Historical Redlining, Contemporary Gentrification, and Severe Maternal Morbidity in California, 2005-2018.

Importance: Historically redlined neighborhoods may experience disinvestment, influencing their likelihood of gentrification, a process of neighborhood (re-)development that unequally distributes harms and benefits by race and class. Understanding the combined outcomes of redlining and gentrification informs how the mutually constitutive systems of structural racism and racial capitalism affect pregnancy outcomes. Objective: To examine if historical redlining and contemporary gentrification is associated with increased severe maternal morbidity (SMM) odds. Design, Setting, and Participants: This cross-sectional study used data from a statewide population-based sample of all live hospital births at 20 weeks' gestation or more between 2005 and 2018 in California. Analysis was conducted from March 2023 to January 2024. Exposure: Redlining (as characterized by the federal Home Owners' Loan Corporation mortgage security maps) and displacement (using present-day sociodemographic and housing market information). Main Outcomes and Measures: Mixed-effects logistic regression models were used to assess the association of census tract-level exposure to historical redlining and contemporary gentrification with increased SMM odds, adjusting for sociodemographic and pregnancy related factors. Outcome classification was based on the Centers for Disease Control and Prevention SMM index, which defines SMM as having any of the 21 procedures and diagnoses based on the International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes. Results: The study sample included 1 554 837 births (median [SD] maternal age, 29.0 [6.4] years; 3464 American Indian or Alaskan Native [0.2%], 224 774 Asian [14.5%], 132 240 Black [8.5%], 880 104 Hispanic [56.6%], 312 490 White [20.1%]), with 22 993 cases of SMM (1.4%). Residents in historically redlined neighborhoods that were undergoing gentrification or displacement were more likely to be Black, Hispanic, and American Indian or Alaskan Native. Independent of individual-level characteristics, SMM odds were greater for individuals living in redlined neighborhoods that experienced displacement (OR, 1.21; 95% CI, 1.14-1.28) and in redlined neighborhoods undergoing gentrification (OR, 1.21; 95% CI, 1.13-1.29) compared with those in continuously advantaged neighborhoods. Conclusions and Relevance: Findings from this cross-sectional study demonstrate that the legacies of redlining, intertwined with current dynamics of displacement and gentrification, affect SMM. Place-based sociopolitical mechanisms that inequitably distribute resources may be important intervention points to address structural drivers of adverse pregnancy outcomes and their racial inequities.

Risk of postpartum hemorrhage with increasing first stage labor duration.

With increasing rates of postpartum hemorrhage (PPH) in high-income countries, an important clinical concern is the impact of labor duration on the risk of PPH. This study examined the relationship between increasing active first stage labor duration and PPH and explored the role of second stage labor duration and cesarean delivery (CD) in this association. Including 77,690 nulliparous women with spontaneous labor onset, first stage labor duration was defined as the time from 5 cm to 10 cm, second stage duration from 10 cm dilation to birth and PPH as estimated blood loss > 1000 ml. Using modified Poisson regression for risk ratios (RR) and confidence intervals (CI), we found a 1.5-fold (RR, 1.53; 95% CI, 1.41‒1.66) increased PPH risk when first stage of labor exceeded 12.1 h compared to the reference (< 7.7 h). Mediation analysis showed that 18.5% (95% CI, 9.7‒29.6) of the increased PPH risk with a prolonged first stage (≥ 7.7 h) was due to a prolonged second stage (> 3 h) or CD. These results suggest that including first stage duration in intrapartum assessments could improve PPH risk identification in first-time mothers with a singleton fetus in vertex presentation at full term with spontaneous labor onset.

Trimester-specific rate of gestational weight loss or gain and birth size: differences by prepregnancy BMI.

OBJECTIVE: The objective of this study was to estimate the effects of trimester-specific gestational weight gain (GWG) on small and large (compared with appropriate) for gestational age (i.e., SGA, LGA, and AGA) by prepregnancy BMI classifications. METHODS: We conducted a cohort study of pregnancies in a national network of community health care organizations, stratifying by prepregnancy BMI (n = 20,676 with normal weight; 19,156 with overweight; 11,647 with obesity class I; 5124 with obesity class II; and 3197 with obesity class III). SGA and LGA (vs. AGA) were modeled as a function of trimester 1, 2, or 3 GWG rate, previous trimester(s) GWG rate, and maternal characteristics using modified Poisson regression. RESULTS: GWG rates ranged from weight loss to substantial gains. GWG-LGA associations were strongest in trimester 1 (risk ratio [RR] range for 10th vs. 50th percentile GWG, across BMI categories: 0.60-0.73). GWG-SGA associations were strongest in lower BMI categories and in trimester 2; RRs were 1.62, 1.40, and 1.17 for prepregnancy normal weight, obesity class I, and obesity class III, respectively, with curvilinear associations for class II and III. CONCLUSIONS: Among people with prepregnancy obesity class II or III, GWG rate is associated with higher LGA risk in a dose-dependent manner, including understudied ranges of weight loss, but with weak associations with SGA.

