Stephanie A. Leonard

All Publications

• Hypertensive Disorders in Pregnancy: Differences by Hispanic Ethnicity and Black Race. Journal of racial and ethnic health disparities Atkinson, J. A., Carmichael, S. L., Leonard, S. A. 2024

  Abstract

  Black individuals carry the greatest burden of maternal mortality, with hypertensive disorders during pregnancy being a significant driving force to this disparity. However, research on maternal health disparities predominantly groups Hispanic Black individuals with all other individuals of Hispanic ethnicity. We hypothesized that this aggregation might obscure the risk patterns of hypertensive disorders in pregnancy for Hispanic-Black and non-Hispanic Black individuals.We analyzed a California statewide dataset of vital records linked to hospitalization discharge data for births from 2007 to 2018. Using multivariable logistic regression models adjusted for age, pre-pregnancy BMI, parity, smoking status, diabetes, and chronic renal disease, we compared the odds of hypertensive disorders in pregnancy between Hispanic Black, non-Hispanic Black, and non-Black Hispanic racial-ethnic groups. Hypertensive disorders were categorized into two groups: (1) any hypertensive disorder and (2) chronic hypertension alone, non-severe hypertensive disorders, and severe hypertensive disorders in pregnancy.Non-Hispanic Black people had 75% increased odds of developing a hypertensive disorder during pregnancy (adjusted odds ratio (aOR); 95% confidence interval (CI): 1.74, 1.78) and Hispanic-Black individuals had a 31% increased odds (95% CI: 1.24, 1.38) as compared with non-Black Hispanic individuals. When considering hypertensive disorders separately, the race-associated differences were largest for chronic hypertension alone, with non-Hispanic Black individuals showing an aOR of 2.35 (95% CI: 2.32, 2.38) and Hispanic-Black individuals an aOR of 1.80 (95% CI: 1.66, 1.95).Compared with non-Black Hispanic individuals, the prevalence of hypertensive disorders in pregnancy was higher in Black-Hispanic individuals and highest in non-Hispanic Black individuals. Racial/ethnic differences were larger for chronic hypertension alone than for preeclampsia.

  View details for DOI 10.1007/s40615-024-02224-5

  View details for PubMedID 39499430

  View details for PubMedCentralID 10144523

• Chronic Hypertension During Pregnancy: Prevalence and Treatment in the United States, 2008-2021. Hypertension (Dallas, Tex. : 1979) Leonard, S. A., Siadat, S., Main, E. K., Huybrechts, K. F., El-Sayed, Y. Y., Hlatky, M. A., Atkinson, J., Sujan, A., Bateman, B. T. 2024

  Abstract

  Treatment of chronic hypertension during pregnancy has been shown to reduce the risk of adverse perinatal outcomes. In this study, we examined the prevalence and treatment of chronic hypertension during pregnancy and assessed changes in these outcomes following the release of the updated 2017 hypertension guidelines of the American College of Cardiology and American Heart Association.We analyzed the MerativeTM Marketscan® Research Database of United States commercial insurance claims from 2007 to 2021. We assessed the prevalence of chronic hypertension during pregnancy and oral antihypertensive medication use over time. We then performed interrupted time series analyses to evaluate changes in these outcomes.The prevalence of chronic hypertension steadily increased from 1.8% to 3.7% among 1 900 196 pregnancies between 2008 and 2021. Antihypertensive medication use among pregnant individuals with chronic hypertension was relatively stable (57%-60%) over the study period. The proportion of pregnant individuals with chronic hypertension treated with methyldopa or hydrochlorothiazide decreased (from 29% to 2% and from 11% to 5%, respectively), while the proportion treated with labetalol or nifedipine increased (from 19% to 42% and from 9% to 17%, respectively). The prevalence or treatment of chronic hypertension during pregnancy did not change following the 2017 American College of Cardiology and American Heart Association hypertension guidelines.The prevalence of chronic hypertension during pregnancy doubled between 2008 and 2021 in a nationwide cohort of individuals with commercial insurance. Labetalol replaced methyldopa as the most commonly used antihypertensive during pregnancy. However, only about 60% of individuals with chronic hypertension in pregnancy were treated with antihypertensive medications.

  View details for DOI 10.1161/HYPERTENSIONAHA.124.22731

  View details for PubMedID 38881466

• Validity of ICD-10 diagnosis codes for placenta accreta spectrum disorders. Paediatric and perinatal epidemiology Jotwani, A. R., Lyell, D. J., Butwick, A. J., Rwigi, W., Leonard, S. A. 2024

  Abstract

  BACKGROUND: The 10th revision of the International Classification of Diseases, Clinical Modification (ICD-10) includes diagnosis codes for placenta accreta spectrum for the first time. These codes could enable valuable research and surveillance of placenta accreta spectrum, a life-threatening pregnancy complication that is increasing in incidence.OBJECTIVE: We sought to evaluate the validity of placenta accreta spectrum diagnosis codes that were introduced in ICD-10 and assess contributing factors to incorrect code assignments.METHODS: We calculated sensitivity, specificity, positive predictive value and negative predictive value of the ICD-10 placenta accreta spectrum code assignments after reviewing medical records from October 2015 to March 2020 at a quaternary obstetric centre. Histopathologic diagnosis was considered the gold standard.RESULTS: Among 22,345 patients, 104 (0.46%) had an ICD-10 code for placenta accreta spectrum and 51 (0.23%) had a histopathologic diagnosis. ICD-10 codes had a sensitivity of 0.71 (95% CI 0.56, 0.83), specificity of 0.98 (95% CI 0.93, 1.00), positive predictive value of 0.61 (95% CI 0.48, 0.72) and negative predictive value of 1.00 (95% CI 0.96, 1.00). The sensitivities of the ICD-10 codes for placenta accreta spectrum subtypes- accreta, increta and percreta-were 0.55 (95% CI 0.31, 0.78), 0.33 (95% CI 0.12, 0.62) and 0.56 (95% CI 0.31, 0.78), respectively. Cases with incorrect code assignment were less morbid than cases with correct code assignment, with a lower incidence of hysterectomy at delivery (17% vs 100%), blood transfusion (26% vs 75%) and admission to the intensive care unit (0% vs 53%). Primary reasons for code misassignment included code assigned to cases of occult placenta accreta (35%) or to cases with clinical evidence of placental adherence without histopatholic diagnostic (35%) features.CONCLUSION: These findings from a quaternary obstetric centre suggest that ICD-10 codes may be useful for research and surveillance of placenta accreta spectrum, but researchers should be aware of likely substantial false positive cases.

  View details for DOI 10.1111/ppe.13076

  View details for PubMedID 38514907

• Validity of Birth Certificate Data Compared With Hospital Discharge Data in Reporting Maternal Morbidity and Disparities. Obstetrics and gynecology Gemmill, A., Passarella, M., Phibbs, C. S., Main, E. K., Lorch, S. A., Kozhimannil, K. B., Carmichael, S. L., Leonard, S. A. 2024

  Abstract

  A growing number of studies are using birth certificate data, despite data-quality concerns, to study maternal morbidity and associated disparities. We examined whether conclusions about the incidence of maternal morbidity, including Black-White disparities, differ between birth certificate data and hospitalization data. Using linked birth certificate and hospitalization data from California and Michigan for 2018 (N=543,469), we found that maternal morbidity measures using birth certificate data alone are substantially underreported and have poor validity. Furthermore, the degree of underreporting in birth certificate data differs between Black and White individuals and results in erroneous inferences about disparities. Overall, Black-White disparities were more modest in the birth certificate data compared with the hospitalization data. Birth certificate data alone are inadequate for studies of maternal morbidity and associated racial disparities.

  View details for DOI 10.1097/AOG.0000000000005497

  View details for PubMedID 38176017

• Chronic Hypertension in Pregnancy and Racial-Ethnic Disparities in Complications. Obstetrics and gynecology Leonard, S. A., Formanowski, B. L., Phibbs, C. S., Lorch, S., Main, E. K., Kozhimannil, K. B., Passarella, M., Bateman, B. T. 2023

  Abstract

  To evaluate whether there are individual- and population-level associations between chronic hypertension and pregnancy complications, and to assess differences across seven racial-ethnic groups.This population-based study used linked vital statistics and hospitalization discharge data from all live and stillbirths in California (2008-2018), Michigan (2008-2020), Oregon (2008-2020), Pennsylvania (2008-2014), and South Carolina (2008-2020). We used multivariable log-binomial regression models to estimate risk ratios (RRs) and population attributable risk (PAR) percentages with 95% CIs for associations between chronic hypertension and several obstetric and neonatal outcomes, selected based on prior evidence and pathologic pathways. We adjusted models for demographic factors (race and ethnicity, payment method, educational attainment), age, body mass index, obstetric history, delivery year, and state, and conducted analyses stratified across seven racial-ethnic groups.The study included 7,955,713 pregnancies, of which 168,972 (2.1%) were complicated by chronic hypertension. Chronic hypertension was associated with several adverse obstetric and neonatal outcomes, with the largest adjusted PAR percentages observed for preeclampsia with severe features or eclampsia (22.4; 95% CI 22.2-22.6), acute renal failure (13.6; 95% CI 12.6-14.6), and pulmonary edema (10.7; 95% CI 8.9-12.6). Estimated RRs overall were similar across racial-ethnic groups, but PAR percentages varied. The adjusted PAR percentages (95% CI) for severe maternal morbidity-a widely used composite of acute severe events-for people who were American Indian or Alaska Native, Asian, Black, Latino, Native Hawaiian or Other Pacific Islander, White, and Multiracial or Other were 5.0 (1.1-8.8), 3.7 (3.0-4.3), 9.0 (8.2-9.8), 3.9 (3.6-4.3), 11.6 (6.4-16.5), 3.2 (2.9-3.5), and 5.5 (4.2-6.9), respectively.Chronic hypertension accounts for a substantial fraction of obstetric and neonatal morbidity and contributes to higher complication rates, particularly for people who are Black or Native Hawaiian or Other Pacific Islander.

  View details for DOI 10.1097/AOG.0000000000005342

  View details for PubMedID 37678888

• Early postpartum hospital encounters among patients with genitourinary and wound infections during hospitalization for birth. American journal of perinatology Leonard, S. A., Girsen, A., Trepman, P., Carmichael, S. L., Darmawan, K., Butwick, A., Gibbs, R. 2023

  Abstract

  To assess the associations between genitourinary and wound infections during the birth hospitalization and early postpartum hospital encounters, and to evaluate clinical risk factors for early postpartum hospital encounters among patients with a genitourinary or wound infection during the birth hospitalization.We conducted a population-based cohort study of births in California during 2016-2018 and postpartum hospital encounters. We identified genitourinary and wound infections using diagnosis codes. Our main outcome was early postpartum hospital encounter, defined as a readmission or ED visit within 3 days after discharge from the birth hospitalization. We evaluated the association of genitourinary and wound infections (overall and subtypes) with early postpartum hospital encounter using logistic regression, adjusting for sociodemographic factors and comorbidities and stratified by mode of birth. We then evaluated factors associated with early postpartum hospital encounter among patients with genitourinary and wound infections.Among 1,217,803 birth hospitalizations, 5.5% were complicated by genitourinary and wound infections and 1.8% resulted in an early postpartum hospital encounter. Genitourinary or wound infection was associated with an early postpartum hospital encounter among patients with both vaginal births (aRR 1.26, 95% CI 1.17, 1.36) and cesarean births (aRR 1.23, 95% CI 1.15, 1.32). Major puerperal infection, followed by wound infection, among patients with a cesarean birth conferred the highest risk of an early postpartum hospital encounter (6.4% and 4.3%, respectively). Among patients with genitourinary and wound infections at birth hospitalization, factors associated with an early postpartum hospital encounter included severe maternal morbidity, major mental health condition, prolonged postpartum hospital stay, and, among cesarean births, postpartum hemorrhage (P-value < 0.05).Genitourinary and wound infections during hospitalization for birth may increase risk of a readmission or ED visit within the first few days after discharge, particularly among patients who have a major puerperal infection or wound infection.

  View details for DOI 10.1055/a-2097-1584

  View details for PubMedID 37216972

• Severity of small-for-gestational-age and morbidity and mortality among very preterm neonates. Journal of perinatology : official journal of the California Perinatal Association Minor, K. C., Bianco, K., Sie, L., Druzin, M. L., Lee, H. C., Leonard, S. A. 2022

  Abstract

  Evaluate the association between small for gestational age (SGA) severity and morbidity and mortality in a contemporary, population of very preterm infants.This secondary analysis of a California statewide database evaluated singleton infants born during 2008-2018 at 24-32 weeks' gestation, with a birthweight <15th percentile. We analyzed neonatal outcomes in relation to weight for gestational age (WGA) and symmetry of growth restriction.An increase in WGA by one z-score was associated with decreased major morbidity or mortality risk (aRR 0.73, 95% CI 0.68-0.77) and other adverse outcomes. The association was maintained across gestational ages and did not differ by fetal growth restriction diagnosis. Symmetric growth restriction was not associated with neonatal outcomes after standardizing for gestational age at birth.Increasing SGA severity had a significant impact on neonatal outcomes among very preterm infants.

