A Pregnant Pause: Rethinking Economic Evaluation in Contraception and Pregnancy.

Pregnancy presents a unique challenge to economic evaluation, requiring methods that can account for both maternal and fetal outcomes. The ethical challenges to healthcare presented by pregnancy are well understood, but these have not yet been incorporated into cost-effectiveness approaches. Economic evaluations of pregnancy currently take an ad hoc approach to outcome valuation, opening the door to biased estimates and inconsistent resource allocation. We summarize the limitations of current economic evaluation methods and outline key areas for future work.

The cost-effectiveness of preimplantation genetic testing for aneuploidy in the United States: an analysis of cost and birth outcomes from 158,665 in vitro fertilization cycles.

BACKGROUND: A controversial and unresolved question in reproductive medicine is the utility of preimplantation genetic testing for aneuploidy as an adjunct to in vitro fertilization. Infertility is prevalent, but its treatment is notoriously expensive and typically not covered by insurance. Therefore, cost-effectiveness is critical to consider in this context. OBJECTIVE: This study aimed to analyze the cost-effectiveness of preimplantation genetic testing for aneuploidy for the treatment of infertility in the United States. STUDY DESIGN: As reported to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System, a national data registry, in vitro fertilization cycles occurring between 2014 and 2016 in the United States were analyzed. A probabilistic decision tree was developed using empirical outputs to simulate the events and outcomes associated with in vitro fertilization with and without preimplantation genetic testing for aneuploidy. The treatment strategies were (1) in vitro fertilization with intended preimplantation genetic testing for aneuploidy and (2) in vitro fertilization with transfers of untested embryos. Patients progressed through the treatment model until they achieved a live birth or 12 months after ovarian stimulation. Clinical costs related to both treatment strategies were extracted from the literature and considered from both the patient and payer perspectives. Outcome metrics included incremental cost (measured in 2018 US dollars), live birth outcomes, incremental cost-effectiveness ratio, and incremental cost per live birth between treatment strategies. RESULTS: The study population included 114,157 first fresh in vitro fertilization stimulations and 44,508 linked frozen embryo transfer cycles. Of the fresh stimulations, 16.2% intended preimplantation genetic testing for aneuploidy and 83.8% did not. In patients younger than 35 years old, preimplantation genetic testing for aneuploidy was associated with worse clinical outcomes and higher costs. At age 35 years and older, preimplantation genetic testing for aneuploidy led to more cumulative births but was associated with higher costs from both perspectives. From a patient perspective, the incremental cost per live birth favored the no preimplantation genetic testing for aneuploidy strategy from the <35 years age group to the 38 years age group and beginning at age 39 years favored preimplantation genetic testing for aneuploidy. From a payer perspective, the incremental cost per live birth favored preimplantation genetic testing for aneuploidy regardless of patient age. CONCLUSION: The cost-effectiveness of preimplantation genetic testing for aneuploidy is dependent on patient age and perspective. From an economic perspective, routine preimplantation genetic testing for aneuploidy should not be universally adopted; however, it may be cost-effective in certain scenarios.

Racial and Ethnic Disparities in Birth Outcomes and Labor and Delivery Charges Among Massachusetts Women With Intellectual and Developmental Disabilities.

Understanding the pregnancy experiences of racial and ethnic minority women with intellectual and developmental disabilities (IDD) is critical to ensuring that policies can effectively support these women. This research analyzed data from the 1998-2013 Massachusetts Pregnancy to Early Life Longitudinal (PELL) data system to examine the racial and ethnic disparities in birth outcomes and labor and delivery charges of U.S. women with IDD. There was significant preterm birth disparity among non-Hispanic Black women with IDD compared to their non-Hispanic White peers. There were also significant racial and ethnic differences in associated labor and delivery-related charges. Further research, examining potential mechanisms behind the observed racial and ethnic differences in labor and delivery-related charges in Massachusetts' women with IDD is needed.

Socioeconomic characteristics of women with substance use disorder during pregnancy and neonatal outcomes in their newborns: A national registry study from the Czech Republic.