A Counterfactual Analysis of Impact of Cesarean Birth in a First Birth on Severe Maternal Morbidity in the Subsequent Birth.

BACKGROUND: It is known that cesarean birth affects maternal outcomes in subsequent pregnancies, but specific effect estimates are lacking. We sought to quantify the effect of cesarean birth reduction among nulliparous, term, singleton, vertex (NTSV) births (i.e., preventable cesarean births) on severe maternal morbidity (SMM) in the second birth. METHODS: We examined birth certificates linked with maternal hospitalization data (2007-19) from California for NTSV births with a second birth (N = 779,382). The exposure was cesarean delivery in first birth and the outcome was SMM in the second birth. We used adjusted Poisson regression models to calculate risk ratios and population attributable fraction for SMM in the second birth and conducted a counterfactual impact analysis to estimate how lowering NTSV cesarean births could reduce SMM in second birth. RESULTS: The adjusted risk ratio for SMM in the second birth given a prior cesarean birth was 1.7 (95% CI 1.5-1.9); 15.5% (95% CI 15.3%-15.7%) of this SMM may be attributable to prior cesarean birth. In a counterfactual analysis where 12% of the California population least likely to get a cesarean birth instead delivered vaginally, we observed 174 fewer SMM events in a population of individuals with a low-risk first birth and a subsequent birth. CONCLUSIONS: In our counterfactual analysis, lowering primary cesarean birth among a NTSV population was associated with fewer downstream SMM events in subsequent births and overall. Additionally, our findings reflect the importance of considering the cumulative accrual of risks across the reproductive life-course.

Development of a University-Government Partnership for Public Health Response and Workforce Development in the State of Oregon.

The COVID-19 pandemic exposed and exacerbated a public health workforce shortage and national strategies have called for the development of clear occupational pathways for students to enter the public health workforce and meaningful public health careers. In response to the immediate need for public health workers during the pandemic, several universities and academic hospitals rapidly mobilized students and employees and partnered with local or state health departments. However, many of those partnerships were based on short-term volunteer effort to support critical COVID-19 public health efforts. In this article, we document the development of Oregon's Public Health Practice Team, a student, staff, and faculty workforce developed at the Oregon Health & Science University-Portland State University (OHSU-PSU) School of Public Health in close collaboration with the Oregon Health Authority (OHA). This project contributed significant effort to several phases of Oregon's statewide public health response to COVID-19, and over time developed into a lasting, multi-purpose, inter-agency collaborative public health practice program. Health equity has been centered at every stage of this work. We describe the phases of the partnership development, the current team structure and operations, and highlight key challenges and lessons learned. This provides a case-study of how an innovative and flexible university-government partnership can contribute to immediate pandemic response needs, and also support ongoing public health responses to emerging needs, while contributing to the development of a skilled and diverse public health workforce.

Pregnancy health in a multi-state U.S. population of systemically underserved patients and their children: PROMISE cohort design and baseline characteristics.