  View details for DOI 10.1038/s41372-022-01544-w

  View details for PubMedID 36302849

• Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth. Epidemiology (Cambridge, Mass.) Leonard, S. A., Panelli, D. M., Gould, J. B., Gemmill, A., Main, E. K. 2022

  Abstract

  The International Classification of Diseases Clinical Modification 10th Revision (ICD-CM-10) introduced diagnosis codes for week of gestation. Our objective was to assess the validity of these codes among live births, which could have major utility in perinatal research and quality improvement.We used linked birth certificate and patient discharge data from births in California during 2016-2019 (N = 1,843,992). We identified gestational age using Z3A.xx ICD-10-CM diagnosis codes in birthing patient discharge data and compared it with the gold standard of obstetric estimate, as recorded on the birth certificate. We further assessed sensitivity and specificity of gestational age categories (≥37 weeks, <37 weeks, <32 weeks, <28 weeks), given these categories are frequently of interest, and evaluated differences in validity of preterm birth (<37 weeks' gestation) by patient characteristics.1,770,103 patients had a gestational age recorded in patient discharge and birth certificate data. When comparing gestational age in patient discharge data with birth certificate data, the concordance correlation coefficient was 0.96 (95% CI: 0.96, 0.96) and the mean difference between the two measurements was 0.047 (95% CI: 0.046, 0.047) weeks. 95% of the differences between the two measurements were between -1.00 week and +1.09 weeks. Sensitivity and specificity were 0.94 to 1.00 for all gestational age categories and were 0.94 to 1.00 for preterm birth across sociodemographic groups.We found week-specific gestational age at delivery ICD-10-CM diagnosis codes in patient discharge data to have high validity when compared with the best obstetric estimate on the birth certificate.

  View details for DOI 10.1097/EDE.0000000000001557

  View details for PubMedID 36166206

• Sexual and/or gender minority disparities in obstetric and birth outcomes. American journal of obstetrics and gynecology Leonard, S. A., Berrahou, I., Zhang, A., Monseur, B., Main, E. K., Obedin-Maliver, J. 2022

  Abstract

  Many sexual and/or gender minority individuals build families through pregnancy and childbirth, but it is unknown whether they experience different clinical outcomes than non-sexual and/or gender minority individuals.To evaluate obstetric and birth outcomes among likely sexual and/or gender minority patients in comparison with likely non-sexual and/or gender minority patients.We performed a population-based cohort study of live birth hospitalizations during 2016-2019 linked to birth certificates in California. California changed its birth certificate in 2016 to include gender-neutral fields "parent giving birth" and "parent not giving birth," with options for each role to specify "mother," "father," or "parent." We classified birthing patients in mother-mother partnerships and those who identified as a father in any partnership as likely sexual and/or gender minority, and classified birthing patients in mother-father partnerships as likely not sexual and/or gender minority. We used multivariable modified Poisson regression models to estimate risk ratios for associations between likely sexual and/or gender minority parental structures and outcomes. Models were adjusted for sociodemographic factors, comorbidities, and multifetal gestation selected by causal diagrams. We replicated analyses after excluding multifetal gestations.In the final birthing patient sample, 1,483,119 were mothers with father partners, 2,572 were mothers with mother partners, and 498 were fathers with any partner. Compared with birthing patients in mother-father partnerships, birthing patients in mother-mother partnerships experienced significantly higher rates of multifetal gestation (aRR 3.9, 95% CI 3.4-4.4), labor induction (aRR 1.2, 95% CI 1.1-1.3), postpartum hemorrhage (aRR 1.4, 95% CI 1.3-1.6), severe morbidity (aRR 1.4, 95% CI 1.2-1.8), and non-transfusion severe morbidity (aRR 1.4, 95% CI 1.1-1.9). Severe morbidity was identified following the Centers for Disease Control and Prevention "severe maternal morbidity" index. Gestational diabetes mellitus, hypertensive disorders of pregnancy, cesarean birth, preterm birth (<37 weeks' gestation), low birthweight (<2,500 g), and low Apgar score (<7 at 5 minutes) did not significantly differ in multivariable analyses. No outcomes significantly differed between father birthing patients in any partnership and birthing patients in mother-father partnerships in either crude or multivariable analyses, although the risk of multifetal gestation was non-significantly higher (aRR 1.5, 95% CI 0.9-2.7). Adjusted risk ratios for outcomes were similar after restriction to singleton gestations.Birthing mothers with mother partners experienced disparities in several obstetric and birth outcomes, independent of sociodemographic factors, comorbidities, and multifetal gestation. Birthing fathers in any partnership were not at significantly elevated risk of any adverse obstetric or birth outcome considered in this study.

  View details for DOI 10.1016/j.ajog.2022.02.041

  View details for PubMedID 35358492

• "Ignored and Invisible": Perspectives from Black Women, Clinicians, and Community-Based Organizations for Reducing Preterm Birth. Maternal and child health journal Smith, K. L., Shipchandler, F., Kudumu, M., Davies-Balch, S., Leonard, S. A. 1800

  Abstract

  OBJECTIVES: The preterm birth rate for Black women in the U.S.is consistently higher than other racial groups. The crisis of preterm birth and adverse birth outcomes among Black people is a historical, systematic confluence of racism, stressors, and an unsupportive and hostile healthcare system. To inform the development of preterm birth risk reduction interventions, this study aimed to collect and synthesize the experiences of Black women who gave birth preterm along with clinicians and community-based organizations who serve them.METHODS: A qualitative study design was employed whereby nine focus groups and 17 key informant interviews that included Black women, clinicians, and representatives from community-based organizations were facilitated in Los Angeles County from March 2019 to March 2020. Participants were recruited through the organizations and the focus groups took place virtually and in person. The process of thematic analysis was employed to analyze the focus group and interview transcripts.RESULTS: Five overarching themes emerged from the data. Black women experience chronic and pregnancy-related stress, and have lasting trauma from adverse maternal health experiences. These issues are exacerbated by racism and cultural incongruence within healthcare and social services systems. Black women have relied on self-education and self-advocacy to endure the barriers related to racism, mistreatment, and their experiences with preterm birth.CONCLUSIONS FOR PRACTICE: Healthcare and social service providers must offer more holistic care that prioritizes, rather than ignores, the racial components of health, placing increased importance on implementing inclusive and culturally-appropriate patient education, attentiveness to patient needs, respectful care, and support for Black women.

  View details for DOI 10.1007/s10995-021-03367-1

  View details for PubMedID 35072869

• Development and validation of a risk prediction index for severe maternal morbidity based on preconception comorbidities among infertile patients. Fertility and sterility Murugappan, G., Alvero, R. J., Lyell, D. J., Khandelwal, A., Leonard, S. A. 2021

  Abstract

  OBJECTIVE: To develop and validate a preconception risk prediction index for severe maternal morbidity (SMM), defined by the Centers for Disease Control and Prevention as indicators of a life-threatening complication, among infertile patients.DESIGN: Retrospective analysis of live births and stillbirths from 2007 to 2017 among infertile women.SETTING: National commercial claims database.PATIENT(S): Infertile women identified on the basis of diagnosis, testing, or treatment codes.INTERVENTION(S): None.MAIN OUTCOME MEASURE(S): The primary outcome was SMM, identified as any indicator from the Centers for Disease Control and Prevention Index except blood transfusion alone, which was found to overestimate cases. Twenty preconception comorbidities associated with a risk of SMM were selected from prior literature. Targeted ensemble learning methods were used to rank the importance of comorbidities as potential risk factors for SMM. The independent strength of the association between each comorbidity and SMM was then used to define each comorbidity's risk score.RESULT(S): Among 94,097 infertile women with a delivery, 2.3% (n = 2,181) experienced an SMM event. The highest risk of SMM was conferred by pulmonary hypertension, hematologic disorders, renal disease, and cardiac disease. Associated significant risks were lowest for substance abuse disorders, prior cesarean section, age ≥40 years, gastrointestinal disease, anemia, mental health disorders, and asthma. The receiver operating characteristic area under the curve for the developed comorbidity score was 0.66. Calibration plots showed good concordance between the predicted and actual risk of SMM.CONCLUSION(S): We developed and validated an index to predict the probability of SMM on the basis of preconception comorbidities in patients with infertility. This tool may inform preconception counseling of infertile women and support maternal health research initiatives.

  View details for DOI 10.1016/j.fertnstert.2021.06.024

  View details for PubMedID 34266662

• Obstetric comorbidity scores and disparities in severe maternal morbidity across marginalized groups. American journal of obstetrics & gynecology MFM Leonard, S. A., Main, E. K., Lyell, D. J., Carmichael, S. L., Kennedy, C. J., Johnson, C., Mujahid, M. S. 2021: 100530

  Abstract

  A recently developed obstetric comorbidity scoring system enables comparisons of severe maternal morbidity rates independent of health status at the time of birth hospitalization. However, the scoring system has not been evaluated in racial-ethnic and socioeconomic groups or used to assess disparities in severe maternal morbidity.To evaluate the performance of applying an obstetric comorbidity scoring system across racial-ethnic and socioeconomic groups and to determine the effect of comorbidity score risk adjustment on disparities in severe maternal morbidity.We analyzed a population-based cohort of live births in California during 2011-2017 with linked birth certificate and birth hospitalization discharge data (n = 3,308,554). We updated a previously developed comorbidity scoring system to include ICD-9-CM and ICD-10-CM diagnosis codes, and applied the scoring system in subpopulations (groups) defined by race-ethnicity, nativity, payment method, and educational attainment. We then calculated risk-adjusted rates of severe maternal morbidity (including and excluding blood transfusion-only cases) in each group and estimated disparities for these outcomes before and after adjustment for the comorbidity score using logistic regression.The obstetric comorbidity scores performed consistently across groups (C-statistics ranged from 0.68-0.76; calibration curves demonstrated overall excellent prediction of absolute risk). All non-White groups had significantly elevated rates of severe maternal morbidity before and after risk adjustment for comorbidities compared to the White group (1.3% before, 1.3% after): American Indian-Alaska Native (2.1% before, 1.8% after), Asian (1.5% before, 1.7% after), Black (2.5% before, 2.0% after), Latinx (1.6% before, 1.7% after), Pacific Islander (2.2% before, 1.9% after), and Multi-race groups (1.7% before, 1.6% after). Risk adjustment also modestly increased disparities for the foreign-born group and non-commercial insurance groups. Increasing educational attainment was associated with decreasing severe maternal morbidity rates, which was largely unaffected by comorbidity risk adjustment. The pattern of results was the same whether or not transfusion-only cases were included as severe maternal morbidity.These results support the use of an updated comorbidity scoring system to assess disparities in severe maternal morbidity. Disparities in severe maternal morbidity decreased in magnitude for some racial-ethnic and socioeconomic groups and increased in magnitude for others after adjustment for the comorbidity score.

  View details for DOI 10.1016/j.ajogmf.2021.100530

  View details for PubMedID 34798329

• An Expanded Obstetric Comorbidity Scoring System for Predicting Severe Maternal Morbidity. Obstetrics and gynecology Leonard, S. A., Kennedy, C. J., Carmichael, S. L., Lyell, D. J., Main, E. K. 2020

  Abstract

  OBJECTIVE: To develop and validate an expanded obstetric comorbidity score for predicting severe maternal morbidity that can be applied consistently across contemporary U.S. patient discharge data sets.METHODS: Discharge data from birth hospitalizations in California during 2016-2017 were used to develop the score. The outcomes were severe maternal morbidity, defined using the Centers for Disease Control and Prevention index, and nontransfusion severe maternal morbidity (excluding cases where transfusion was the only indicator of severe maternal morbidity). We selected 27 potential patient-level risk factors for severe maternal morbidity, identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used a targeted causal inference approach integrated with machine learning to rank the risk factors based on adjusted risk ratios (aRRs). We used these results to assign scores to each comorbidity, which sum to a single numeric score. We validated the score in California and national data sets and compared the performance to that of a previously developed obstetric comorbidity index.RESULTS: Among 919,546 births, the rates of severe maternal morbidity and nontransfusion severe maternal morbidity were 168 and 74 per 10,000 births, respectively. The highest risk comorbidity was placenta accreta spectrum (aRR of 30.5 for severe maternal morbidity and 54.7 for nontransfusion severe maternal morbidity) and the lowest was gestational diabetes mellitus (aRR of 1.06 for severe maternal morbidity and 1.12 for nontransfusion severe maternal morbidity). Normalized scores based on the aRR were developed for each comorbidity, which ranged from 1 to 59 points for severe maternal morbidity and from 1 to 36 points for nontransfusion severe maternal morbidity. The overall performance of the expanded comorbidity scores was good (C-statistics were 0.78 for severe maternal morbidity and 0.84 for nontransfusion severe maternal morbidity in California data and 0.82 and 0.87, respectively, in national data) and improved on prior comorbidity indices developed for obstetric populations. Calibration plots showed good concordance between predicted and actual risks of the outcomes.CONCLUSION: We developed and validated an expanded obstetric comorbidity score to improve comparisons of severe maternal morbidity rates across patient populations with different comorbidity case mixes.

  View details for DOI 10.1097/AOG.0000000000004022

  View details for PubMedID 32769656

• Weight gain during pregnancy and the risk of severe maternal morbidity by prepregnancy BMI. The American journal of clinical nutrition Leonard, S. A., Abrams, B., Main, E. K., Lyell, D. J., Carmichael, S. L. 2020

  Abstract

  BACKGROUND: High and low prepregnancy BMI are risk factors for severe maternal morbidity (SMM), but the contribution of gestational weight gain (GWG) is not well understood.OBJECTIVES: We evaluated associations between GWG and SMM by prepregnancy BMI group.METHODS: We analyzed administrative records from 2,483,684 Californian births (2007-2012), utilizing z score charts to standardize GWG for gestational duration. We fit the z scores nonlinearly and categorized GWG as above, within, or below the Institute of Medicine (IOM) recommendations after predicting equivalent GWG at term from the z score charts. SMM was defined using a validated index. Associations were estimated using multivariable logistic regression models.RESULTS: We found generally shallow U-shaped relations between GWG z score and SMM in all BMI groups, except class 3 obesity (≥40kg/m2), for which risk was lowest with weight loss. The weight gain amount associated with the lowest risk of SMM was within the IOM recommendations for underweight and class 2 obesity, but above the IOM recommendations for normal weight, overweight, and class 1 obesity. The adjusted risk ratios (RRs) and 95% CIs for GWG below the IOM recommendations, compared with GWG within the recommendations, were the following for underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity: 1.13 (0.99, 1.29), 1.09 (1.04, 1.14), 1.10 (1.01, 1.19), 1.07 (0.95, 1.21), 1.03 (0.88, 1.22), and 0.89 (0.73, 1.08), respectively. For GWG above the recommendations, the corresponding RRs and 95% CIs were 0.99 (0.84, 1.15), 1.04 (0.99, 1.08), 0.98 (0.92, 1.04), 1.03 (0.95, 1.13), 1.07 (0.94, 1.23), and 1.08 (0.91, 1.30), respectively.CONCLUSIONS: High and low GWG may be modestly associated with increased risk of SMM across BMI groups, except in women with class 3 obesity, for whom low weight gain and weight loss may be associated with decreased risk of SMM.