BACKGROUND: Maternal substance use can pose a risk to the fetal health. We studied the background characteristics of women with substance use disorders (SUDs) and selected neonatal outcomes in their children. MATERIAL AND METHODS: A database-linkage study was performed. The sample consisted of pregnant women with a SUD during pregnancy (ICD-10 diagnosis F10-F19 except F17, n = 1710), women not diagnosed with a SUD (n = 1,511,310) in Czechia in 2000-2014, and their children. The monitored neonatal outcomes were gestational age, birth weight, preterm birth, and small-for-gestational age (SGA). Binary logistic regression adjusted for age, marital status, education, concurrent substance use, and prenatal care was performed. RESULTS: Women with illicit SUDs were younger, more often unmarried, with a lower level of education, a higher abortion rate, a higher smoking rate, and lower compliance to prenatal care than women with a SUD related to alcohol, or sedatives and hypnotics (SH). Women with a SUD had worse socioeconomic situations, poorer pregnancy care, and worse neonatal outcomes than women without a SUD. After adjustment, we found no difference in SGA between the illicit SUD groups and the alcohol and the SH groups. The newborns from all SUD groups had a higher risk of SGA when compared to women without a SUD. However after adjustment, the difference remained significant just in the alcohol group (OR = 1.9, 95 % CI = 1.4-2.6). CONCLUSION: Mother's SUD during pregnancy increased risk of fetal growth restriction as measured by SGA. The role of maternal socioeconomic and lifestyle factors for the risk of SGA was substantial.

Cost-effectiveness of a mobile health-supported lifestyle intervention for pregnant women with an elevated body mass index.

OBJECTIVE: To assess the cost-effectiveness of a mobile health-supported lifestyle intervention compared with usual care. METHODS: We conducted a cost-effectiveness analysis from the perspective of the publicly-funded health care system. We estimated costs associated with the intervention and health care utilisation from first antenatal care appointment through delivery. We used bootstrap methods to quantify the uncertainty around cost-effectiveness estimates. Health outcomes assessed in this analysis were gestational weight gain (GWG; kg), incidence of excessive GWG, quality-adjusted life years (QALYs), and incidence of large-for-gestational-age (LGA). Incremental cost-effectiveness ratios (ICERs) were calculated as cost per QALY gained, cost per kg of GWG avoided, cost per case of excessive GWG averted, and cost per case of LGA averted. RESULTS: Total mean cost including intervention and health care utilisation was €3745 in the intervention group and €3471 in the control group (mean difference €274, P = 0.08). The ICER was €2914 per QALY gained. Assuming a ceiling ratio of €45,000, the probability that the intervention was cost-effective based on QALYs was 79%. Cost per kg of GWG avoided was €209. The cost-effectiveness acceptability curve (CEAC) for kg of GWG avoided reached a confidence level of 95% at €905, indicating that if one is willing to pay a maximum of an additional €905 per kg of GWG avoided, there is a 95% probability that the intervention is cost-effective. Costs per case of excessive GWG averted and case of LGA averted were €2117 and €5911, respectively. The CEAC for case of excessive GWG averted and for case of LGA averted reached a confidence level of 95% at €7090 and €25,737, respectively. CONCLUSIONS: Results suggest that a mobile-health lifestyle intervention could be cost-effective; however, a better understanding of the short- and long-term costs of LGA and excessive GWG is necessary to confirm the results.

Estimating the Financial Impact of Reducing Primary Cesareans.

INTRODUCTION: Preventing a primary cesarean birth in nulliparous women with term, singleton, vertex pregnancies (NTSV) is recognized as an important strategy to reduce maternal morbidities and risks to the newborn. Multiple professional organizations are supporting approaches to safely reduce NTSV cesarean rates, including the American College of Obstetricians and Gynecologists; the Society for Maternal-Fetal Medicine; and the Association of Women's Health, Obstetric and Neonatal Nurses. The American College of Nurse-Midwives (ACNM) is leading one such effort as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative. The objective of this study is to estimate the cost savings of a decrease in NTSV cesareans at one hospital participating in the RPC Learning Collaborative. METHODS: All women giving birth at Baystate Medical Center from October 1, 2016, to March 31, 2017, and their newborns were identified by Medicare Severity Diagnosis Related Group (N = 1747). Total hospital costs were calculated using a resource consumption profile for each of 6 groups: women who had vaginal birth, primary cesarean, and repeat cesarean and their linked newborns. A model was developed to estimate cost differences for the first and second births and overall cost savings. RESULTS: For the NTSV birth, total costs for primary cesarean and newborn care were $5989 higher compared with vaginal birth and newborn care. For the subsequent birth, repeat cesareans and newborn care were $4250 higher compared with vaginal birth. In 2016, 69 primary cesareans were prevented, for an actual cost savings of $413,241. Projecting the prevention of 66 subsequent repeat cesareans would result in additional savings of $280,500, for a total savings of $693,741. Apgar score at 5 minutes and length of stay remained unchanged. DISCUSSION: Participation in ACNM's RPC Learning Collaborative led to significant savings in hospital costs during the first year without affecting quality metrics. This cost comparison model could be replicated by other hospitals involved in cesarean reduction endeavors.