BACKGROUND: Gestational weight gain (GWG) is a routinely monitored aspect of pregnancy health, yet critical gaps remain about optimal GWG in pregnant people from socially marginalized groups, or with pre-pregnancy body mass index (BMI) in the lower or upper extremes. The PROMISE study aims to determine overall and trimester-specific GWG associated with the lowest risk of adverse birth outcomes and detrimental infant and child growth in these underrepresented subgroups. This paper presents methods used to construct the PROMISE cohort using electronic health record data from a network of community-based healthcare organizations and characterize the cohort with respect to baseline characteristics, longitudinal data availability, and GWG. METHODS: We developed an algorithm to identify and date pregnancies based on outpatient clinical data for patients 15 years or older. The cohort included pregnancies delivered in 2005-2020 with gestational age between 20 weeks, 0 days and 42 weeks, 6 days; and with known height and adequate weight measures needed to examine GWG patterns. We linked offspring data from birth records and clinical records. We defined study variables with attention to timing relative to pregnancy and clinical data collection processes. Descriptive analyses characterize the sociodemographic, baseline, and longitudinal data characteristics of the cohort, overall and within BMI categories. RESULTS: The cohort includes 77,599 pregnancies: 53% had incomes below the federal poverty level, 82% had public insurance, and the largest race and ethnicity groups were Hispanic (56%), non-Hispanic White (23%) and non-Hispanic Black (12%). Pre-pregnancy BMI groups included 2% underweight, 34% normal weight, 31% overweight, and 19%, 8%, and 5% Class I, II, and III obesity. Longitudinal data enable the calculation of trimester-specific GWG; e.g., a median of 2, 4, and 6 valid weight measures were available in the first, second, and third trimesters, respectively. Weekly rate of GWG was 0.00, 0.46, and 0.51 kg per week in the first, second, and third trimesters; differences in GWG between BMI groups were greatest in the second trimester. CONCLUSIONS: The PROMISE cohort enables characterization of GWG patterns and estimation of effects on child growth in underrepresented subgroups, ultimately improving the representativeness of GWG evidence and corresponding guidelines.

Pelvic floor dysfunction after intervention, compared with expectant management, in prolonged second stage of labour: A population-based questionnaire and cohort study.

OBJECTIVE: To investigate the effect of vacuum extraction (VE) or caesarean section (CS), compared with expectant management, on pelvic floor dysfunction (PFD) 1-2 years postpartum in primiparous women with a prolonged second stage of labour. DESIGN: A population-based questionnaire and cohort study. SETTING: Stockholm, Sweden. POPULATION: A cohort of 1302 primiparous women with a second stage duration of ≥3 h, delivering from December 2017 to November 2018. METHODS: The 1-year follow-up questionnaire from the Swedish National Perineal Laceration Register was distributed 12-24 months postpartum. Exposure was VE or CS at 3-4 h or 4-5 h, compared with expectant management. MAIN OUTCOME MEASURES: Pelvic floor dysfunction was defined as at least weekly symptoms of urinary incontinence, pelvic organ prolapse or a Wexner score of ≥4. The risk of PFD was calculated using Poisson regression with robust variance estimation, presented as crude and adjusted relative risks (RRs and aRRs) with 95% confidence intervals (95% CIs). The implication of obstetric anal sphincter injury (OASI) on pelvic floor disorders was investigated through mediation analysis. RESULTS: In total, 35.1% of women reported PFD. Compared with expectant management, the risk of PFD was increased after VE at 3-4 h (aRR 1.33, 95% CI 1.06-1.65) and 4-5 h (aRR 1.34, 95% CI 1.05-1.70), but remained unchanged after CS. The increased risk after VE was not mediated by OASI. CONCLUSIONS: Pelvic floor dysfunction was common in primiparous women after a prolonged second stage, and the risk of PFD increased after VE but was unaffected by CS, compared with expectant management. If a spontaneous vaginal delivery eventually occurred, allowing an extended duration of labour did not increase the risk of PFD.

Pre-Pregnancy Health Risks by Presence and Extent of Disability, 2019-2020.

INTRODUCTION: Prior studies have shown that, compared to non-disabled women, women with disabilities have a higher burden of preconception mental and physical health risks that are associated with adverse pregnancy outcomes. This cross-sectional study assesses how the extent of disability relates to pre-pregnancy health risks. METHODS: This study used 2019-2020 PRAMS data from 22 sites that included the Washington Group Short Set of Questions on Disability (n=37,006). In 2023, associations between extent of disability (none [reference group], some difficulty, or a lot of difficulty) and preconception health risks were examined using multivariable Poisson regression with robust standard errors to calculate adjusted prevalence ratios (aPRs) and 95% CIs while controlling for sociodemographic characteristics. Preconception health risks included smoking, heavy drinking, high blood pressure, diabetes, no multivitamin use, and experiencing physical abuse, depression, or obesity. Individual risks were analyzed, as well as the total number of risks experienced. RESULTS: Of respondents, 33.6% had some difficulty and 6.3% had a lot of difficulty. The likelihood of experiencing preconception health risks increased with extent of disability. Compared to respondents with no difficulty, those with some or a lot of difficulty had a higher prevalence of experiencing 1-2 health risks (aPR=1.13, 95% CI 1.09, 1.18; aPR=1.20; 95% CI 1.53, 2.25) and 3+ health risks (aPR=1.86, 95% CI 1.53, 2.25; aPR=2.42, 95% CI 1.98, 2.97), respectively. CONCLUSIONS: Disabled women, especially those with more difficulty, are vulnerable to preconception health risks that could potentially be mitigated before conception. These findings highlight the need for enhanced efforts to support preconception health of disabled women.