  View details for DOI 10.1093/ajcn/nqaa033

  View details for PubMedID 32119734

• The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity. BMC pregnancy and childbirth Leonard, S. A., Main, E. K., Carmichael, S. L. 2019; 19 (1): 16

  Abstract

  Severe maternal morbidity - life-threatening childbirth complications - has more than doubled in the United States over the past 15 years, affecting more than 50,000 women (1.4% of deliveries) annually. During this time period, maternal age, obesity, comorbidities, and cesarean delivery also increased and may be related to the rise in severe maternal morbidity. We sought to evaluate: (1) the association of advanced maternal age, pre-pregnancy obesity, pre-pregnancy comorbidities, and cesarean delivery with severe maternal morbidity, and (2) whether changes in the prevalence of these risk factors affected the trend of severe maternal morbidity.This population-based cohort study used linked birth record and patient discharge data from live births in California during 2007-2014 (n = 3,556,206). We used multivariable logistic regression models to assess the association of advanced maternal age (≥35 years), pre-pregnancy obesity (body mass index ≥30 kg/m2), pre-pregnancy comorbidity (index of 12 conditions), and cesarean delivery with severe maternal morbidity prevalence and trends. Severe maternal morbidity was identified by an index of 18 diagnosis and procedure indicators. We estimated odds ratios, predicted prevalence, and population attributable risk percentages.The prevalence of severe maternal morbidity increased by 65% during 2007-2014. Advanced maternal age, pre-pregnancy obesity, and pre-pregnancy comorbidity also increased during this period, but cesarean delivery did not. None of these risk factors affected the increasing trend of severe maternal morbidity. However, the pre-pregnancy risk factors together were estimated to contribute to 13% (95% confidence interval: 12, 14%) of severe maternal morbidity cases in the study population overall, and cesarean delivery was estimated to contribute to 37% (95% confidence interval: 36, 38%) of cases.Pre-pregnancy health and cesarean delivery are important risk factors for severe maternal morbidity but do not explain an increasing trend of severe maternal morbidity in California during 2007-2014. Investigation of other potential contributors is needed in order to identify ways to reverse the trend of severe maternal morbidity.

  View details for DOI 10.1186/s12884-018-2169-3

  View details for PubMedID 30626349

  View details for PubMedCentralID PMC6327483

• Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Annals of epidemiology Leonard, S. A., Main, E. K., Scott, K. A., Profit, J. n., Carmichael, S. L. 2019

  Abstract

  Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of maternal and obstetric factors.We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997-2014 (n = 8,252,025).The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other maternal characteristics.The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.

  View details for PubMedID 30928320

• Risk of severe maternal morbidity in relation to prepregnancy body mass index: Roles of maternal co-morbidities and caesarean birth. Paediatric and perinatal epidemiology Leonard, S. A., Carmichael, S. L., Main, E. K., Lyell, D. J., Abrams, B. n. 2019

  Abstract

  An association between prepregnancy body mass index (BMI) and severe maternal morbidity (SMM) has been reported, but evidence has been mixed and potential explanations have not been examined.To evaluate the association between prepregnancy BMI and SMM in a large, diverse birth cohort and assess potential mediation by obesity-related co-morbidities and caesarean birth.This cohort study used linked birth certificate and hospitalisation discharge records from Californian births during 2007-2012. We assessed associations between prepregnancy BMI and SMM, and used inverse probability weighting for multiple mediators to estimate relative and absolute natural direct and indirect effects accounting for mediation by co-morbidities (hypertensive conditions, diabetes, asthma) and caesarean birth.Among 2 650 182 births, the prevalence of SMM was 1.42%. Adjusted risk ratios for the total association between prepregnancy BMI category and SMM were 1.12 (95% confidence interval [CI] 1.07, 1.18) for underweight, 1.02 (95% CI 0.99, 1.04) for overweight, 1.04 (95% CI 1.00, 1.07) for obesity class 1, 1.14 (95% CI 1.09, 1.20) for obesity class 2, and 1.28 (95% CI 1.22, 1.36) for obesity class 3 compared to women with normal weight. After accounting for mediation by co-morbidity and caesarean birth, the risk ratios were 1.19 (95% CI 1.14, 1.26) for underweight, 0.91 (95% CI 0.89, 0.94) for overweight, 0.86 (95% CI 0.84, 0.89) for obesity class 1, 0.88 (95% CI 0.84, 0.92) for obesity class 2, and 0.89 (95% CI 0.83, 0.95) for obesity class 3.Co-morbidities and caesarean birth explained an association between high prepregnancy BMI and SMM. These findings suggest that promotion of healthy prepregnancy weight, along with management of co-morbidities and support of vaginal birth in pregnant women with high BMI, could reduce the risk of SMM. However, these mediators did not reduce the elevated risk of SMM observed in women with low BMI.

  View details for DOI 10.1111/ppe.12555

  View details for PubMedID 31106879

• Trajectories of maternal weight from before pregnancy through postpartum and associations with childhood obesity. The American journal of clinical nutrition Leonard, S. A., Rasmussen, K. M., King, J. C., Abrams, B. 2017

  Abstract

  Background: Prepregnancy body mass index [BMI (in kg/m(2))], gestational weight gain, and postpartum weight retention may have distinct effects on the development of child obesity, but their combined effect is currently unknown.Objective: We described longitudinal trajectories of maternal weight from before pregnancy through the postpartum period and assessed the relations between maternal weight trajectories and offspring obesity in childhood.Design: We analyzed data from 4436 pairs of mothers and their children in the National Longitudinal Survey of Youth 1979 (1981-2014). We used latent-class growth modeling in addition to national recommendations for prepregnancy BMI, gestational weight gain, and postpartum weight retention to create maternal weight trajectory groups. We used modified Poisson regression models to assess the associations between maternal weight trajectory group and offspring obesity at 3 age periods (2-5, 6-11, and 12-19 y).Results: Our analysis using maternal weight trajectories based on either latent-class results or recommendations showed that the risk of child obesity was lowest in the lowest maternal weight trajectory group. The differences in obesity risk were largest after 5 y of age and persisted into adolescence. In the latent-class analysis, the highest-order maternal weight trajectory group consisted almost entirely of women who were obese before pregnancy and was associated with a >2-fold increase in the risk of offspring obesity at ages 6-11 y (adjusted RR: 2.39; 95% CI: 1.97, 2.89) and 12-19 y (adjusted RR: 2.74; 95% CI: 2.13, 3.52). In the analysis with maternal weight trajectory groups based on recommendations, the risk of child obesity was consistently highest for women who were overweight or obese at the beginning of pregnancy.Conclusion: These findings suggest that high maternal weight across the childbearing period increases the risk of obesity in offspring during childhood, but high prepregnancy BMI has a stronger influence than either gestational weight gain or postpartum weight retention.

  View details for DOI 10.3945/ajcn.117.158683

  View details for PubMedID 28877895

• Weight gain during pregnancy and the black-white disparity in preterm birth. Annals of epidemiology Leonard, S. A., Petito, L. C., Stephansson, O., Hutcheon, J. A., Bodnar, L. M., Mujahid, M. S., Cheng, Y., Abrams, B. 2017; 27 (5): 323-328.e1

  Abstract

  To quantify the relationship between pregnancy weight gain with early and late preterm birth and evaluate whether associations differed between non-Hispanic (NH) black and NH white women.We analyzed a retrospective cohort of all live births to NH black and NH white women in the United States 2011-2015 (n = 10,714,983). We used weight gain z-scores in multiple logistic regression models stratified by prepregnancy body mass index (BMI) and race to calculate population attributable risk (PAR) percentages for the contribution of high and low pregnancy weight gain to early and late preterm birth.Pregnancy weight gain was related to early and late preterm birth, but associations varied by BMI and race. For early preterm birth, the PAR percentage for high pregnancy weight gain ranged from 8 to 10% in NH black women and from 6 to 8% in NH white women. There was little evidence of racial differences in late preterm birth: PAR percentages ranged from 2 to 7% in NH black women and from 3 to 7% in NH white women.Moderate gestational weight gain is associated with lower rate of preterm birth, with greatest reductions for early preterm birth in NH black women.

  View details for DOI 10.1016/j.annepidem.2017.05.001

  View details for PubMedID 28595737

• Maternal History of Child Abuse and Obesity Risk in Offspring: Mediation by Weight in Pregnancy. Childhood obesity Leonard, S. A., Petito, L. C., Rehkopf, D. H., Ritchie, L. D., Abrams, B. 2017

  Abstract

  Women's experience of childhood adversity may contribute to their children's risk of obesity. Possible causal pathways include higher maternal weight and gestational weight gain, which have been associated with both maternal childhood adversity and obesity in offspring.This study included 6718 mother-child pairs from the National Longitudinal Survey of Youth 1979 in the United States (1979-2012). We applied multiple log-binomial regression models to estimate associations between three markers of childhood adversity (physical abuse, household alcoholism, and household mental illness) and offspring obesity in childhood. We estimated natural direct effects to evaluate mediation by prepregnancy BMI and gestational weight gain.Among every 100 mothers who reported physical abuse in childhood, there were 3.7 (95% confidence interval: -0.1 to 7.5) excess cases of obesity in 2- to 5-year olds compared with mothers who did not report physical abuse. Differences in prepregnancy BMI, but not gestational weight gain, accounted for 25.7% of these excess cases. There was no evidence of a similar relationship for household alcoholism or mental illness or for obesity in older children.In this national, prospective cohort study, prepregnancy BMI partially explained an association between maternal physical abuse in childhood and obesity in preschool-age children. These findings underscore the importance of life-course exposures in the etiology of child obesity and the potential multi-generational consequences of child abuse. Research is needed to determine whether screening for childhood abuse and treatment of its sequelae could strengthen efforts to prevent obesity in mothers and their children.

  View details for DOI 10.1089/chi.2017.0019

  View details for PubMedID 28440693

• Gestational Weight Gain-for-Gestational Age Z-Score Charts Applied across U.S. Populations. Paediatric and perinatal epidemiology Leonard, S. A., Hutcheon, J. A., Bodnar, L. M., Petito, L. C., Abrams, B. n. 2017

  Abstract

  Gestational weight gain may be a modifiable contributor to infant health outcomes, but the effect of gestational duration on gestational weight gain has limited the identification of optimal weight gain ranges. Recently developed z-score and percentile charts can be used to classify gestational weight gain independent of gestational duration. However, racial/ethnic variation in gestational weight gain and the possibility that optimal weight gain differs among racial/ethnic groups could affect generalizability of the z-score charts. The objectives of this study were (1) to apply the weight gain z-score charts in two different U.S. populations as an assessment of generalisability and (2) to determine whether race/ethnicity modifies the weight gain range associated with minimal risk of preterm birth.The study sample included over 4 million live, singleton births in California (2007-2012) and Pennsylvania (2003-2013). We implemented a noninferiority margin approach in stratified subgroups to determine weight gain ranges for which the adjusted predicted marginal risk of preterm birth (gestation <37 weeks) was within 1 or 2 percentage points of the lowest observed risk.There were minimal differences in the optimal ranges of gestational weight gain between California and Pennsylvania births, and among several racial/ethnic groups in California. The optimal ranges decreased as severity of prepregnancy obesity increased in all groups.The findings support the use of weight gain z-score charts for studying gestational age-dependent outcomes in diverse U.S. populations and do not support weight gain recommendations tailored to race/ethnicity.

  View details for DOI 10.1111/ppe.12435

  View details for PubMedID 29281119

• Weight gain in pregnancy and child weight status from birth to adulthood in the United States. Pediatric obesity Leonard, S. A., Petito, L. C., Rehkopf, D. H., Ritchie, L. D., Abrams, B. 2016

  Abstract

  High weight gain in pregnancy has been associated with child adiposity, but few studies have assessed the relationship across childhood or in racially/ethnically diverse populations.The objectives of the study are to test if weight gain in pregnancy is associated with high birthweight and overweight/obesity in early, middle and late childhood and whether these associations differ by maternal race/ethnicity.Mother-child dyads (n = 7539) were included from the National Longitudinal Survey of Youth 1979, a nationally representative cohort study in the USA (1979-2012). Log-binomial regression models were used to analyse associations between weight gain and the outcomes: high birthweight (>4000 g) and overweight/obesity at ages 2-5, 6-11 and 12-19 years.Excessive weight gain was positively associated, and inadequate weight gain was negatively associated with high birthweight after confounder adjustment (P < 0.05). Only excessive weight gain was associated with overweight in early, middle and late childhood. These associations were not significant in Hispanics or Blacks although racial/ethnic interaction was only significant ages 12-19 years (P = 0.03).Helping pregnant women gain weight within national recommendations may aid in preventing overweight and obesity across childhood, particularly for non-Hispanic White mothers.

