however, it is unclear to what extent this recommendation has been implemented. METHODS: Pregnant individuals were recruited via advertisements on a pregnancy app and a separate study on sleep. Respondents completed the initial screening questions to determine their risk for perinatal depression, defined as self-reported history of depression; recent stressors; history of emotional, sexual, or physical abuse; mild depressive symptoms; anxiety symptoms; single; diabetes diagnosis; or unwanted pregnancy. Eligible respondents reported their providers' recommendations for preventing depression, and their utilization of interventions to prevent depression (n = 303). RESULTS: Fewer than 15% of participants reported that a provider referred them for therapy or counseling to prevent depression; recommendations included cognitive behavioral therapy (4%), interpersonal psychotherapy (2.3%), mindfulness-based cognitive therapy (4.3%), or other/unknown (6.6%). Approximately 12% reported that a provider recommended medication to prevent depression. Provider referral rates varied by risk factor, but not by patient demographics. Nearly 20% of participants reported using therapy or counseling to prevent depression, and nearly 13% reported using medication to prevent depression. CONCLUSIONS: We explore potential factors affecting the uptake of the USPSTF recommendation and underscore the importance of preventing perinatal depression.

Trajectories of depressive symptoms among mothers of preterm and full-term infants in a national sample.

To examine postpartum depressive symptom trajectories from birth to age 5 and their risk factors in a national sample of mothers of preterm and full-term infants. The racially and ethnically diverse sample comprised 11,320 maternal participants (Mage = 29; SD = 5.9) in the Environmental influences on Child Health Outcomes (ECHO) Program in the USA with data on newborn gestational age at birth (≥ 22 weeks) and maternal depression symptoms during the first 5 years following childbirth. Growth mixture models determined the number and trajectory of postpartum depression classes among women in the preterm and full-term groups, and we examined predictors of class membership. Five trajectories described depressive symptoms for both groups; however, notable differences were observed. One in 5 mothers of preterm infants developed clinically relevant depressive symptoms over time compared with 1 in 10 mothers of full-term infants. Among women who delivered preterm compared with those who delivered full-term, symptoms were more likely to increase over time and become severe when offspring were older. Distinct subgroups describe mothers' depressive symptom trajectories through 5 years following childbirth. Mild to moderate depressive symptoms may onset or persist for many women beyond the initial postpartum period regardless of newborn gestational age at birth. For women with preterm infants, initially mild symptoms may increase to high levels of severity during the preschool and toddler years.

Examining Experiences of Poor Sleep During Pregnancy: A Qualitative Study to Inform the Development of a Prenatal Sleep Intervention.

Background: Poor sleep is common during pregnancy and is associated with increased risk of negative health outcomes. Research indicates that physical discomfort and having an active mind are primary factors for prenatal sleep disturbances. Mindfulness-based interventions have the potential for addressing these factors, but have yet to be optimized for this purpose in this population. Objective: The objective of this study was to gather input from pregnant and postpartum individuals about the value of a mindfulness-based program for improving prenatal sleep and their preferred content and delivery format. Methods: We conducted 2 focus groups with 12 pregnant people experiencing poor sleep quality and 3 individual interviews with postpartum people. Interviews were thematically analyzed. Results: The majority of participants expressed strong interest in a mindfulness program for improving prenatal sleep. Participants reported that pregnancy-specific physical discomfort and worry (both general and pregnancy-specific) affected their sleep. Participants wanted sleep education, and strategies for calming the mind, reducing physical discomfort, reducing impact of bedtime partners on sleep, and tips for improving sleep schedule and quality. Participants recognized the convenience of an online intervention and the social benefits of an in-person intervention and favored a hybrid delivery model. Conclusion: Addressing prenatal sleep problems is an unmet need. Given the challenges and discomfort women face during pregnancy, and the importance of adequate sleep for promoting mental and physical health during pregnancy, sleep difficulties are critical to address. A mindfulness-based intervention for improving prenatal sleep was deemed of high interest to this perinatal population.