Cervical pessary vs vaginal progesterone for prevention of preterm birth in women with twin pregnancy and short cervix: economic analysis following randomized controlled trial.

OBJECTIVE: To compare the cost-effectiveness of cervical pessary vs vaginal progesterone to prevent preterm birth and neonatal morbidity in women with twin pregnancy and a short cervix. METHODS: Between 4 March 2016 and 3 June 2017, we performed this economic analysis following a randomized controlled trial (RCT), performed at My Duc Hospital, Ho Chi Minh City, Vietnam, that compared cervical pessary to vaginal progesterone in women with twin pregnancy and cervical length < 38 mm between 16 and 22 weeks of gestation. We used morbidity-free neonatal survival as a measure of effectiveness. Data on pregnancy outcome, maternal morbidity and neonatal complications were collected prospectively from medical files; additional information was obtained via telephone interviews with the patients. The incremental cost-effectiveness ratio was calculated as the incremental cost required to achieve one extra surviving morbidity-free neonate in the pessary group compared with in the progesterone group. Probabilistic and one-way sensitivity analyses were also performed. RESULTS: During the study period, we screened 1113 women with twin pregnancy, of whom 300 fulfilled the inclusion criteria of the RCT and gave informed consent to participate. These women were assigned randomly to receive cervical pessary (n = 150) or vaginal progesterone (n = 150), with two women and one woman, respectively, being lost to follow-up. The rate of morbidity-free neonatal survival was significantly higher in the pessary group compared with the progesterone group (n = 241/296 (81.4%) vs 219/298 (73.5%); relative risk, 1.11 (95% CI, 1.02-1.21), P = 0.02). The mean total cost per woman was 3146 € in the pessary group vs 3570 € in the progesterone group (absolute difference, -424 € (95% CI, -842 to -3 €), P = 0.048). The cost per morbidity-free neonate was significantly lower in the pessary group compared with that in the progesterone group (2492 vs 2639 €; absolute difference, -147 € (95% CI, -284 to 10 €), P = 0.035). CONCLUSION: In women with twin pregnancy and a short cervix, cervical pessary improves significantly the rate of morbidity-free neonatal survival while reducing costs, as compared with vaginal progesterone. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Association of Medicaid Expansion With Coverage and Access to Care for Pregnant Women.

OBJECTIVE: To identify the association of the Affordable Care Act's Medicaid expansion with payment for delivery, early access to prenatal care, preterm birth, and birth weights considered small for gestational age (SGA). METHODS: A difference-in-difference design was used to assess changes in outcomes before and after Medicaid expansion in expansion states, using nonexpansion states as a control group. We used national birth certificate data from 2009 to 2017. Difference-in-difference linear probability models were used to assess the effects of the policy implementation, adjusting for demographics, month of birth, state, year, and county-level unemployment rates. Standard errors were clustered at the state level. Two prespecified subgroup analyses were performed of nulliparous women and women with no more than a high school diploma. RESULTS: The study sample included 8,701,889 women from 15 expansion states and 9,509,994 from 11 nonexpansion states. In the adjusted analysis, the percentage of Medicaid-covered deliveries increased by 2.3 absolute percentage points (95% CI 0.2-4.4, P=.04) in expansion states compared with nonexpansion states. There were no significant changes in the proportion of women who were uninsured, as there was a relative decrease in the percentage of deliveries covered by private insurance (-2.8 percentage points [95% CI -4.9 to -0.8, P=.01]). There were also no significant differences in the rate of women initiating prenatal care in the first trimester, preterm birth rates, or rates of low birth weight after the Medicaid expansion. Findings were similar in both subgroups. CONCLUSION: Medicaid expansion was associated with increased Medicaid coverage for childbirth in expansion states; similar gains in private coverage were seen in nonexpansion states. There were no associations with changes in early access to prenatal care, preterm birth, or SGA birth weights.