  View details for DOI 10.1111/ijpo.12163

  View details for PubMedID 27350375

  View details for PubMedCentralID PMC5404997

• Prepregnancy Risk Factors for Preterm Birth and the Role of Maternal Nativity in a Low-Income, Hispanic Population MATERNAL AND CHILD HEALTH JOURNAL Leonard, S. A., Crespi, C. M., Gee, D. C., Zhu, Y., Whaley, S. E. 2015; 19 (10): 2295-2302

  Abstract

  The aim of this study was to assess potential prepregnancy risk factors for preterm birth in a low-income, Hispanic population in Southern California. Additionally, the study assessed whether the prevalence of preterm birth and any associations between risk factors and preterm birth differed between U.S.- and foreign-born mothers.The study sample included 1174 mothers participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) within 1 year postpartum, including an augment sample of mothers who delivered preterm. Maternal sociodemographic traits, prepregnancy health-related characteristics and behaviors, and birth outcomes were collected by telephone survey. Odds ratios for associations between risk factors and preterm birth were estimated by logistic regression with sampling weights. Effect measure modification of any association by maternal nativity was also assessed using interaction terms.After adjustment for confounding, significant prepregnancy risk factors for preterm birth included maternal age ≥35 years (OR 2.00; 95 % CI 1.04, 3.84) compared to age 18-24 years, and experience of a financially stressful life event among U.S.-born, but not foreign-born, women (OR 2.61; 95 % CI 1.43, 4.77). The weighted prevalence of preterm birth was 15.1 % and did not significantly differ by maternal nativity (P = 0.19).Further investigation with large, prospective studies is needed to better understand the risk factors for and disparities in preterm birth among the growing Hispanic population in the U.S. so that women who are at risk prepregnancy can be identified and provided risk-specific services.

  View details for DOI 10.1007/s10995-015-1748-4

  View details for Web of Science ID 000361625100023

  View details for PubMedID 25994418

  View details for PubMedCentralID PMC4575879

• Associations Between Preterm Birth, Low Birth Weight, and Postpartum Health in a Predominantly Hispanic WIC Population JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR Leonard, S. A., Gee, D., Zhu, Y., Crespi, C. M., Whaley, S. E. 2014; 46 (6): 499-505

  Abstract

  To describe the postpartum health of predominantly Hispanic participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and identify how health characteristics differ between mothers who delivered preterm or low birth weight infants and those who did not.Cross-sectional survey among postpartum WIC mothers.Los Angeles and Orange Counties, CA.WIC participants within 1 year of delivery (n = 1,420).Postpartum health behaviors, health characteristics, and birth spacing intentions and behaviors.Frequencies of health characteristics were estimated using analyses with sample weights. Differences were assessed with chi-square and Fisher exact tests with Bonferroni correction for pairs of tests.Many women exhibited postpartum risk factors for future adverse health events, including overweight or obesity (62.3%), depressive symptoms (27.5%), and no folic acid supplementation (65.5%). Most characteristics did not differ significantly (P > .025) between mothers of preterm infants and full-term infants or between mothers of low birth weight and normal birth weight infants.Despite few differences between postpartum characteristics of mothers who delivered preterm or low birth weight infants and those who did not, a high percentage of mothers had risk factors that need to be addressed. Current postpartum educational activities of WIC programs should be evaluated and shared.

  View details for DOI 10.1016/j.jneb.2014.06.008

  View details for Web of Science ID 000345000500010

  View details for PubMedID 25092236

  View details for PubMedCentralID PMC4252510

• Larger Infant Size at Birth Reduces the Negative Association between Maternal Prepregnancy Body Mass Index and Breastfeeding Duration JOURNAL OF NUTRITION Leonard, S. A., Rasmussen, K. M. 2011; 141 (4): 645-653

  Abstract

  Women who are overweight or obese prepregnancy have shorter durations of producing milk (PM) and feeding breast milk exclusively (FBM-ex) than normal-weight women. We proposed that infant size at birth may reduce the negative associations between prepregnancy BMI and the durations of PM and FBM-ex. We used data from 2798 participants in the Infant Feeding Practices Study II and characterized infant size at birth as weight-for-gestational age (WGA). To assess possible mediation of the associations between maternal BMI and the durations of PM and FBM-ex by infant size at birth, Baron and Kenny's methods, the Sobel test, and bootstrapping were used. As expected, prepregnancy BMI was negatively associated (P < 0.0001) with the durations of PM and FBM-ex; it also was positively associated (P < 0.0001) with infant size at birth. However, infant WGA was positively associated (P < 0.0003) with the durations of PM and FBM-ex after adjustment for BMI. Thus, the negative associations between BMI and the durations of PM and FBM-ex were reduced by infant WGA; i.e. the statistical removal of infant size at birth increased the magnitude of the negative associations between BMI and the durations of PM and FBM-ex. Thus, the tendency of heavier mothers to deliver heavier infants reduces the true magnitude of the association between maternal prepregnancy BMI and shortened breastfeeding duration.

  View details for DOI 10.3945/jn.110.129874

  View details for Web of Science ID 000288876800016

  View details for PubMedID 21346096

• Associations between high prepregnancy body mass index, breast-milk expression, and breast-milk production and feeding AMERICAN JOURNAL OF CLINICAL NUTRITION Leonard, S. A., Labiner-Wolfe, J., Geraghty, S. R., Rasmussen, K. M. 2011; 93 (3): 556-563

  Abstract

  Breast-milk expression is widely practiced by American mothers, but little is known about who expresses milk, how expression affects breastfeeding, or whether overweight or obese women, who have less breastfeeding success than do normal-weight women, express milk differently.We investigated 1) whether breast-milk expression behavior differed by body mass index (BMI; in kg/m(2)) category and 2) whether the different breastfeeding behaviors of overweight (BMI: ≥25 and <30) and obese (BMI: ≥30) women resulted in different breastfeeding outcomes.The subjects (n = 2288) provided information on BMI and breast-milk production, feeding, and expression in mail-in questionnaires as part of the Infant Feeding Practices Study II. Longitudinal and cross-sectional data were analyzed by using regression procedures adjusted for confounding.Women of different BMI categories overall did not differ in whether, when, or why they expressed breast milk. Before 2 mo postpartum, however, obese women were more likely (P = 0.04, unadjusted) to try milk expression and were less likely (P = 0.01, unadjusted) to express milk successfully. In addition, overweight or obesity was associated (P < 0.03, unadjusted) with a shorter duration of breast-milk production only in women who never expressed milk. In overweight or obese women, those who ever expressed milk had longer durations of breastfeeding (P < 0.003, unadjusted) than did those who never expressed milk.Breast-milk expression behaviors may differ by maternal BMI category only in the early postpartum period. In addition, breast-milk expression may reduce differences between BMI categories in the duration of breastfeeding and support longer durations of breastfeeding.

  View details for DOI 10.3945/ajcn.110.002352

  View details for Web of Science ID 000287475000014

  View details for PubMedID 21209224

• Evaluation of Statewide Program to Reduce Cesarean Deliveries Among Nulliparous Individuals With Singleton Pregnancies at Term Gestation in Vertex Presentation. Obstetrics and gynecology Rosenstein, M. G., Chang, S. C., Tucker, C. M., Sakowski, C., Leonard, S. A., Main, E. K. 2024; 144 (4): 507-515

  Abstract

  To evaluate the effect of statewide efforts to reduce nulliparous, term, singleton, vertex (NTSV) cesarean delivery rates in California.This was a population-based study of all NTSV births in California from 2015 to 2019. In 2015, all California hospitals with NTSV cesarean delivery rates above the 23.9% Healthy People 2020 target were invited to join a CMQCC (California Maternal Quality Care Collaborative)-sponsored, 3-year, multifaceted collaborative or a system-level quality collaborative to safely support vaginal birth. We examined the cesarean delivery rate overall and by participation or nonparticipation in a collaborative program. Secondarily, for hospitals that started with an NTSV cesarean delivery rate above 23.9%, we compared patient-level, hospital-level, and obstetric management characteristics between hospitals that met the Healthy People 2020 target (cesarean delivery rate below 23.9%) in 2019 and those that did not.There were 758,268 NTSV births at 238 hospitals. Annual mean NTSV cesarean delivery rates decreased among all racial and ethnic groups statewide and among all patients, regardless of payer, maternal age, or body mass index (BMI). The decrease in cesarean delivery was driven largely by a decrease in the frequency of cesarean delivery performed for labor dystocia (14.9% in 2015 to 12.8% in 2019) and from cesarean delivery before the onset of labor (4.2% in 2015 to 3.3% in 2019). For hospitals that started with an NTSV cesarean delivery rate above 23.9%, NTSV cesarean delivery rates among 80 hospitals participating in the CMQCC had a mean±SD decline of 6.9±5.9%, 13 hospitals participating in the system-level collaborative had a 5.0±4.5% decline, and those not participating in any collaborative had a 2.1±6.0% decline. In multivariable analysis, there was no association between meeting the Healthy People target and any of the hospital-level factors or aggregated patient-level characteristics. Rates of induction of labor increased in both groups and were not associated with a change in cesarean delivery rates.Hospitals in California between 2015 and 2019 with a wide variation in institutional and patient characteristics successfully reduced their NTSV cesarean delivery rates. Reduction in the NTSV cesarean delivery rate at hospitals that started above the Healthy People target was not associated with differences in patient characteristics but rather a reduction in cesarean deliveries for labor dystocia and cesarean deliveries performed before the onset of labor.

  View details for DOI 10.1097/AOG.0000000000005696

  View details for PubMedID 39441957

• Virtual simulation training for postpartum hemorrhage in low-to-moderate-volume hospitals in the US. AJOG global reports Minor, K. C., Bianco, K., Mayo, J. A., Abir, G., Judy, A. E., Lee, H. C., Leonard, S. A., Ayotte, S., Hedli, L. C., Schaffer, K., Sie, L., Daniels, K. 2024; 4 (3): 100357

  Abstract

  Maternal mortality in the United States is rising and many deaths are preventable. Emergencies, such as postpartum hemorrhage, occur less frequently in non-teaching, rural, and urban low-birth volume hospitals. There is an urgent need for accessible, evidence-based, and sustainable inter-professional education that creates the opportunity for clinical teams to practice their response to rare, but potentially devastating events.To assess the feasibility of virtual simulation training for the management of postpartum hemorrhage in low-to-moderate-volume delivery hospitals.The study occurred between December 2021 and March 2022 within 8 non-academic hospitals in the United States with low-to-moderate-delivery volumes, randomized to one of two models: direct simulation training and train-the-trainer. In the direct simulation training model, simulation faculty conducted a virtual simulation training program with participants. In the train-the-trainer model, simulation faculty conducted virtual lessons with new simulation instructors on how to prepare and conduct a simulation course. Following this training, the instructors led their own simulation training program at their respective hospitals. The direct simulation training participants and students trained by new instructors from the train-the-trainer program were evaluated with a multiple-choice questionnaire on postpartum hemorrhage knowledge and a confidence and attitude survey at 3 timepoints: prior to, immediately after, and at 3 months post-training. Paired t-tests were performed to assess for changes in knowledge and confidence within teaching models across time points. ANOVA was performed to test cross-sectionally for differences in knowledge and confidence between teaching models at each time point.Direct simulation training participants (n=22) and students of the train-the-trainer instructors (n=18) included nurses, certified nurse midwives and attending physicians in obstetrics, family practice or anesthesiology. Mean pre-course knowledge and confidence scores were not statistically different between direct simulation participants and the students of the instructors from the train-the-trainer course (79%+/-13 versus 75%+/-14, respectively, P-value=.45). Within the direct simulation group, knowledge and confidence scores significantly improved from pre- to immediately post-training (knowledge score mean difference 9.81 [95% CI 3.23-16.40], P-value<.01; confidence score mean difference 13.64 [95% CI 6.79-20.48], P-value<.01), which were maintained 3-months post-training. Within the train-the-trainer group, knowledge and confidence scores immediate post-intervention were not significantly different compared with pre-course or 3-month post-course scores. Mean knowledge scores were significantly greater for the direct simulation group compared to the train-the-trainer group immediately post-training (89%+/-7 versus 74%+/-8, P-value<.01) and at 3-months (88%+/-7 versus 76%+/-12, P-value<.01). Comparisons between groups showed no difference in confidence and attitude scores at these timepoints. Both direct simulation participants and train-the-trainer instructors preferred virtual education, or a hybrid structure, over in-person education.Virtual education for obstetric simulation training is feasible, acceptable, and effective. Utilizing a direct simulation model for postpartum hemorrhage management resulted in enhanced knowledge acquisition and retention compared to a train-the-trainer model.

  View details for DOI 10.1016/j.xagr.2024.100357

  View details for PubMedID 38975047

  View details for PubMedCentralID PMC11227018

• Parenthood and the Physical and Mental Health of Sexual and Gender Minority Parents: A Cross-Sectional, Observational Analysis from The PRIDE Study. Annals of epidemiology Tordoff, D. M., Lunn, M. R., Snow, A., Monseur, B., Flentje, A., Lubensky, M. E., Dastur, Z., Kaysen, D., Leonard, S. A., Obedin-Maliver, J. 2024

  Abstract

  To compare the physical and mental health of sexual and gender minority (SGM) parents to SGM non-parents.A cross-sectional analysis using 2018-2020 data from The PRIDE Study, a national longitudinal cohort of SGM adults. We used Poisson regression adjusted for age, gender, relationship status, race/ethnicity, household income, and education to assess the association between parental status and each outcome.Among 9,625 SGM participants, 1,460 (15%) were parents. Older participants were more likely to be parents: 2% of participants aged 18-30, 18% aged 30-39, and 38% aged 40+ were parents. In adjusted analyses, parenthood was associated with greater depression, anxiety, and post-traumatic stress symptoms as well as ever cigarette smoking. Among individuals assigned female sex at birth, parents were twice as likely to have been diagnosed with pelvic inflammatory disease compared to non-parents. There was no association between parenthood status and alcohol use, substance use, diabetes, HIV, hypertension, or autism.In this national cohort of SGM adults, parenthood was associated with differences in physical and mental health measures. Understanding how parenthood influences the health and well-being of the estimated 3 million SGM parents in the US will help our health systems support diverse families.