Insurance coverage and discontinuity during pregnancy: Frequency and associations documented in the PROMISE cohort.

OBJECTIVE: To describe insurance patterns and discontinuity during pregnancy, which may affect the experiences of the pregnant person: their timely access to care, continuity of care, and health outcomes. DATA SOURCES AND STUDY SETTING: Data are from the PROMISE study, which utilizes data from community-based health care organizations (CHCOs) (e.g., federally qualified health centers that serve patients regardless of insurance status or ability to pay) in the United States from 2005 to 2021. STUDY DESIGN: This descriptive study was a cohort utilizing longitudinal electronic health record data. DATA COLLECTION/EXTRACTION METHODS: Insurance type at each encounter was recorded in the clinical database and coded as Private, Public, and Uninsured. Pregnant people were categorized into one of several insurance patterns. We analyzed the frequency and timing of insurance changes and care utilization within each group. PRINCIPAL FINDINGS: Continuous public insurance was the most common insurance pattern (69.2%), followed by uninsured/public discontinuity (11.8%), with 6.4% experiencing uninsurance throughout the entirety of pregnancy. Insurance discontinuity was experienced by 16.6% of pregnant people; a majority of these reflect people transitioning to public insurance. Those with continuous public insurance had the highest frequency of inadequate prenatal care (19.5%), while those with all three types of insurance during pregnancy had the highest percentage of intensive prenatal care (16.5%). The majority (71.7%-81.2%) of those with a discontinuous pattern experienced a single insurance change. CONCLUSIONS: Insurance discontinuity and uninsurance are common within our population of pregnant people seeking care at CHCOs. Our findings suggest that insurance status should be regarded as a dynamic rather than a static characteristic during pregnancy and should be measured accordingly. Future research is needed to assess the drivers of perinatal insurance discontinuity and if and how these discontinuities may affect health care access, utilization, and birth outcomes.

Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017.

BACKGROUND: Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks. OBJECTIVE: To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status. METHODS: Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores. RESULTS: Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88). CONCLUSIONS: Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.

Severe Perineal Lacerations in First Delivery: Association with Subsequent Reproductive Outcomes.

Background: Severe perineal lacerations (SPLs), common worldwide, are associated with short- and long-term complications: pelvic floor disorders, fecal incontinence, fistula, and profound psychological impacts. Limited research suggests that experiencing SPL may influence future reproductive intentions, but research on outcomes is lacking. Methods: We analyzed the effect of experiencing SPL during a first delivery among a large cohort of Swedish births between 1992 and 2013. We used linear and multinomial logistic regression to estimate the associations between SPL and four reproductive outcomes: subsequent total birth number, probability of a second birth, interpregnancy interval (IPI), and subsequent scheduled cesarean birth. Results: Among 947,035 singleton live-born first-births, we found that experiencing SPL was associated with slightly fewer overall births in fully adjusted models (a decrease of -0.020 births; 95% confidence interval [CI]: -0.028 to -0.012), but no difference in the probability of a second birth (risk ratio [RR]: 1.00; 95% CI: 0.99 to 1.00) or IPI. Scheduled cesarean was increased in births after SPL (adjusted RR: 4.57; 95% CI: 4.42 to 4.73). A secondary comparison of SPL to severe postpartum hemorrhage suggests that some of these observed differences may be related to experiencing any severe outcome, and some specifically to perineum disruption. Conclusion: This study provides a deeper understanding of the long-term impacts of SPL, which may be useful in informing best clinical practices for supporting women who have experienced SPL.

Estimating the effect of timing of earned income tax credit refunds on perinatal outcomes: a quasi-experimental study of California births.