Lessons Learned Recruiting and Retaining Pregnant and Postpartum Individuals in Digital Trials: Viewpoint.

In an increasingly connected world and in the midst of a global pandemic, digital trials offer numerous advantages over traditional trials that rely on physical study sites. Digital trials have the potential to improve access to research and clinical treatments for the most vulnerable and minoritized, including pregnant and postpartum individuals. However, digital trials are underutilized in maternal and child health research, and there is limited evidence to inform the design and conduct of digital trials. Our research collaborative, consisting of 5 research teams in the U.S. and Australia, aimed to address this gap. We collaborated to share lessons learned from our experiences recruiting and retaining pregnant and postpartum individuals in digital trials of social and behavioral interventions. We first discuss the promise of digital trials in improving participation in research during the perinatal period, as well as the unique challenges they pose. Second, we present lessons learned from 12 completed and ongoing digital trials that have used platforms such as Ovia, Facebook, and Instagram for recruitment. Our trials evaluated interventions for breastfeeding, prenatal and postpartum depression, insomnia, decision making, and chronic pain. We focus on challenges and lessons learned in 3 key areas: (1) rapid recruitment of large samples with a diversity of minoritized identities, (2) retention of study participants in longitudinal studies, and (3) prevention of fraudulent enrollment. We offer concrete strategies that we pilot-tested to address these challenges. Strategies presented in this commentary can be incorporated, as well as formally evaluated, in future studies.

Randomized controlled trial of digital cognitive behavior therapy for prenatal insomnia symptoms: effects on postpartum insomnia and mental health.

STUDY OBJECTIVES: To evaluate the effects of digital cognitive behavior therapy for insomnia (dCBT-I) delivered during pregnancy on subjective sleep outcomes, depressive symptoms, and anxiety symptoms through 6 months postpartum. METHODS: People up to 28 weeks gestation (N = 208) with insomnia were randomized to 6 weekly sessions of dCBT-I or standard care. We report follow-up data at 3 and 6 months postpartum. The primary outcome was insomnia symptom severity. Secondary sleep outcomes included global sleep quality and insomnia caseness. Mental health outcomes included depressive and anxiety symptom severity. We evaluated between-condition differences in change from baseline for each postpartum timepoint and categorical outcomes. RESULTS: dCBT-I participants did not experience significantly greater improvements in insomnia symptom severity relative to standard care participants, but they did experience higher rates of insomnia remission and lower rates of insomnia caseness at 6 months postpartum. dCBT-I participants experienced greater improvements in depressive symptom severity from baseline to both postpartum timepoints, and in anxiety symptom severity from baseline to 3 months postpartum. The proportion of participants with probable major depression at 3 months postpartum was significantly higher among standard care (18%) than dCBT-I (4%, p = 0.006) participants; this between-condition difference was pronounced among the subset (n = 143) with minimal depressive symptoms at baseline (18% vs 0%). CONCLUSION: dCBT-I use during pregnancy leads to enduring benefits for postpartum insomnia remission. Findings provide strong preliminary evidence that dCBT-I use during pregnancy may prevent postpartum depression and anxiety, which is notable when considering the high frequency and importance of these problems.Clinical Trials: ClinicalTrials.gov, https://clinicaltrials.gov/ct2/show/NCT02805998, NCT02805998.

The association of COVID-19 infection in pregnancy with preterm birth: A retrospective cohort study in California.