  View details for DOI 10.1016/j.annepidem.2024.07.046

  View details for PubMedID 39038746

• Racial and Ethnic Disparities in Cervical Insufficiency, Cervical Cerclage, and Preterm Birth. Journal of women's health (2002) Miller, H. E., Mayo, J. A., Reddy, R. A., Leonard, S. A., Lee, H. C., Suharwardy, S., Lyell, D. J. 2024

  Abstract

  Background: The frequency of cervical insufficiency differs among the major racial and ethnic groups, with limited data specific to Asian American and Native Hawaiian/Pacific Islander (AANHPI) subpopulations. We assessed cervical insufficiency diagnoses and related outcomes across 10 racial and ethnic groups, including disaggregated AANHPI subgroups, in a large population-based cohort. Study Design: We performed a retrospective cohort study of all singleton births between 20-42 weeks' gestation in California from 2007 to 2018. Logistic regression models were performed to estimate the odds of cervical insufficiency and, among people with cervical insufficiency, the odds of cerclage and preterm birth according to self-reported race and ethnicity. Results: Among 5,114,470 births, 38,605 (0.8%) had a diagnosis code for cervical insufficiency. Compared with non-Hispanic White people, non-Hispanic Black people had the highest odds of cervical insufficiency (adjusted odds ratio [aOR] 3.07; 95% confidence interval [CI], 2.97, 3.18), for cerclage placement and higher odds for preterm birth. Disaggregating AANHPI subgroups showed that Indian people had the highest odds (aOR 1.94; 95% CI, 1.82, 2.07) of cervical insufficiency and had significantly higher odds of cerclage without increased odds of preterm birth; Southeast Asian people had the highest odds of preterm birth. Conclusion: Within a large, diverse population-based cohort, non-Hispanic Black people experienced the highest rates of cervical insufficiency, and among those with cervical insufficiency, had among the highest rates of cerclage and preterm birth. Among AANHPI subgroups specifically, Indian people had the highest rates of cervical insufficiency and cerclage placement, without increased rates of preterm birth; Southeast Asian people had the highest rates of preterm birth, without increased rates of cerclage. Disaggregating AANHPI subgroups identifies important differences in obstetric risk factors and outcomes.

  View details for DOI 10.1089/jwh.2024.0088

  View details for PubMedID 38923943

• A Novel Fetal Magnetic Resonance Imaging Lung Volume Nomogram Stratified by Estimated Fetal Weight. Fetal diagnosis and therapy Farladansky-Gershnabel, S., Jayapal, P., Zalcman, M., Barth, R. A., Rubesova, E., Hintz, S. R., Zhang, J., Leonard, S. A., El-Sayed, Y. Y., Blumenfeld, Y. J. 2024: 1-8

  Abstract

  Fetal magnetic resonance imaging (MRI) lung volume nomograms are increasingly used to prognosticate neonatal outcomes in fetuses with suspected pulmonary hypoplasia. However, pregnancies complicated by fetal anomalies associated with pulmonary hypoplasia may also be complicated by fetal growth restriction (FGR). If a small lung volume is suspected in such cases, it is often unclear whether the lungs are "small" because of underlying lung pathology, or small fetal size. Existing MRI lung volume nomograms have mostly been stratified by gestational age (GA), rather than estimated fetal weight (EFW). Therefore, we aimed to develop a novel fetal lung volume nomogram stratified by EFW.Consecutive fetal MRIs performed at a quaternary medical center from 2019 to 2021 were analyzed. MRIs performed due to fetal lung anomalies and cases with FGR were excluded. All MRIs were performed without IV contrast on GE 3 or 1.5 Tesla scanners (GE Healthcare). Images were reviewed by three experienced fetal radiologists. Freehand ROI in square centimeter was drawn around the contours of the lungs on consecutive slices from the apex to the base. The volume of the right, left and total lungs were calculated in mL. Lung volumes were plotted by both EFW and GA.Among 301 MRI studies performed during the study period, 170 cases met inclusion criteria and were analyzed. MRIs were performed between 19- and 38-week gestation, and a sonographic EFW was obtained within a mean of 2.9 days (SD ± 5.5 days, range 0-14 days) of each MRI. Nomograms stratified by both EFW and GA were created using 200 g. and weekly intervals respectively. A formula using EFW to predict total lung volume was calculated: LV = 0.07497804 EFW0.88276 (R2 = 0.87).We developed a novel fetal lung volume nomogram stratified by EFW. If validated, this nomogram may assist clinicians predict outcomes in cases of fetal pulmonary hypoplasia with concomitant FGR.

  View details for DOI 10.1159/000539709

  View details for PubMedID 38843783

• Associations between anxiety, sleep, and blood pressure parameters in pregnancy: a prospective pilot cohort study. BMC pregnancy and childbirth Miller, H. E., Simpson, S. L., Hurtado, J., Boncompagni, A., Chueh, J., Shu, C. H., Barwick, F., Leonard, S. A., Carvalho, B., Sultan, P., Aghaeepour, N., Druzin, M., Panelli, D. M. 2024; 24 (1): 366

  Abstract

  The potential effect modification of sleep on the relationship between anxiety and elevated blood pressure (BP) in pregnancy is understudied. We evaluated the relationship between anxiety, insomnia, and short sleep duration, as well as any interaction effects between these variables, on BP during pregnancy.This was a prospective pilot cohort of pregnant people between 23 to 36 weeks' gestation at a single institution between 2021 and 2022. Standardized questionnaires were used to measure clinical insomnia and anxiety. Objective sleep duration was measured using a wrist-worn actigraphy device. Primary outcomes were systolic (SBP), diastolic (DBP), and mean (MAP) non-invasive BP measurements. Separate sequential multivariable linear regression models fit with generalized estimating equations (GEE) were used to separately assess associations between anxiety (independent variable) and each BP parameter (dependent variables), after adjusting for potential confounders (Model 1). Additional analyses were conducted adding insomnia and the interaction between anxiety and insomnia as independent variables (Model 2), and adding short sleep duration and the interaction between anxiety and short sleep duration as independent variables (Model 3), to evaluate any moderating effects on BP parameters.Among the 60 participants who completed the study, 15 (25%) screened positive for anxiety, 11 (18%) had subjective insomnia, and 34 (59%) had objective short sleep duration. In Model 1, increased anxiety was not associated with increases in any BP parameters. When subjective insomnia was included in Model 2, increased DBP and MAP was significantly associated with anxiety (DBP: β 6.1, p = 0.01, MAP: β 6.2 p < 0.01). When short sleep was included in Model 3, all BP parameters were significantly associated with anxiety (SBP: β 9.6, p = 0.01, DBP: β 8.1, p < 0.001, and MAP: β 8.8, p < 0.001). No moderating effects were detected between insomnia and anxiety (p interactions: SBP 0.80, DBP 0.60, MAP 0.32) or between short sleep duration and anxiety (p interactions: SBP 0.12, DBP 0.24, MAP 0.13) on BP.When including either subjective insomnia or objective short sleep duration, pregnant people with anxiety had 5.1-9.6 mmHg higher SBP, 6.1-8.1 mmHg higher DBP, and 6.2-8.8 mmHg higher MAP than people without anxiety.

  View details for DOI 10.1186/s12884-024-06540-w

  View details for PubMedID 38750438

  View details for PubMedCentralID 2941423

• Magnesium sulfate and risk of hypoxic ischemic encephalopathy in a high-risk cohort. American journal of obstetrics and gynecology Minor, K. C., Liu, J., Druzin, M. L., El-Sayed, Y. Y., Hintz, S. R., Bonifacio, S. L., Leonard, S. A., Lee, H. C., Profit, J., Karakash, S. D. 2024

  Abstract

  Hypoxic ischemic encephalopathy contributes to morbidity and mortality among neonates ≥ 360 weeks' gestation. Evidence of preventative antenatal treatment is limited. Magnesium sulfate has neuroprotective properties among preterm fetuses. Hypertensive disorders of pregnancy are a risk factor for hypoxic ischemic encephalopathy and magnesium sulfate is recommended for maternal seizure prophylaxis among patients with pre-eclampsia with severe features.1) Determine trends in incidence of hypertensive disorders of pregnancy, antenatal magnesium sulfate and hypoxic ischemic encephalopathy, 2) evaluate the association between hypertensive disorders of pregnancy and hypoxic ischemic encephalopathy and 3) evaluate if, among patients with hypertensive disorders of pregnancy, the odds of hypoxic ischemic encephalopathy is mitigated by receipt of antenatal magnesium sulfate. STUDY DESIGN: We conducted an analysis of a prospective cohort of live births ≥360 weeks' gestation between 2012-2018 within the California Perinatal Quality Care Collaborative registry, linked with the California Department of Health Care Access and Information files. We used Cochran-Armitage tests to assess trends in hypertensive disorders, encephalopathy diagnoses, and magnesium sulfate utilization, and compared demographic factors between patients with or without hypertensive disorders of pregnancy or treatment with magnesium sulfate. Hierarchical logistic regression models were built to explore if hypertensive disorders of pregnancy were associated with any severity and moderate/severe hypoxic ischemic encephalopathy. Separate hierarchical logistic regression models were built among those with hypertensive disorders of pregnancy to evaluate the association of magnesium sulfate with hypoxic ischemic encephalopathy.Among 44,314 unique infants, the diagnosis of hypoxic ischemic encephalopathy, maternal hypertensive disorders of pregnancy and the use of magnesium sulfate increased over time. Compared to patients with hypertensive disorders of pregnancy alone, patients with hypertensive disorders treated with magnesium sulfate represented a higher risk population. They were more likely to be publicly insured, born 36-38 weeks' gestation, be small for gestational age, have lower Apgar scores, require a higher level of resuscitation at delivery, have prolonged rupture of membranes, preterm labor, fetal distress, and undergo operative delivery (all p-values <0.002). Hypertensive disorders of pregnancy were associated with hypoxic ischemic encephalopathy (aOR 1.26, 95% CI 1.13-1.40, p-value <.001) and specifically moderate/severe hypoxic ischemic encephalopathy (aOR 1.26, 95% CI 1.11-1.42, p-value <.001). Among patients with hypertensive disorders of pregnancy, treatment with magnesium sulfate was associated with 29% reduction in the odds of neonatal hypoxic ischemic encephalopathy (aOR 0.71, 95% CI 0.52-0.97, p-value= 0.03) and a 37% reduction in the odds of moderate/severe neonatal hypoxic ischemic encephalopathy (aOR 0.63, 95% CI 0.42-0.94, p-value=0.03).Hypertensive disorders of pregnancy are associated with hypoxic ischemic encephalopathy and specifically, moderate/severe disease. Among people with hypertensive disorders, receipt of antenatal magnesium sulfate is associated with significant reduction in the odds of hypoxic ischemic encephalopathy and moderate/severe disease in a neonatal cohort admitted to the NICU ≥360 weeks' gestation. The findings of this observational study cannot prove causality and are intended to be hypothesis generating for future clinical trials on MgSO4 in term infants.

  View details for DOI 10.1016/j.ajog.2024.04.001

  View details for PubMedID 38580044

• Prevalence and Outcomes of Emergency Room Care for Postpartum Endometritis. Perlman, N., Mayo, J., Leonard, S., Carmichael, S., Gibbs, R. SPRINGER HEIDELBERG. 2024: 140A

  View details for Web of Science ID 001287525000241

• In Reply. Obstetrics and gynecology Leonard, S. A., Phibbs, C. S., Main, E. K., Kozhimannil, K. B., Bateman, B. T. 2024; 143 (1): e18-e19

  View details for DOI 10.1097/AOG.0000000000005457

  View details for PubMedID 38096558

• Hypertensive disorders of pregnancy and severe maternal morbidity according to race/ ethnicity, California 2007-2018 Mayo, J. A., Perlman, N., Girsen, A., Carmichael, S. L., Leonard, S. A. MOSBY-ELSEVIER. 2024: S411

  View details for Web of Science ID 001282913904001

• Associations between antepartum anemia and uterine fibroids in pregnancy by race and ethnicity Igbinosa, I., Mayo, J. A., Leonard, S. A., Iwekaogwu, I., Carmichael, S. L., Lyell, D. J., Eunice Kennedy Shriver Natl Inst Child Hlth Human Dev MOSBY-ELSEVIER. 2024: S264

  View details for Web of Science ID 001282913902108

• Mifepristone as an adjunct to transcervical balloon for labor induction (MiLI): a randomized controlled trial Miller, H. E., Jennings, M. T., Leonard, S. A., Mayo, J. A., Lyell, D. J., El Sayed, Y. Y., Blumenthal, P., Shaw, K. MOSBY-ELSEVIER. 2024: S140-S141

  View details for Web of Science ID 001282913901061

• Joint effects of epilepsy and mental health on severe maternal morbidity Perlman, N., Mayo, J. A., Leonard, S. A., Carmichael, S. L., McElrath, T., Meador, K., Druzin, M. L., Panelli, D. M. MOSBY-ELSEVIER. 2024: S161-S162

  View details for Web of Science ID 001282913901104

• Association of antenatal anxiety, short sleep duration, and blood pressure parameters: a pilot study Miller, H. E., Simpson, S. L., Hurtado, J., Shu, C., Chueh, J., Barwick, F., Leonard, S. A., Carvalho, B., Sultan, P., Aghaeepour, N., Druzin, M. L., Panelli, D. M. MOSBY-ELSEVIER. 2024: S287

  View details for Web of Science ID 001282913902153

• Bedsharing among breastfeeding physicians: Results of a nationwide survey. PloS one Louis-Jacques, A. F., Bartick, M., Awomolo, A., Zhang, J., Feldman-Winter, L., Leonard, S. A., Meek, J., Mitchell, K. B., Crowe, S. 2024; 19 (8): e0305625

  Abstract

  INTRODUCTION: Bedsharing is common but advised against by the American Academy of Pediatrics. It is unknown if breastfeeding physicians bedshare more or less than the general population.OBJECTIVES: To determine the prevalence of bedsharing among physicians, their reasons for bedsharing or not, and whether bedsharing was associated with a longer duration of breastfeeding.METHODS: An online survey was adapted from surveys administered by the Centers for Disease Control and Prevention. The survey was administered to physicians and medical students who birthed children from October 2020 through August 2021. Respondents were asked to report on a singleton birth, and questions centered around sleep practices and breastfeeding. Survival analysis was used to examine the association between bedsharing and breastfeeding duration.RESULTS: Of 546 respondents with bedsharing data, 68% reported some history of bedsharing, and 77% were in specialties that involved caring for pregnant people and/or infants. Those who bedshared breastfed an average of four months longer than those who never bedshared (18.08 versus 14.08 months p<0.001). The adjusted risk of breastfeeding cessation was markedly lower for those who bedshared compared to those who did not (Hazard Ratio 0.57, 95% Confidence Interval 0.45, 0.71). The primary reason for bedsharing was to breastfeed (73%); the primary reason for not bedsharing was safety concerns (92%). Among those who bedshared (n = 373), 52% did not inform their child's healthcare provider.CONCLUSIONS: Bedsharing is common among our sample of mainly breastfeeding physicians, including those who care for pregnant people and/or infants. It is also associated with a longer duration of breastfeeding, which has implications for population health. Practicing bedsharing implies cognitive dissidence and may affect how physicians counsel about bedsharing. Additionally, lack of disclosure of bedsharing practices has implications for practical guidance about having open non-judgmental conversations and may be a missed opportunity to counsel on bedsharing safety.