In utero exposure to economic fluctuations and birth outcomes: An analysis of the relevance of the local unemployment rate in Brazilian state capitals.

OBJECTIVE: Analyze if in utero exposure to economic downturns is associated with worsened birth outcomes. METHODS: We used birth records from all live singleton births in the 27 Brazilian state capitals between October 2012 and December 2016 (n = 2,952,430) and linked them to local unemployment rates according to the mother's residence. We estimated the association between different birth outcomes and the local unemployment rate in the three trimesters before birth. We included maternal characteristics and month, year and municipality fixed effects as covariates. We also estimated the association for different groups of mothers, based on marital status, educational level, age and race. RESULTS: A 1 p.p. increase in the local unemployment rate in the trimester before birth is associated with 2.68% higher odds of being born with very low birthweight (< 1500 grams) (OR: 1.0268, 95% CI: 1.0006-1.0536). That result is pushed by the effect among newborns from mothers younger than 24 (OR: 1.0684, 95%CI: 1.0353-1.1024), from mothers with 11 years of schooling or less (OR: 1.0477, 95% CI: 1.0245-1.0714), and from brown or black mothers (OR: 1.0387, 95%CI: 1.0156-1.0624). The associations among children born from younger, less educated and black or brown mothers are robust to the application of a procedure to control for multiple testing, albeit the results considering the whole sample are not. CONCLUSIONS: Our study shows that there is an association between in utero exposure to higher unemployment rates during the last gestational trimester and the odds of being born with VLBW among children born from mothers younger than 24 years old, with less of 11 years of education and black or brown. These results suggest that children born from women of low socioeconomic status are more vulnerable to in utero exposure to economic downturns.

Does economic recession impact newborn health? Evidence from Greece.

This study examines the impact of the Greek recession on newborn health. Using a large administrative dataset of 838,700 births from 2008 to 2015, our analysis shows that birth weight (BW) and pregnancy length are generally procyclical with respect to prenatal economic climate, while the risk of low birth weight and preterm birth are both countercyclical. We report heterogeneity in the relationship between business cycle fluctuations during pregnancy and newborn health across socioeconomic groups. Birth outcomes of children born to low socioeconomic status (SES) families are sensitive to economic fluctuations during the first and third trimesters of the pregnancy, whereas those of high-SES newborns respond to economic volatility only in the first trimester. These results are robust, even after using different measures of economic climate and uncertainty. After accounting for potential selection into pregnancy, we find that in utero exposure to economic crisis is linked with a BW loss, which is driven by the low-SES children. Our findings have social policy implications. The impact of economic crisis on birth indicators is more detrimental for the low-SES children, resulting in a widening of the BW gap between children of low- and high-SES families. This could, in turn, exacerbate long-term socioeconomic and health inequalities and hinder social mobility.

Is socio-economic status associated with adverse birth outcomes in Poland?

INTRODUCTION: Low birth weight (LBW) is an important indicator of the healthy of the population and reflects the living conditions, health and health behaviours of pregnant women. OBJECTIVE: To assess the relationship between Gross Enrollment Rate at the Tertiary Education Level, average salary, Gross Domestic Product per capita, unemployment, housing area, urbanization and low birth weight in Polish sub-regions. MATERIAL AND METHODS: An ecological study was undertaken using data on socio-economic and demographic features and LBW in 2005-2014. The units of observation were 66 Polish sub-regions according to the NUTS-3 classification. Two models were used to assess the influence of SES variables on LBW incidence rate in a 10-year study period. The first was the Poisson regression model adjusted for density of population, which was followed by the multivariable model using the GEE method of model parameters estimation. RESULTS: In Poland, significant slow changes in the LBW incidence rate were observed in 2005-2014 (AAPC = -0.44%/year). In model 1, the increase in LBW was associated with an increase in unemployment (1.005) and decrease of average salary (0.987), GERTEL (0.990) and housing area (0.991). In model 2, an unfavorable association was detected between the density of population (1.068) and a still existing relationship with unemployment (1.004), average salary (0.990) and GERTEL (0.991). CONCLUSIONS: Protective factors for newborns' health were a higher level of education and income. The results indicate the need to take actions to reduce the risk factors of LBW among pregnant women living in densely populated areas.

Outcomes, care utilization, and expenditures in adolescent pregnancy complicated by diabetes.