INTRODUCTION: Our understanding of the association between coronavirus disease 19 (COVID-19) and preterm or early term birth among racially and ethnically diverse populations and people with chronic medical conditions is limited. METHODS: We determined the association between COVID-19 and preterm (PTB) birth among live births documented by California Vital Statistics birth certificates between July 2020 and January 2021 (n=240,147). We used best obstetric estimate of gestational age to classify births as very preterm (VPTB, <32 weeks), PTB (< 37 weeks), early term (37 and 38 weeks), and term (39-44 weeks), as each confer independent risks to infant health and development. Separately, we calculated the joint effects of COVID-19 diagnosis, hypertension, diabetes, and obesity on PTB and VPTB. FINDINGS: COVID-19 diagnoses on birth certificates increased for all racial/ethnic groups between July 2020 and January 2021 and were highest for American Indian/Alaska Native (12.9%), Native Hawaiian/Pacific Islander (11.4%), and Latinx (10.3%) birthing people. COVID-19 diagnosis was associated with an increased risk of VPTB (aRR 1.6, 95% CI [1.4, 1.9]), PTB (aRR 1.4, 95% CI [1.3, 1.4]), and early term birth (aRR 1.1, 95% CI [1.1, 1.2]). There was no effect modification of the overall association by race/ethnicity or insurance status. COVID-19 diagnosis was associated with elevated risk of PTB in people with hypertension, diabetes, and/or obesity. INTERPRETATION: In a large population-based study, COVID-19 diagnosis increased the risk of VPTB, PTB, and early term birth, particularly among people with medical comorbidities. Considering increased circulation of COVID-19 variants, preventative measures, including vaccination, should be prioritized for birthing persons. FUNDING: UCSF-Kaiser Department of Research Building Interdisciplinary Research Careers in Women's Health Program (BIRCWH) National Institute of Child Health and Human Development (NICHD) and the Office of Research on Women's Health (ORWH) [K12 HD052163] and the California Preterm Birth Initiative, funded by Marc and Lynn Benioff.

Cannabis-related diagnosis in pregnancy and adverse maternal and infant outcomes.

BACKGROUND: Cannabis use and cannabis use disorders are increasing in prevalence, including among pregnant women. The objective was to evaluate the association of a cannabis-related diagnosis (CRD) in pregnancy and adverse maternal and infant outcomes. METHODS: We queried an administrative birth cohort of singleton deliveries in California between 2011-2017 linked to maternal and infant hospital discharge records. We classified pregnancies with CRD from International Classification of Disease codes. We identified nicotine and other substance-related diagnoses (SRD) in the same manner. Outcomes of interest included maternal (hypertensive disorders) and infant (prematurity, small for gestational age, NICU admission, major structural malformations) adverse outcomes. RESULTS: From 3,067,069 pregnancies resulting in live births, 29,112 (1.0 %) had a CRD. CRD was associated with an increased risk of all outcomes studied; the strongest risks observed were for very preterm birth (aRR 1.4, 95 % CI 1.3, 1.6) and small for gestational age (aRR 1.4, 95 % CI 1.3, 1.4). When analyzed with or without co-exposure diagnoses, CRD alone conferred increased risk for all outcomes compared to no use. The strongest effects were seen for CRD with other SRD (preterm birth aRR 2.3, 95 % CI 2.2, 2.5; very preterm birth aRR 2.6, 95 % CI 2.3, 3.0; gastrointestinal malformations aRR 2.0, 95 % CI 1.6, 2.6). The findings were generally robust to unmeasured confounding and misclassification analyses. CONCLUSIONS: CRD in pregnancy was associated with increased risk of adverse maternal and infant outcomes. Providing education and effective treatment for women with a CRD during prenatal care may improve maternal and infant health.

Prenatal Maternal Objective and Subjective Stress Exposures and Rapid Infant Weight Gain.

OBJECTIVES: To evaluate the associations between 3 prenatal stress exposures and rapid infant weight gain. STUDY DESIGN: Participants were 162 maternal-child dyads drawn from a nonrandomized controlled trial evaluating a prenatal intervention for reducing women's stress and excessive gestational weight gain and subsequent longitudinal observational study of offspring outcomes. Participants were predominantly low-income and racial or ethnic minorities, and mothers were overweight or obese prepregnancy. Primary exposures were objective stress exposures (number of stressful life events) and subjective distress (maternal perceived stress and depressive symptoms) during pregnancy. The primary outcome was rapid infant weight gain from birth to 6 months, assessed via birth records and in-person anthropometry measurements. RESULTS: In total, 28% of the sample (N = 40) met criteria for rapid infant weight gain. In adjusted models, exposure to prenatal stressful life events was associated with increased odds of rapid infant weight gain (OR 1.40, 95% CI 1.07-1.83, P = .014). Neither prenatal perceived stress (OR 0.47, 95% CI 0.16-1.37, P = .17) nor depressive symptoms (OR 0.89, 95% CI 0.76-1.03, P = .13) were significantly associated with rapid infant weight gain. CONCLUSIONS: Each additional stressful life event a woman experienced during pregnancy was associated with 40% greater odds of rapid infant weight gain. Future research should evaluate whether prenatal interventions that focus on reducing exposure to stressful events prevent rapid infant weight gain.