  View details for DOI 10.1371/journal.pone.0305625

  View details for PubMedID 39088472

• Trends and Disparities in Severe Maternal Morbidity Indicator Categories During Childbirth Hospitalization in California from 1997-2017. American journal of perinatology El Ayadi, A. M., Lyndon, A., Kan, P., Mujahid, M. S., Main, E. K., Carmichael, S. 2023

  Abstract

  Objective Severe maternal morbidity (SMM) is increasing and characterized by substantial racial and ethnic disparities. Analyzing trends and disparities across time by etiologic or organ system groups instead of an aggregated index may inform specific, actionable pathways to equitable care. We explored trends and racial and ethnic disparities in seven SMM categories at childbirth hospitalization. Study Design We analyzed California birth cohort data on all live and stillbirths ≥20 weeks gestation from 1997-2017 (n=10,580,096) using the Centers for Disease Control and Prevention's SMM index. Cases were categorized into seven non-mutually exclusive indicator categories (cardiac, renal, respiratory, hemorrhage, sepsis, other obstetric, and other medical SMM). We compared prevalence and trends in SMM indicator categories overall and by racial and ethnic group using logistic and linear regression. Results SMM occurred in 1.16% of births and non-transfusion SMM in 0.54%. Hemorrhage SMM occurred most frequently (27 per 10,000 births), followed by other obstetric (11), respiratory (7), and sepsis, cardiac, and renal SMM (5). Hemorrhage, renal, respiratory, and sepsis SMM increased over time for all racial and ethnic groups. The largest disparities were for Black individuals, including over three-fold increased odds of other medical SMM. Renal and sepsis morbidity had the largest relative increases over time (717% and 544%). Sepsis and hemorrhage SMM had the largest absolute changes over time (17 per 10,000 increase). Disparities increased over time for respiratory SMM among Black, US-born Hispanic, and non-US-born Hispanic individuals and for sepsis SMM among Asian or Pacific Islander individuals. Disparities decreased over time for sepsis SMM among Black individuals yet remained substantial. Conclusion Our research further supports the critical need to address SMM and disparities as a significant public health priority in the United States and suggests that examining SMM subgroups may reveal helpful nuance for understanding trends, disparities and potential needs for intervention.

  View details for DOI 10.1055/a-2223-3520

  View details for PubMedID 38057087

• Racial and Ethnic Disparities in Anemia and Severe Maternal Morbidity. Obstetrics and gynecology Igbinosa, I. I., Leonard, S. A., Noelette, F., Davies-Balch, S., Carmichael, S. L., Main, E., Lyell, D. J. 2023

  Abstract

  To evaluate antepartum anemia prevalence by race and ethnicity, to assess whether such differences contribute to severe maternal morbidity (SMM), and to estimate the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity.We conducted a population-based cohort study using linked vital record and birth hospitalization data for singleton births at or after 20 weeks of gestation in California from 2011 through 2020. Pregnant patients with hereditary anemias, out-of-hospital births, unlinked records, and missing variables of interest were excluded. Antepartum anemia prevalence and trends were estimated by race and ethnicity. Centers for Disease Control and Prevention criteria were used for SMM and nontransfusion SMM indicators. Multivariable logistic regression modeling was used to estimate risk ratios (RRs) for SMM and nontransfusion SMM by race and ethnicity after sequential adjustment for social determinants, parity, obstetric comorbidities, delivery, and antepartum anemia. Population attributable risk percentages were calculated to assess the contribution of antepartum anemia to SMM and nontransfusion SMM by race and ethnicity.In total, 3,863,594 births in California were included. In 2020, Black pregnant patients had the highest incidence of antepartum anemia (21.5%), followed by Pacific Islander (18.2%), American Indian-Alaska Native (14.1%), multiracial (14.0%), Hispanic (12.6%), Asian (10.6%), and White pregnant patients (9.6%). From 2011 to 2020, the prevalence of anemia increased more than100% among Black patients, and there was a persistent gap in prevalence among Black compared with White patients. Compared with White patients, the adjusted risk for SMM was high among most racial and ethnic groups; adjustment for anemia after sequential modeling for known confounders decreased SMM risk most for Black pregnant patients (approximated RR 1.47, 95% CI 1.42-1.53 to approximated RR 1.27, 95% CI 1.22-1.37). Compared with White patients, the full adjusted nontransfusion SMM risk remained high for most groups except Hispanic and multiracial patients. Within each racial and ethnic group, the population attributable risk percentage for antepartum anemia and SMM was highest for multiracial patients (21.4%, 95% CI 17.5-25.0%), followed by Black (20.9%, 95% CI 18.1-23.4%) and Hispanic (20.9%, 95% CI 19.9-22.1%) patients. The nontransfusion SMM population attributable risk percentages for Asian, Black, and White pregnant patients were less than 8%.Antepartum anemia, most prevalent among Black pregnant patients, contributed to disparities in SMM by race and ethnicity. Nearly one in five to six SMM cases among Black, Hispanic, American Indian-Alaska Native, Pacific Islander, and multiracial pregnant patients is attributable in part to antepartum anemia.

  View details for DOI 10.1097/AOG.0000000000005325

  View details for PubMedID 37678935

• Perinatal Care Measures Are Incomplete If They Do Not Assess The Birth Parent-Infant Dyad As A Whole. Health affairs (Project Hope) Handley, S. C., Formanowski, B., Passarella, M., Kozhimannil, K. B., Leonard, S. A., Main, E. K., Phibbs, C. S., Lorch, S. A. 2023; 42 (9): 1266-1274

  Abstract

  Measures of perinatal care quality and outcomes often focus on either the birth parent or the infant. We used linked vital statistics and hospital discharge data to describe a dyadic measure (including both the birth parent and the infant) for perinatal care during the birth hospitalization. In this five-state cohort of 2010-18 births, 21.6 percent of birth parent-infant dyads experienced at least one complication, and 9.6 percent experienced a severe complication. Severe infant complications were eight times more prevalent than severe birth parent complications. Among birth parents with a severe complication, the co-occurrence of a severe infant complication ranged from 2 percent to 51 percent, whereas among infants with a severe complication, the co-occurrence of a severe birth parent complication was rare, ranging from 0.04 percent to 5 percent. These data suggest that measures, clinical interventions, public reporting, and policies focused on either the birth parent or the infant are incomplete in their assessment of a healthy dyad. Thus, clinicians, administrators, and policy makers should evaluate dyadic measures, incentivize positive outcomes for both patients (parent and infant), and create policies that support the health of the dyad.

  View details for DOI 10.1377/hlthaff.2023.00398

  View details for PubMedID 37669487

• Hospital-level variation in racial disparities in low-risk nulliparous cesarean birth rates. American journal of obstetrics & gynecology MFM Main, E. K., Chang, S. C., Tucker, C. M., Sakowski, C., Leonard, S. A., Rosenstein, M. G. 2023: 101145

  Abstract

  Nationally, rates of cesarean birth are highest among Black patients, compared with other racial/ethnic groups. These observed inequities are a relatively new phenomenon (in the 1980s, cesarean birth rates among Black patients were lower than average) indicating an opportunity to narrow the gap. Cesarean birth rates vary greatly among hospitals, masking racial disparities that are unseen when rates are reported in aggregate.This study explored reasons for the current large Black-White disparity in first-birth cesarean rates by first examining the hospital-level variation in first-birth cesarean rates among different racial/ethnic groups. We then identified hospitals that had low first-birth cesarean rates among Black patients and compared them to hospitals with high rates. We sought to identify differences in facility or patient characteristics could provide insights for the racial disparity.A population cross-sectional study was performed on 1,267,493 California live births from 2018 through 2020 using birth certificate data linked with maternal patient discharge records. Annual nulliparous term singleton vertex cesarean delivery (first-birth) rates were calculated for the most common racial/ethnic groups statewide and for each hospital. Self-identified race/ethnicity categories as selected on the birth certificate were used. Relative risk (RR) and 95% confidence intervals for first-birth cesarean comparing 2019 to 2015 were estimated using a log-binomial model for each racial/ethnic group. Patient and hospital characteristics were compared between hospitals that had first-birth cesarean rates <23.9% for Black patients compared with hospitals with rates ≥23.9% for Black patients.Hospitals with at least 30 nulliparous term singleton vertex Asian, Black, Hispanic and White patients each were identified. Black patients had a very different distribution with significantly higher rate (28.4%), wider standard deviation (7.1) and interquartile range (6.5) than other racial groups (P<0.01). 29 hospitals with a low first-birth cesarean rate among Black patients were identified using the Healthy People 2020 target of 23.9% and compared to 106 hospitals with higher rates. The low group has a cesarean rate of 19.9% compared to 30.7% in the higher group. There were no significant differences between the groups in hospital characteristics (ownership, delivery volume, Neonatal level, proportion of midwife deliveries) or patient characteristics (age, education, insurance, onset of prenatal care, BMI, hypertension, diabetes). Among the 106 hospitals that did not meet the target for Black patients, 63 met it for white patients with a mean rate of 21.4%. In the same hospitals the mean rate for Black patients was 29.5%. Cesarean indications among Black patients in the group that did not meet the 23.9% target were significantly higher for all indications: labor dystocia, fetal concern (spontaneous labor), and no labor (e.g. macrosomia), all indications with a high degree of subjectivity.The statewide cesarean rate for Black patients is significantly higher and has substantially greater hospital variation than other racial or ethnic groups. The lack of difference in facility or patient characteristics between hospitals with low cesarean rates among Black patients and those with high rates suggests unconscious bias and structural racism potentially play important roles in creating these racial differences.

  View details for DOI 10.1016/j.ajogmf.2023.101145

  View details for PubMedID 37648109

• Abortion Bans and Resource Utilization for Congenital Heart Disease: A Decision Analysis. Obstetrics and gynecology Miller, H. E., Fraz, F., Zhang, J., Henkel, A., Leonard, S. A., Maskatia, S. A., El-Sayed, Y. Y., Blumenfeld, Y. J. 2023

  Abstract

  To investigate the implications of potential national abortion ban scenarios on the incidence of neonatal single-ventricle cardiac defects.A decision tree model was developed to predict the incidence of neonatal single-ventricle cardiac defects and related outcomes in the United States under four theoretical national abortion bans: 1) abortion restrictions in existence immediately before the June 2022 Dobbs v Jackson Women's Health Organization Supreme Court decision, 2) 20 weeks of gestation, 3) 13 weeks of gestation, and 4) a complete abortion ban. The model included incidence of live births of neonates with single-ventricle cardiac defects, neonatal heart surgery (including heart transplant and extracorporeal membrane oxygenation [ECMO]), and neonatal death. Cohort size was based on national pregnancy incidence and different algorithm decision point probabilities were aggregated from the existing literature. Monte Carlo simulations were conducted with 10,000 iterations per model.In the scenario before the Dobbs decision, an estimated 6,369,000 annual pregnancies in the United States resulted in 1,006 annual cases of single-ventricle cardiac defects. Under a complete abortion ban, the model predicted a 53.7% increase in single-ventricle cardiac defects, or an additional 9 cases per 100,000 live births. This increase would result in an additional 531 neonatal heart surgeries, 16 heart transplants, 77 ECMO utilizations, and 102 neonatal deaths annually. More restrictive gestational age-based bans are predicted to confer increases in cases of neonatal single-ventricle cardiac defects and related adverse outcomes as well.Universal abortion bans are estimated to increase the incidence of neonatal single-ventricle cardiac defects, associated morbidity, and resource utilization. States considering limiting abortion should consider the implications on the resources required to care for increasing number of children that will be born with significant and complex medical needs, including those with congenital heart disease.