BACKGROUND AND OBJECTIVE: Adolescence and pregestational diabetes separately increase risks of adverse pregnancy outcomes, but little is known about their combined effect. To analyze pregnancy outcomes, healthcare utilization, and expenditures in adolescent pregnancies with and without pregestational diabetes using a national claims database. METHODS: Retrospective study using Truven Health MarketScan Commercial Claims and Encounters Database, 2011 to 2015. Females 12 to 19 years old, continuously enrolled for at least 12 months before a livebirth until 2 months after, were included. Pregestational diabetes, diabetes complications (ketoacidosis, retinopathy, neuropathy, nephropathy), comorbidities, and pregnancy outcomes (preeclampsia, preterm delivery, high birthweight, cesarean delivery) were identified using claims data algorithms. Healthcare utilization and payer expenditure were tabulated per enrollee. Multivariate logistic regressions assessed pregnancy outcomes; multivariate OLS regression assessed payer expenditures. RESULTS: About 33 502 adolescents were included. Adolescents without diabetes had pregnancy outcomes consistent with national estimates. Adolescents with uncomplicated diabetes had increased odds of preeclampsia adjusted odds ratios 2.41 (95% confidence interval 1.93-3.02), preterm delivery 1.50 (1.21-1.87), high birthweight 1.84 (1.50-2.27), and cesarean delivery 1.81 (1.52-2.15). Diabetes with ketoacidosis and/or end-organ damage had higher odds of preeclampsia 5.62 (2.77-11.41), preterm delivery 5.81 (3.00-11.25), high birthweight 2.38 (1.08-5.24), and cesarean delivery 3.43 (1.78-6.64). Adolescents with diabetes utilized significantly more outpatient and inpatient care during pregnancy. Payer expenditures increased by 45.3% (34.8-55.9%) among adolescents with diabetes and by 82.6% (49.1-116.0%) among adolescents with diabetes complicated by ketoacidosis and/or end-organ damage. CONCLUSION: Compared with normal adolescent pregnancies, pregestational diabetes significantly increases risks of adverse pregnancy outcomes and significantly escalates healthcare utilization and cost.

Impact of in vitro fertilization-preimplantation genetic testing (IVF-PGT) funding policy on clinical outcome: An issue that stems beyond effectiveness of treatment.

OBJECTIVE(S): The aim of this study was to compare the patient characteristics, type of genetic disease and inheritance, volume of activity, practice patterns and pregnancy outcomes, in private versus publically funded IVF pre-implantation genetic testing (PGT) for translocation (IVF-PGT-SR) and aneuploidy (PGT-A) periods. STUDY DESIGN: This study retrospectively analyzed data during both privately funded period (PRP) and publically funded period (PUP) of assisted reproductive technology (ART) for a total of 275 patients. 83 patients underwent IVF-PGT-SR and 192 patients underwent IVF-PGT-A. Given that PGT-SR is a chromosomal abnormality hereditary in nature, whereas PGT-A is sporadic in addition to the contrasting funding policies, the two cohorts were analyzed separately. To achieve the proposed objective, the two groups under analysis were grouped in accordance with their respective coverage systems for infertility. RESULTS: Among translocation patients, 94 normal/balanced embryos were obtained from 47 IVF-PGT cycles in PRP whereas 145 embryos were obtained from 92 IVF-PGT cycles in PUP. The average number of embryos transferred per embryo transfer cycle was significantly lower in PUP in comparison to PRP (1.13 vs. 1.74, p < 0.0001). 13 singletons and 2 sets of twins were conceived in PRP. 14 singletons were conceived in PUP. Regardless of funding period, there were more reciprocal translocation carriers (79.4% in PRP and 76.4% in PUP) and more male carriers (82.4% in PRP and 60% in PUP), of which the majority had abnormal sperm parameters. Among aneuploidy patients, on average 2.5 embryos in PRP and 1.4 embryos in PUP were transferred per ET cycle (p = 0.05). There was a 13.3% increase in number of IVF-PGT-A attempts per patient in PRP compared to PUP. Live birth rate per IVF-PGT-A was higher in PRP (29.7% vs. 15%, P = 0.02), which consisted of 48 singletons and 18 multiparous pregnancies in PRP and 9 singletons in PUP. CONCLUSION(S): Public coverage of ART is associated with a greater utilization ART, as well as a reduced number in embryo transfer (ET) per cycle, a lower proportion of cycles resulting in successful pregnancy and a lower multiple birth rate. Our study ultimately shines light on the effect of providers' and patients' monetary conscious on pregnancy outcome.