Outcomes of Online Mindfulness-Based Cognitive Therapy for Patients With Residual Depressive Symptoms: A Randomized Clinical Trial.

Importance: Patients with residual depressive symptoms face a gap in care because few resources, to date, are available to manage the lingering effects of their illness. Objective: To evaluate the effectiveness for treating residual depressive symptoms with Mindful Mood Balance (MMB), a web-based application that delivers mindfulness-based cognitive therapy, plus usual depression care compared with usual depression care only. Design, Setting, and Participants: This randomized clinical trial was conducted in primary care and behavioral health clinics at Kaiser Permanente Colorado, Denver. Adults identified with residual depressive symptoms were recruited between March 2, 2015, and November 30, 2018. Outcomes were assessed for a 15-month period, comprising a 3-month intervention interval and a 12-month follow-up period. Interventions: Patients were randomized to receive usual depression care (UDC; n = 230) or MMB plus UDC (n = 230), which included 8 sessions delivered online for a 3-month interval plus minimal phone or email coaching support. Main Outcomes and Measures: Primary outcomes were reduction in residual depressive symptom severity, assessed using the Patient Health Questionaire-9 (PHQ-9); rates of depressive relapse (PHQ-9 scores ≥15); and rates of remission (PHQ-9 scores <5). Secondary outcomes included depression-free days, anxiety symptoms (General Anxiety Disorder-7 Item Scale), and functional status (12-Item Short Form Survey). Results: Among 460 randomized participants (mean [SD] age, 48.30 [14.89] years; 346 women [75.6%]), data were analyzed for the intent-to-treat sample, which included 362 participants (78.7%) at 3 months and 330 (71.7%) at 15 months. Participants who received MMB plus UDC had significantly greater reductions in residual depressive symptoms than did those receiving UDC only (mean [SE] PHQ-9 score, 0.95 [0.39], P < .02). A significantly greater proportion of patients achieved remission in the MMB plus UDC group compared with the UDC only group (PHQ-9 score, <5: ß [SE], 0.38 [0.14], P = .008), and rates of depressive relapse were significantly lower in the MMB plus UDC group compared with the UDC only group (hazard ratio, 0.61; 95% CI, 0.39-0.95; P < .03). Compared with the UDC only group, the MMB plus UDC group had decreased depression-free days (mean [SD], 281.14 [164.99] days vs 247.54 [158.32] days; difference, -33.60 [154.14] days; t = -2.33; P = .02), decreased anxiety (mean [SE] General Anxiety Disorder-7 Item Scale score, 1.21 [0.42], P = .004), and improved mental functioning (mean [SE] 12-Item Short Form Survey score, -5.10 [1.37], P < .001), but there was no statistically significant difference in physical functioning. Conclusions and Relevance: Use of MMB plus UDC resulted in significant improvement in depression and functional outcomes compared with UDC only. The MMB web-based treatment may offer a scalable approach for the management of residual depressive symptoms. Trial Registration: ClinicalTrials.gov identifier: NCT02190968.

Efficacy of Digital Cognitive Behavioral Therapy for the Treatment of Insomnia Symptoms Among Pregnant Women: A Randomized Clinical Trial.