  View details for DOI 10.1097/AOG.0000000000005291

  View details for PubMedID 37535962

• Feasibility and impact of a mental health chatbot on postpartum mental health: a randomized controlled trial. AJOG global reports Suharwardy, S., Ramachandran, M., Leonard, S. A., Gunaseelan, A., Lyell, D. J., Darcy, A., Robinson, A., Judy, A. 2023; 3 (3): 100165

  Abstract

  BACKGROUND: Perinatal mood disorders are common yet underdiagnosed and un- or undertreated. Barriers exist to accessing perinatal mental health services, including limited availability, time, and cost. Automated conversational agents (chatbots) can deliver evidence-based cognitive behavioral therapy content through text message-based conversations and reduce depression and anxiety symptoms in select populations. Such digital mental health technologies are poised to overcome barriers to mental health care access but need to be evaluated for efficacy, as well as for preliminary feasibility and acceptability among perinatal populations.OBJECTIVE: To evaluate the acceptability and preliminary efficacy of a mental health chatbot for mood management in a general postpartum population.STUDY DESIGN: An unblinded randomized controlled trial was conducted at a tertiary academic center. English-speaking postpartum women aged 18 years or above with a live birth and access to a smartphone were eligible for enrollment prior to discharge from delivery hospitalization. Baseline surveys were administered to all participants prior to randomization to a mental health chatbot intervention or to usual care only. The intervention group downloaded the mental health chatbot smartphone application with perinatal-specific content, in addition to continuing usual care. Usual care consisted of routine postpartum follow up and mental health care as dictated by the patient's obstetric provider. Surveys were administered during delivery hospitalization (baseline) and at 2-, 4-, and 6-weeks postpartum to assess depression and anxiety symptoms. The primary outcome was a change in depression symptoms at 6-weeks as measured using two depression screening tools: Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale. Secondary outcomes included anxiety symptoms measured using Generalized Anxiety Disorder-7, and satisfaction and acceptability using validated scales. Based on a prior study, we estimated a sample size of 130 would have sufficient (80%) power to detect a moderate effect size (d=.4) in between group difference on the Patient Health Questionnaire-9.RESULTS: A total of 192 women were randomized equally 1:1 to the chatbot or usual care; of these, 152 women completed the 6-week survey (n=68 chatbot, n=84 usual care) and were included in the final analysis. Mean baseline mental health assessment scores were below positive screening thresholds. At 6-weeks, there was a greater decrease in Patient Health Questionnaire-9 scores among the chatbot group compared to the usual care group (mean decrease=1.32, standard deviation=3.4 vs mean decrease=0.13, standard deviation=3.01, respectively). 6-week mean Edinburgh Postnatal Depression Scale and Generalized Anxiety Disorder-7 scores did not differ between groups and were similar to baseline. 91% (n=62) of the chatbot users were satisfied or highly satisfied with the chatbot, and 74% (n=50) of the intervention group reported use of the chatbot at least once in 2 weeks prior to the 6-week survey. 80% of study participants reported being comfortable with the use of a mobile smartphone application for mood management.CONCLUSION: Use of a chatbot was acceptable to women in the early postpartum period. The sample did not screen positive for depression at baseline and thus the potential of the chatbot to reduce depressive symptoms in this population was limited. This study was conducted in a general obstetric population. Future studies of longer duration in high-risk postpartum populations who screen positive for depression are needed to further understand the utility and efficacy of such digital therapeutics for that population.

  View details for DOI 10.1016/j.xagr.2023.100165

  View details for PubMedID 37560011

• Obstetric Volume and Severe Maternal Morbidity Among Low-Risk and Higher-Risk Patients Giving Birth at Rural and Urban US Hospitals. JAMA health forum Kozhimannil, K. B., Leonard, S. A., Handley, S. C., Passarella, M., Main, E. K., Lorch, S. A., Phibbs, C. S. 2023; 4 (6): e232110

  Abstract

  Identifying hospital factors associated with severe maternal morbidity (SMM) is essential to clinical and policy efforts.To assess associations between obstetric volume and SMM in rural and urban hospitals and examine whether these associations differ for low-risk and higher-risk patients.This retrospective cross-sectional study of linked vital statistics and patient discharge data was conducted from 2022 to 2023. Live births and stillbirths (≥20 weeks' gestation) at hospitals in California (2004-2018), Michigan (2004-2020), Pennsylvania (2004-2014), and South Carolina (2004-2020) were included. Data were analyzed from December 2022 to May 2023.Annual birth volume categories (low, medium, medium-high, and high) for hospitals in urban (10-500, 501-1000, 1001-2000, and >2000) and rural (10-110, 111-240, 241-460, and >460) counties.The main outcome was SMM (excluding blood transfusion); covariates included age, payer status, educational attainment, race and ethnicity, and obstetric comorbidities. Analyses were stratified for low-risk and higher-risk obstetric patients based on presence of at least 1 clinical comorbidity.Among more than 11 million urban births and 519 953 rural births, rates of SMM ranged from 0.73% to 0.50% across urban hospital volume categories (high to low) and from 0.47% to 0.70% across rural hospital volume categories (high to low). Risk of SMM was elevated for patients who gave birth at rural hospitals with annual birth volume of 10 to 110 (adjusted risk ratio [ARR], 1.65; 95% CI, 1.14-2.39), 111 to 240 (ARR, 1.37; 95% CI, 1.10-1.70), and 241 to 460 (ARR, 1.26; 95% CI, 1.05-1.51), compared with rural hospitals with greater than 460 births. Increased risk of SMM occurred for low-risk and higher-risk obstetric patients who delivered at rural hospitals with lower birth volumes, with low-risk rural patients having notable discrepancies in SMM risk between low (ARR, 2.32; 95% CI, 1.32-4.07), medium (ARR, 1.66; 95% CI, 1.20-2.28), and medium-high (ARR, 1.68; 95% CI, 1.29-2.18) volume hospitals compared with high volume (>460 births) rural hospitals. Among hospitals in urban counties, there was no significant association between birth volume and SMM for low-risk or higher-risk obstetric patients.In this cross-sectional study of births in US rural and urban counties, risk of SMM was elevated for low-risk and higher-risk obstetric patients who gave birth in lower-volume hospitals in rural counties, compared with similar patients who gave birth at rural hospitals with greater than 460 annual births. These findings imply a need for tailored quality improvement strategies for lower volume hospitals in rural communities.

  View details for DOI 10.1001/jamahealthforum.2023.2110

  View details for PubMedID 37354537

• Clinical and Physician Factors Associated With Failed Operative Vaginal Delivery. Obstetrics and gynecology Panelli, D. M., Leonard, S. A., Joudi, N., Judy, A. E., Bianco, K., Gilbert, W. M., Main, E. K., El-Sayed, Y. Y., Lyell, D. J. 2023

  Abstract

  To examine clinical and physician factors associated with failed operative vaginal delivery among individuals with nulliparous, term, singleton, vertex (NTSV) births.This was a retrospective cohort study of individuals with NTSV live births with an attempted operative vaginal delivery by a physician between 2016 and 2020 in California. The primary outcome was cesarean birth after failed operative vaginal delivery, identified using linked diagnosis codes, birth certificates, and physician licensing board data stratified by device type (vacuum or forceps). Clinical and physician-level exposures were selected a priori, defined using validated indices, and compared between successful and failed operative vaginal delivery attempts. Physician experience with operative vaginal delivery was estimated by calculating the number of operative vaginal delivery attempts made per physician during the study period. Multivariable mixed effects Poisson regression models with robust standard errors were used to estimate risk ratios of failed operative vaginal delivery for each exposure, adjusted for potential confounders.Of 47,973 eligible operative vaginal delivery attempts, 93.2% used vacuum and 6.8% used forceps. Of all operative vaginal delivery attempts, 1,820 (3.8%) failed; the success rate was 97.3% for vacuum attempts and 82.4% for forceps attempts. Failed operative vaginal deliveries were more likely with older patient age, higher body mass index, obstructed labor, and neonatal birth weight more than 4,000 g. Between 2016 and 2020, physicians who attempted more operative vaginal deliveries were less likely to fail. When vacuum attempts were successful, physicians who conducted them had a median of 45 vacuum attempts during the study period, compared with 27 attempts when vacuum attempts were unsuccessful (adjusted risk ratio [aRR] 0.95, 95% CI 0.93-0.96). When forceps attempts were successful, physicians who conducted them had a median of 19 forceps attempts, compared with 11 attempts when forceps attempts were unsuccessful (aRR 0.76, 95% CI 0.64-0.91).In this large, contemporary cohort with NTSV births, several clinical factors were associated with operative vaginal delivery failure. Physician experience was associated with operative vaginal delivery success, more notably for forceps attempts. These results may provide guidance for physician training in maintenance of operative vaginal delivery skills.

  View details for DOI 10.1097/AOG.0000000000005181

  View details for PubMedID 37141591

• Vaginal Progesterone is Associated with Intrahepatic Cholestasis of Pregnancy. American journal of perinatology Tsur, A., Leonard, S. A., Kan, P., Datoc, I., Girsen, A., Shaw, G. M., Stevenson, D. K., El-Sayed, Y. Y., Druzin, M. L., Blumenfeld, Y. J. 2023

  Abstract

  Background The frequency of intrahepatic cholestasis of pregnancy peaks during the third trimester of pregnancy when plasma progesterone levels are highest. Furthermore, twin pregnancies are characterized by higher progesterone levels than singletons, and have a higher frequency of cholestasis. Therefore, we hypothesized that exogenous progestogens administered for reducing the risk of spontaneous preterm birth may increase the risk of cholestasis. Objectives Utilizing the large IBM MarketScan Commercial Claims and Encounters Database, we investigated the frequency of cholestasis in patients treated with vaginal progesterone or intramuscular 17alpha-hydroxyprogesterone caproate for the prevention of preterm birth. Study design We identified 1,776,092 live-born singleton pregnancies between 2010-2014. We confirmed 2nd and 3rd trimester administration of progestogens by cross-referencing the dates of progesterone prescriptions with the dates of scheduled pregnancy events such as nuchal translucency scan, fetal anatomy scan, glucose challenge test, and Tdap vaccination. We excluded pregnancies with missing data regarding timing of scheduled pregnancy events, or progesterone treatment prescribed only during the 1st trimester. Cholestasis of pregnancy was identified based on prescriptions for ursodeoxycholic acid. We used multivariable logistic regression to estimate adjusted (for maternal age) odds ratios for cholestasis in patients treated with vaginal progesterone, and in patients treated with 17alpha-hydroxyprogesterone caproate compared to those not treated with any type of progestogen (the reference group). Results The final cohort consisted of 870,599 pregnancies. Among patients treated with vaginal progesterone during the 2nd and 3rd trimester, the frequency of cholestasis was significantly higher than the reference group (0.75% vs 0.23%, aOR 3.16, 95% CI 2.23-4.49). In contrast, there was no significant association between 17alpha-hydroxyprogesterone caproate and cholestasis (0.27%, aOR 1.12, 95% CI 0.58-2.16) Conclusions Using a robust dataset, we observed that vaginal progesterone but not intramuscular 17alpha-hydroxyprogesterone caproate was associated with an increased risk for intrahepatic cholestasis of pregnancy.

  View details for DOI 10.1055/a-2081-2573

  View details for PubMedID 37100422

• Racial/Ethnic Disparities in Costs, Length of Stay, and Severity of Severe Maternal Morbidity. American journal of obstetrics & gynecology MFM Phibbs, C. M., Kristensen-Cabrera, A., Kozhimannil, K. B., Leonard, S. A., Lorch, S. A., Main, E. K., Schmitt, S. K., Phibbs, C. S. 2023: 100917

  Abstract

  BACKGROUND: In contrast to other high-resource countries, the US has experienced increases in the rates of severe maternal morbidity. The US also has pronounced racial/ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people.OBJECTIVE(S): The objective of this study was to examine if the racial/ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity.STUDY DESIGN: This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009-2011. Of the 1.5 million linked records, 250,000 were excluded due to incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnostic-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days postpartum. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial/ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race/ethnicity with costs and length of stay.RESULTS: Asian/Pacific Islander, Non-Hispanic Black, Hispanic, and Other race/ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio 1.61, p<0.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (p<0.001) higher costs (marginal effect $5,023) and 24% (p<0.001) longer hospital stays (marginal effect 1.4 days) compared to non-Hispanic White patients. These effects changed when cases where a blood transfusion was the only indication of severe maternal morbidity were excluded, with 29% higher costs (p<0.001) and 15% longer length of stay (p<0.001). For other racial/ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significant different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients but significantly lower costs and length of stay.CONCLUSION(S): There were racial/ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; additionally, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity supports greater case severity in that population. These findings suggest that efforts to address racial/ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation.

  View details for DOI 10.1016/j.ajogmf.2023.100917

  View details for PubMedID 36882126

• Prepregnancy body mass index and gestational diabetes mellitus across Asian and Pacific Islander subgroups in California. AJOG global reports Sperling, M. M., Leonard, S. A., Blumenfeld, Y. J., Carmichael, S. L., Chueh, J. 2023; 3 (1): 100148

  Abstract

  The American College of Obstetricians and Gynecologists recommends early screening for gestational diabetes mellitus among pregnant Asian people with a prepregnancy body mass index ≥23.0 kg/m2, in contrast with the recommended screening at a body mass index ≥25 kg/m2 for other races and ethnicities. However, there is significant heterogeneity within Asian and Pacific Islander populations, and gestational diabetes mellitus and its association with body mass index among Asian and Pacific Islander subgroups may not be uniform across all groups.This study aimed to analyze the association between body mass index and gestational diabetes mellitus among Asian and Pacific Islander subgroups in California, specifically gestational diabetes mellitus rates among those with a body mass index above vs below 23 kg/m2, which is the cutoff point for the designation of being overweight among Asians populations.Using a linked delivery hospitalization discharge and vital records database, we identified patients who gave birth in California between 2007 and 2017 and who self-reported to be 1 of 13 Asian and Pacific Islander subgroups, which was collected from birth and fetal death certificates. In each subgroup, we evaluated the association between body mass index and gestational diabetes mellitus using multivariable logistic regression models adjusted for age, education, parity, payment method, the trimester in which prenatal care was initiated, and nativity. We fit body mass index nonlinearly with splines and categorized body mass index as being above or below 23 kg/m2. Predicted probabilities of gestational diabetes mellitus with 95% confidence intervals were calculated across body mass index values using the nonlinear regression models.The overall prevalence of gestational diabetes mellitus was 14.3% (83,400/584,032), ranging between 8.4% and 17.1% across subgroups. The highest prevalence was among Indian (17.1%), Filipino (16.7%), and Vietnamese (15.5%) subgroups. In these subgroups, gestational diabetes mellitus was diagnosed in 10% to 13% of those with a body mass index <23.0 kg/m2 and in 22% of those with a body mass index ≥23 kg/m2. Gestational diabetes mellitus was least common among Korean (8.4%), Japanese (9.0%), and Samoan (9.8%) subgroups with a gestational diabetes mellitus rate of 5% to 7% among those with a body mass index <23.0 kg/m2 and in 10% to 15% among those with a body mass index ≥23 kg/m2. Although Samoan patients had the highest rate of obesity, defined as body mass index ≥30 kg/m2 (57.4%), they had the third lowest prevalence of gestational diabetes mellitus. Conversely, Vietnamese patients had the second lowest rate of obesity (2.4%) but the highest rate of gestational diabetes mellitus at a body mass index of ≥23 kg/m2 (22.3%).Gestational diabetes mellitus and its association with body mass index varied among Asian subgroups but increased as body mass index increased. Subgroups with the lowest prevalence of obesity trended toward a higher prevalence of gestational diabetes mellitus and those with a higher prevalence of obesity trended toward a lower prevalence of gestational diabetes mellitus.