Health Facility Cost of Cesarean Delivery at a Rural District Hospital in Rwanda Using Time-Driven Activity-Based Costing.

Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended.

Short interpregnancy intervals and adverse maternal outcomes in high-resource settings: An updated systematic review.

BACKGROUND: Currently, no federal guidelines provide recommendations on healthy birth spacing for women in the United States. This systematic review summarises associations between short interpregnancy intervals and adverse maternal outcomes to inform the development of birth spacing recommendations for the United States. METHODS: PubMed/Medline, POPLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, and a previous systematic review were searched to identify relevant articles published from 1 January 2006 and 1 May 2017. Included studies reported maternal health outcomes following a short versus longer interpregnancy interval, were conducted in high-resource settings, and adjusted estimates for at least maternal age. Two investigators independently assessed study quality and applicability using established methods. RESULTS: Seven cohort studies met inclusion criteria. There was limited but consistent evidence that short interpregnancy interval is associated with increased risk of precipitous labour and decreased risks of labour dystocia. There was some evidence that short interpregnancy interval is associated with increased risks of subsequent pre-pregnancy obesity and gestational diabetes, and decreased risk of preeclampsia. Among women with a previous caesarean delivery, short interpregnancy interval was associated with increased risk of uterine rupture in one study. No studies reported outcomes related to maternal depression, interpregnancy weight gain, maternal anaemia, or maternal mortality. CONCLUSIONS: In studies from high-resource settings, short interpregnancy intervals are associated with both increased and decreased risks of adverse maternal outcomes. However, most outcomes were evaluated in single studies, and the strength of evidence supporting associations is low.

Short interpregnancy intervals and adverse perinatal outcomes in high-resource settings: An updated systematic review.

BACKGROUND: This systematic review summarises association between short interpregnancy intervals and adverse perinatal health outcomes in high-resource settings to inform recommendations for healthy birth spacing for the United States. METHODS: Five databases and a previous systematic review were searched for relevant articles published between 1966 and 1 May 2017. We included studies meeting the following criteria: (a) reporting of perinatal health outcomes after a short interpregnancy interval since last livebirth; (b) conducted within a high-resource setting; and (c) estimates were adjusted for maternal age and at least one socio-economic factor. RESULTS: Nine good-quality and 18 fair-quality studies were identified. Interpregnancy intervals <6 months were associated with a clinically and statistically significant increased risk of adverse outcomes in studies of preterm birth (eg, aOR ≥ 1.20 in 10 of 14 studies); spontaneous preterm birth (eg, aOR ≥ 1.20 in one of two studies); small-for-gestational age (eg, aOR ≥ 1.20 in 5 of 11 studies); and infant mortality (eg, aOR ≥ 1.20 in four of four studies), while four studies of perinatal death showed no association. Interpregnancy intervals of 6-11 and 12-17 months generally had smaller point estimates and confidence intervals that included the null. Most studies were population-based and few included adjustment for detailed measures of key confounders. CONCLUSIONS: In high-resource settings, there is some evidence showing interpregnancy intervals <6 months since last livebirth are associated with increased risks for preterm birth, small-for-gestational age and infant death; however, results were inconsistent. Additional research controlling for confounding would further inform recommendations for healthy birth spacing for the United States.

The impact of early life shocks on human capital formation: evidence from El Niño floods in Ecuador.

This paper investigates the persistent effects of negative shocks in utero and in infancy on low-income children's health and cognitive outcomes and examines whether timing of exposure matters differentially by skill type. Specifically, I exploit the geographic intensity of extreme floods in Ecuador during the 1997-1998 El Niño phenomenon, which provides exogenous variation in exposure at different periods of early development. I show that children exposed to severe floods in utero, especially during the third trimester, are shorter in stature five and seven years later. Also, children affected by the floods in the first trimester of pregnancy score lower on cognitive tests. Additionally, I explore potential mechanisms by studying health at birth and family inputs (income, consumption, and breastfeeding). I find that children exposed to El Niño floods, especially during the third trimester in utero, were more likely to be born with low birth weight. Furthermore, households affected by El Niño suffered a decline in income, total consumption, and food consumption in the aftermath of the shock. Falsification exercises and robustness checks suggest that selection concerns such as selective fertility, mobility, and infant mortality do not drive these results.