Importance: Despite the prevalence and adverse consequences of prenatal insomnia, a paucity of research is available regarding interventions to improve insomnia symptoms during pregnancy. Objective: To test the efficacy of digital cognitive behavioral therapy for insomnia (CBT-I) compared with standard treatment among pregnant women with insomnia symptoms. Design, Setting, and Participants: This randomized clinical trial enrolled pregnant women from November 23, 2016, to May 22, 2018. Of the 2258 women assessed for eligibility using an online self-report questionnaire, 208 were randomized to receive digital CBT-I (n = 105) or standard treatment (n = 103) for insomnia. Participants were pregnant up to 28 weeks' gestation, and they either had elevated insomnia symptom severity or met the criteria for insomnia caseness as determined by self-report questionnaires. Participants completed outcome measures at 10 weeks (postintervention) and 18 weeks (follow-up) after randomization. All study visits were completed remotely, and the intervention was delivered digitally. Data were analyzed between December 12, 2018, and July 2, 2019. Interventions: Digital CBT-I consisted of 6 weekly sessions of approximately 20 minutes each. Standard treatment reflected standard care. Women receiving standard treatment had no limits placed on the receipt of nonstudy treatments, including medication and psychotherapy. Main Outcomes and Measures: All outcomes were assessed remotely using self-report questionnaires administered via online survey. The primary outcome was the change in insomnia symptom severity (measured by the Insomnia Severity Index) from baseline to postintervention. Secondary outcomes were sleep efficiency and nightly sleep duration (defined by sleep diary), global sleep quality (measured by the Pittsburgh Sleep Quality Index), depressive symptom severity (measured by the Edinburgh Postnatal Depression Scale), and anxiety symptom severity (measured by the Generalized Anxiety Disorder Scale-7). For each outcome, we also examined the change from baseline to follow-up. Results: The 208 participants had a mean (SD) age of 33.6 (3.7) years and a mean (SD) gestational age of 17.6 (6.3) weeks at baseline. Most of the participants were white (138 [66.3%]), married or cohabiting (196 [94.2%]), had a college degree (180 [86.5%]), and earned $100 000 or more per year (141 [67.8%]). Women randomized to receive digital CBT-I experienced statistically significantly greater improvements in insomnia symptom severity from baseline to postintervention compared with women randomized to receive standard treatment (time-by-group interaction, difference = -0.36; 95% CI, -0.48 to -0.23; χ2 = 29.8; P < .001; d = -1.03). Improvements from baseline to postintervention for all secondary outcomes, with the exception of sleep duration, were statistically significant. A similar pattern of results was evident for the change from baseline to follow-up. Conclusions and Relevance: In this trial, digital CBT was an effective, scalable, safe, and acceptable intervention for improving insomnia symptoms during pregnancy. Trial Registration: ClinicalTrials.gov identifier: NCT02805998.

Pregnant Patient Perceptions of Provider Detection and Treatment of Insomnia.

Objective: To survey pregnant patients about whether their health care providers assessed insomnia, the types of treatment recommendations providers made, and the types of treatments patients utilized. Participants: Participants were 423 English-speaking pregnant women. Methods: In this cross-sectional study, participants self-reported insomnia symptoms on the Insomnia Severity Index and indicated whether they discussed their sleep with a health care provider, whether they received any recommendations to improve their sleep, and whether they utilized any interventions or aids to improve their sleep during their current pregnancy. Results: Approximately one-third (39%) of participants reported that they discussed their sleep with a health care provider at some point during their pregnancy. Among participants who reported moderate to severe insomnia symptoms (Insomnia Severity Index>14), 57% reported that they had discussed their sleep with a health care provider, and 28% reported receiving an insomnia diagnosis. Over-the-counter medication was the most commonly recommended (53%) and utilized (39%) sleep intervention among women with moderate to severe insomnia symptoms. Conclusions: According to patient report, insomnia may be under-detected during pregnancy. When insomnia is recognized, treatment recommendations do not match clinical practice guidelines or women's preferences for receiving cognitive behavior therapy for insomnia. Taken together with previous research on the prevalence and consequences of prenatal insomnia, these findings suggest the need for an increased focus on the importance of sleep during pregnancy.