BACKGROUND: The largest poverty alleviation program in the US is the earned income tax credit (EITC), providing $60 billion to over 25 million families annually. While research has shown positive impacts of EITC receipt in pregnancy, there is little evidence on whether the timing of receipt may lead to differences in pregnancy outcomes. We used a quasi-experimental difference-in-differences design, taking advantage of EITC tax disbursement each spring to examine whether trimester of receipt was associated with perinatal outcomes. METHODS: We conducted a difference-in-differences analysis of California linked birth certificate and hospital discharge records. The sample was drawn from the linked CA birth certificate and discharge records from 2007-2012 (N = 2,740,707). To predict eligibility, we created a probabilistic algorithm in the Panel Study of Income Dynamics and applied it to the CA data. Primary outcome measures included preterm birth, small-for-gestational age (SGA), gestational diabetes, and gestational hypertension/preeclampsia. RESULTS: Eligibility for EITC receipt during the third trimester was associated with a lower risk of preterm birth compared with preconception. Eligibility for receipt in the preconception period resulted in improved gestational hypertension and SGA. CONCLUSION: This analysis offers a novel method to impute EITC eligibility using a probabilistic algorithm in a data set with richer sociodemographic information relative to the clinical and administrative data sets from which outcomes are drawn. These results could be used to determine the optimal intervention time point for future income supplementation policies. Future work should examine frequent income supplementation such as the minimum wage or basic income programs.

Neighborhood gentrification, displacement, and severe maternal morbidity in California.

Gentrification, a racialized and profit-driven process in which historically disinvested neighborhoods experience an influx of development that contributes to the improvement of physical amenities, increasing housing costs, and the dispossession and displacement of existing communities, may influence the risk of severe maternal morbidity (SMM). Leveraging a racially diverse population-based sample of all live hospital births in California between 2006 and 2017, we examined associations between neighborhood-level gentrification and SMM. SMM was defined as having one of 21 procedures and diagnoses, as described in the SMM index developed by Centers for Disease Control and Prevention. We compared three gentrification measures to determine which operationalization best captures aspects of gentrification most salient to SMM: Freeman, Landis 3-D, and Urban Displacement Project Gentrification and Displacement Typology. Descriptive analysis assessed bivariate associations between gentrification and birthing people's characteristics. Overall and race and ethnicity-stratified mixed-effects logistic models assessed associations between gentrification and SMM, adjusting for individual sociodemographic and pregnancy factors while accounting for clustering by census tract. The study sample included 5,256,905 births, with 72,718 cases of SMM (1.4%). The percentage of individuals living in a gentrifying neighborhood ranged from 5.7% to 11.7% across exposure assessment methods. Net of individual and pregnancy-related factors, neighborhood-level gentrification, as measured by the Freeman method, was protective against SMM (OR = 0.89, 95% CI: 0.86-0.93); in comparison, gentrification, as measured by the Gentrification and Displacement Typology, was associated with greater risk of SMM (OR = 1.18, 95% CI: 1.14-1.23). These associations were significant among non-Hispanic White, non-Hispanic Black, and Hispanic individuals. Findings demonstrate that gentrification plays a role in shaping the risk of SMM among birthing people in California. Differences in how gentrification is conceptualized and measured, such as an emphasis on housing affordability compared to a broader characterization of gentrification's multiple aspects, may explain the heterogeneity in the directions of observed associations.

Postpartum Hospital Readmissions With and Without Severe Maternal Morbidity Within 1 Year of Birth, Oregon, 2012-2017.

Postpartum readmissions (PPRs) represent a critical marker of maternal morbidity after hospital childbirth. Most severe maternal morbidity (SMM) events result in a hospital admission, but most PPRs do not have evidence of SMM. Little is known about PPR and SMM beyond the first 6 weeks postpartum. We examined the associations of maternal demographic and clinical factors with PPR within 12 months postpartum. We categorized PPR as being with or without evidence of SMM to assess whether risk factors and timing differed. Using the Oregon All Payer All Claims database, we analyzed hospital births from 2012-2017. We used log-binomial regression to estimate associations between maternal factors and PPR. Our final analytical sample included 158,653 births. Overall, 2.6% (n = 4,141) of births involved at least 1 readmission within 12 months postpartum (808 (19.5% of PPRs) with SMM). SMM at delivery was the strongest risk factor for PPR with SMM (risk ratio (RR) = 5.55, 95% confidence interval (CI): 4.14, 7.44). PPR without SMM had numerous risk factors, including any mental health diagnosis (RR = 2.10, 95% CI: 1.91, 2.30), chronic hypertension (RR = 2.17, 95% CI: 1.85, 2.55), and prepregnancy diabetes (RR = 2.85, 95% CI: 2.47, 3.30), all which were on par with SMM at delivery (RR = 1.89, 95% CI: 1.49, 2.40).