Repeat Screening for Syphilis in the Third Trimester of Pregnancy: A Cost-Effectiveness Analysis.

OBJECTIVE: To estimate the cost-effectiveness of screening all women during the first and third trimesters compared with screening just once during pregnancy. METHODS: We used a theoretical cohort of 3.9 million women in the United States to model syphilis screening approaches in pregnancy, particularly comparing one-time screening with repeat third-trimester screening. Outcomes of syphilis infection included in the model were congenital syphilis, intrauterine fetal demise, neonatal death, and total quality-adjusted life-years (QALYs). Probabilities, utilities, and costs were obtained from the literature, and a cost-effectiveness threshold was set at $100,000 per QALY. A societal perspective was assumed. RESULTS: Our model demonstrated that repeat screening in the third trimester for syphilis in pregnancy will result in fewer maternal and neonatal adverse outcomes and higher QALYs when compared with screening once in the first trimester. Specifically, we demonstrated that repeat screening results in 41 fewer neonates with evidence of congenital syphilis, 73 fewer cases of intrauterine fetal demise, 27 fewer neonatal and infant deaths, in addition to a cost savings of $52 million and 4,000 additional QALYs. CONCLUSION: Using our baseline assumptions, our data support that in pregnancy, repeat screening for syphilis is superior to single screening during the first trimester and is both cost-effective and results in improvement in maternal and neonatal outcomes. When screening policies are being created for pregnant women, the cost-effectiveness of repeat screening for syphilis should be considered.

Burden of care is the primary reason why insured women terminate in vitro fertilization treatment.

OBJECTIVE: To study the reason(s) why insured patients discontinue in vitro fertilization (IVF) before achieving a live birth. DESIGN: Cross-sectional study. SETTING: Private academically affiliated infertility center. PATIENT(S): A total of 893 insured women who had completed one IVF cycle but did not return for treatment for at least 1 year and who had not achieved a live birth were identified; 312 eligible women completed the survey. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Reasons for treatment termination. RESULT(S): Two-thirds of the participants (65.2%) did not seek care elsewhere and discontinued treatment. When asked why they discontinued treatment, these women indicated that further treatment was too stressful (40.2%), they could not afford out-of-pocket costs (25.1%), they had lost insurance coverage (24.6%), or they had conceived spontaneously (24.1%). Among those citing stress as a reason for discontinuing treatment (n = 80), the top sources of stress included already having given IVF their best chance (65.0%), feeling too stressed to continue (47.5%), and infertility taking too much of a toll on their relationship (36.3%). When participants were asked what could have made their experience better, the most common suggestions were evening/weekend office hours (47.4%) and easy access to a mental health professional (39.4%). Of the 34.8% of women who sought care elsewhere, the most common reason given was wanting a second opinion (55.7%). CONCLUSION(S): Psychologic burden was the most common reason why insured patients reported discontinuing IVF treatment. Stress reduction strategies are desired by patients and could affect the decision to terminate treatment.

Adverse neonatal outcomes and house prices in London.

Objective To explore whether the average price of houses per postcode sector [sector house average prices (SHAP)] is related to perinatal outcomes and whether gestational age would be lower and mortality higher in the least expensive areas compared to the most expensive. Methods All neonatal unit admissions at King's College Hospital from 1/1/2012 to 31/12/2016 were reviewed. The SHAP was retrieved from the Land Registry and the population was divided in equal quintiles with quintiles 1 and 5 representing the most and least expensive areas, respectively. Gestational age and birth weight z-score were collected. Mortality was defined as death before discharge from neonatal care. Results Three thousand three hundred and sixty infants were included and divided in quintiles consisting of 672 infants. Gestational age was lower in quintile 5 compared to all other quintiles (adjusted P<0.001). Birthweight z-score was not significantly different between the quintiles. The SHAP was lower in the infants who died before discharge (n=92) compared to the SHAP of the infants who were alive at discharge (n=3268) (P<0.001). Infants of quintile 5 had 6 times higher risk of death before discharge from neonatal care compared to infants of quintile 1. Conclusion Low SHAPs were associated with poorer perinatal outcomes suggesting SHAP could potentially be used in perinatal populations to determine socio-economic status and associated outcomes.