Associations between unstable housing, obstetric outcomes, and perinatal health care utilization.

BACKGROUND: While there is a growing interest in addressing social determinants of health in clinical settings, there are limited data on the relationship between unstable housing and both obstetric outcomes and health care utilization. OBJECTIVE: The objective of the study was to investigate the relationship between unstable housing, obstetric outcomes, and health care utilization after birth. STUDY DESIGN: This was a retrospective cohort study. Data were drawn from a database of liveborn neonates linked to their mothers' hospital discharge records (2007-2012) maintained by the California Office of Statewide Health Planning and Development. The analytic sample included singleton pregnancies with both maternal and infant data available, restricted to births between the gestational age of 20 and 44 weeks, who presented at a hospital that documented at least 1 woman as having unstable housing using the International Classification of Diseases, ninth edition, codes (n = 2,898,035). Infants with chromosomal abnormalities and major birth defects were excluded. Women with unstable housing (lack of housing or inadequate housing) were identified using International Classification of Diseases, ninth edition, codes from clinical records. Outcomes of interest included preterm birth (<37 weeks' gestational age), early term birth (37-38 weeks gestational age), preterm labor, preeclampsia, chorioamnionitis, small for gestational age, long birth hospitalization length of stay after delivery (vaginal birth, >2 days; cesarean delivery, >4 days), emergency department visit within 3 months and 1 year after delivery, and readmission within 3 months and 1 year after delivery. We used exact propensity score matching without replacement to select a reference population to compare with the sample of women with unstable housing using a one-to-one ratio, matching for maternal age, race/ethnicity, parity, prior preterm birth, body mass index, tobacco use during pregnancy, drug/alcohol abuse during pregnancy, hypertension, diabetes, mental health condition during pregnancy, adequacy of prenatal care, education, and type of hospital. Odds of an adverse obstetric outcome were estimated using logistic regression. RESULTS: Of 2794 women with unstable housing identified, 83.0% (n = 2318) had an exact propensity score-matched control. Women with an unstable housing code had higher odds of preterm birth (odds ratio, 1.2, 95% confidence interval, 1.0-1.4, P < .05), preterm labor (odds ratio, 1.4, 95% confidence interval, 1.2-1.6, P < .001), long length of stay (odds ratio, 1.6, 95% confidence interval, 1.4-1.8, P < .001), emergency department visits within 3 months (odds ratio, 2.4, 95% confidence interval, 2.1-2.8, P < .001) and 1 year after birth (odds ratio, 2.7, 95% confidence interval, 2.4-3.0, P < .001), and readmission within 3 months (odds ratio, 2.7, 95% confidence interval, 2.2-3.4, P < .0014) and 1 year after birth (odds ratio, 2.6, 95% confidence interval, 2.2-3.0, P < .001). CONCLUSION: Unstable housing documentation is associated with adverse obstetric outcomes and high health care utilization. Housing and supplemental income for pregnant women should be explored as a potential intervention to prevent preterm birth and prevent increased health care utilization.

Effect of prenatal mindfulness training on depressive symptom severity through 18-months postpartum: A latent profile analysis.

OBJECTIVE: We examined whether prenatal mindfulness training was associated with lower depressive symptoms through 18-months postpartum compared to treatment as usual (TAU). METHOD: A controlled, quasi-experimental trial compared prenatal mindfulness training (MMT) to TAU. We collected depressive symptom data at post-intervention, 6-, and 18-months postpartum. Latent profile analysis identified depressive symptom profiles, and multinomial logistic regression examined whether treatment condition predicted profile. RESULTS: Three depressive symptom severity profiles emerged: none/minimal, mild, and moderate. Adjusting for relevant covariates, MMT participants were less likely than TAU participants to be in the moderate profile than the none/minimal profile (OR = 0.13, 95% CI = 0.03-0.54, p = .005). CONCLUSIONS: Prenatal mindfulness training may have benefits for depressive symptoms during the transition to parenthood.