  View details for DOI 10.1016/j.xagr.2022.100148

  View details for PubMedID 36632428

  View details for PubMedCentralID PMC9826825

• Quasi-experimental study designs can inform pandemic effects on nutrition and weight gain in pregnancy. The American journal of clinical nutrition Leonard, S. A., Panelli, D. M. 2023; 117 (2): 216-217

  View details for DOI 10.1016/j.ajcnut.2022.09.004

  View details for PubMedID 36863821

• Red Blood Cell Transfusion in Patients With Placenta Accreta Spectrum: A Systematic Review and Meta-analysis. Obstetrics and gynecology Miller, S. E., Leonard, S. A., Meza, P. K., Ku, S., Ren, L. Y., Lyell, D. J., Sultan, P., Butwick, A. 2023; 141 (1): 49-58

  Abstract

  OBJECTIVE: To evaluate red blood cell use during delivery in patients with placenta accreta spectrum.DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL, Cochrane Central, ClinicalTrials.gov, and Scopus for clinical trials and observational studies published between 2000 and 2021 in countries with developed economies.METHODS OF STUDY SELECTION: Abstracts (n=4,275) and full-text studies (n=599) were identified and reviewed by two independent reviewers. Data on transfused red blood cells were included from studies reporting means and SDs, medians with interquartile ranges, or individual patient data. The primary outcome was the weighted mean number of units of red blood cells transfused per patient. Between-study heterogeneity was assessed with an I2 statistic. Secondary analyses included red blood cell usage by placenta accreta subtype.TABULATION, INTEGRATION, AND RESULTS: Of the 599 full-text studies identified, 20 met criteria for inclusion in the systematic review, comprising 1,091 cases of placenta accreta spectrum. The number of units of red blood cells transfused was inconsistently described across studies, with five studies (25.0%) reporting means, 11 (55.0%) reporting medians, and four (20.0%) reporting individual patient data. The weighted mean number of units transfused was 5.19 (95% CI 4.12-6.26) per patient. Heterogeneity was high across studies (I2=91%). In a sensitivity analysis of five studies reporting mean data, the mean number of units transfused was 6.61 (95% CI 4.73-8.48; n=220 patients). Further quantification of units transfused by placenta accreta subtype was limited due to methodologic inconsistencies between studies and small cohort sizes.CONCLUSION: Based on the upper limit of the CI in our main analysis and the high study heterogeneity, we recommend that a minimum of 6 units of red blood cells be available before delivery for patients with placenta accreta spectrum. These findings may inform future guidelines for predelivery blood ordering and transfusion support.SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021240993.

  View details for DOI 10.1097/AOG.0000000000004976

  View details for PubMedID 36701609

• Adverse Pregnancy Outcomes Among Asian Subgroups - Does Gestational Diabetes Mellitus Increase the Risk? Perlman, N. C., Sperling, M. M., Mayo, J., Leonard, S. A., Blumenfeld, Y. J., Carmichael, S. L., Maine, E., Chueh, J., Bianco, K. SPRINGER HEIDELBERG. 2023: 131A-132A

  View details for Web of Science ID 001043029500223

• In Virtual Simulation is Teaching to Fish Better Than Giving a Fish? Bianco, K., Minor, K., Schaffer, K., Sei, L., Mayo, J., Leonard, S. A., Daniels, K. SPRINGER HEIDELBERG. 2023: 215A-216A

  View details for Web of Science ID 001043029500432

• Increased rates of postpartum emergency department visits and inpatient readmissions in people with epilepsy Darmawan, K. F., Leonard, S. A., Meador, K., McElrath, T. F., Carmichael, S. L., Lyell, D. J., El-Sayed, Y. Y., Herrero, T., Druzin, M. L., Panelli, D. M. MOSBY-ELSEVIER. 2023: S163

  View details for Web of Science ID 000909337400235

• Impact of psychiatric conditions on the risk of severe maternal morbidity in veterans Panelli, D. M., Esmaeili, A., Joyce, V., Chan, C., Gujral, K., Schmitt, S., Murphy, N., Kimerling, R., Leonard, S. A., Shaw, J. G., Phibbs, C. S. MOSBY-ELSEVIER. 2023: S457-S458

  View details for Web of Science ID 000909337401261

• Antenatal wildfire smoke exposure and hypertensive disorders of pregnancy Waldrop, A. R., Blumenfeld, Y. J., Mayo, J. A., Panelli, D. M., Heft-Neal, S., Burke, M., Leonard, S. A., Shaw, G. M. MOSBY-ELSEVIER. 2023: S59-S60

  View details for Web of Science ID 000909337400072

• Abortion restriction impact on burden of neonatal single ventricle congenital heart disease: a decision-analytic model Miller, H. E., Henkel, A., Zhang, J., Leonard, S. A., Quirin, A. P., Maskatia, S. A., El Sayed, Y. Y., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2023: S483

  View details for Web of Science ID 000909337401304

• Severe maternal morbidity among people with cardiac disease: getting to the heart of the problem Darmawan, K. F., Panelli, D. M., Mayo, J. A., Leonard, S. A., Girsen, A., Carmichael, S. L., Bianco, K. MOSBY-ELSEVIER. 2023: S163-S164

  View details for Web of Science ID 000909337400236

• Increased primary cesarean delivery rate among people with epilepsy: Risks, drivers and future directions Darmawan, K. F., Leonard, S. A., Meador, K., McElrath, T. F., Carmichael, S. L., Lyell, D. J., El-Sayed, Y. Y., Herrero, T., Druzin, M. L., Panelli, D. M. MOSBY-ELSEVIER. 2023: S162-S163

  View details for Web of Science ID 000909337400234

• Hospital intrapartum practices and disparities in severe maternal and neonatal morbidity Leonard, S. A., Xu, X., Davies-Balch, S., Main, E., Bateman, B. T., Rehkopf, D., Lee, H. C., Illuzzi, J., Igbinosa, I., Iwekaogwu, I., Lyell, D. J. MOSBY-ELSEVIER. 2023: S233

  View details for Web of Science ID 000909337400348

• The association of anxiety and insomnia on blood pressure parameters in pregnancy: a pilot study Miller, H. E., Simpson, S. L., Hurtado, J., Boncompagni, A. C., Chueh, J., Druzin, M. L., Panelli, D. M. MOSBY-ELSEVIER. 2023: S483-S484

  View details for Web of Science ID 000909337401305

• Factors contributing to delay in family building among sexual/gender minority people in the COVID19 pandemic Waldrop, A. R., Zhang, J., Flentje, A., Lunn, M. R., Lubensky, M. E., Leonard, S. A., Dastur, Z., Obedin-Maliver, J. MOSBY-ELSEVIER. 2023: S434

  View details for Web of Science ID 000909337401223

• A novel fetal MRI lung volume nomogram stratified by estimated fetal weight Gershnabel, S., Jayapal, P., Zalcman, M., Barth, R. A., Rubesova, E., Hintz, S., Zhang, J., Leonard, S. A., El-Sayed, Y. Y., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2023: S577

  View details for Web of Science ID 000909337401449

• A novel virtual simulation training improves providers' knowledge and confidence to manage obstetric emergencies Minor, K. C., Mayo, J. A., Bianco, K., Judy, A., Abir, G., Lee, H. C., Leonard, S. A., Sie, L., Ayotte, S., Daniels, K. I. MOSBY-ELSEVIER. 2023: S160

  View details for Web of Science ID 000909337400230

• Fasting Compared With Fed and Oral Intake Before the 1-Hour Oral Glucose Tolerance Test: A Randomized Controlled Trial. Obstetrics and gynecology Sperling, M. M., Leonard, S. A., Miller, S. E., Hurtado, J., El-Sayed, Y. Y., Herrero, T., Faig, J., Carter, S., Blumenfeld, Y. J. 2023; 141 (1): 126-133

  Abstract

  OBJECTIVE: To evaluate the effect of fasting compared with eating before the 1-hour oral glucose tolerance test (OGTT) on gestational diabetes mellitus (GDM) screening results.METHODS: In a single-center, prospective randomized trial, participants were randomized to: 1) fasting for 6 or more hours or 2) oral intake ("fed") within 2 hours of the 50-g, 1-hour OGTT. The 1-hour OGTT was administered after 24 weeks of gestation. A positive screen result was defined as a serum glucose level of 140 mg/dL or higher. Protocol adherence was assessed by a survey administered immediately after the OGTT. We planned to enroll 100 participants in each group to detect an absolute difference of 20 percentage points or more on the 1-hour OGTT screen-positive rate using Fisher exact test, assuming an estimated screen-positive rate of 45% in the fasting and 25% in the fed group and 10% attrition, with a two-sided alpha=0.05, power=0.8. The primary outcome was the 1-hour OGTT screen-positive rate. Secondary outcomes included mean 1-hour OGTT glucose values, GDM diagnosis, maternal and neonatal outcomes, and patient perceptions regarding the 1-hour OGTT.RESULTS: From November 2020 through April 2021, 200 participants were randomized. One hundred ninety-five completed the 1-hour OGTT (97 fasting, 98 fed). Participant surveys confirmed 97.9% (n=95) adherence to the fasting and 91.8% (n=90) adherence to the fed groups. The screen-positive rate was significantly higher in the fasting than the fed group (32.0% vs 13.3%, respectively, P=.002), as was the mean glucose value (127.7 mg/dL vs 113.3 mg/dL, P=.002). The incidence of GDM in the fasting group was 12.4% (n=12) and in the fed group was 5.1% (n=5) (P=.08). There were no significant differences in maternal or neonatal outcomes.CONCLUSION: Fasting for 6 or more hours doubled the incidence of a positive 1-hour OGTT result when compared with eating within 2 hours of the test.CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT04547023.

  View details for DOI 10.1097/AOG.0000000000005013

  View details for PubMedID 36701613

• An exploratory analysis of leukocyte telomere length among pregnant and non-pregnant people. Brain, behavior, & immunity - health Panelli, D. M., Diwan, M., Cruz, G. I., Leonard, S. A., Chueh, J., Gotlib, I. H., Bianco, K. 2022; 25: 100506

  Abstract

  Background: Leukocyte telomere length (LTL) is a biomarker that is affected by older age, psychosocial stress, and medical comorbidities. Despite the relevance of these factors to obstetric practice, little is known about LTL in pregnancy. Our study explored longitudinal LTL dynamics in pregnant and non-pregnant people.Objective: This pilot study compares changes in LTL between pregnant and non-pregnant people over time, explores potential correlations between LTL and mental health measures, and investigates associations between short first-trimester LTL and adverse pregnancy outcomes.Study design: This was a prospective pilot cohort study of nulliparous pregnant and non-pregnant people between ages 18 and 50 who presented for care at a single institution from January to November 2020. Pregnant people were enrolled between 10 and 14 weeks gestation. Participants had two blood samples drawn for LTL; the first on the day of enrollment and the second on postpartum day 1 (pregnant cohort) or 7 months later (non-pregnant cohort). LTL was measured using quantitative PCR. The primary outcome was the difference between pregnant and non-pregnant people in LTL change between the two timepoints (basepair difference per 30-day period). Secondary outcomes included differences in responses to the Patient Health Questionnaire-9 (PHQ-9) and a survey about stress related to COVID-19. Differences in LTL were tested using t-tests and linear regression models, both crude and adjusted for age. A subgroup analysis was conducted within the pregnant cohort to examine whether shorter first-trimester LTL was associated with adverse pregnancy outcomes. We conducted t-tests to compare LTL between people with and without each categorical outcome and computed Pearson correlation coefficients between LTL and continuous outcomes such as gestational age at delivery.Results: 46 pregnant and 30 non-pregnant people were enrolled; 44 pregnant and 18 non-pregnant people completed all LTL assessments. There were no between-group differences in LTL change (-4.2±22.2 bp per 30 days pregnant versus -6.4±11.2 bp per 30 days non-pregnant, adjusted beta 2.1, 95% CI -9.0-13.2, p=0.60). The prevalence of depression and pandemic-related stress were both low overall. The two groups did not differ in PHQ-9 scores, and no correlations were significant between LTL and PHQ-9 scores. Among the 44 pregnant people, shorter first-trimester LTL was significantly correlated with earlier gestational age at delivery (r=0.35, p=0.02).Conclusion: In this exploratory pilot cohort of reproductive-aged people with low levels of psychological stress, we described baseline changes in LTL over time in pregnant and non-pregnant participants. We found a correlation between shorter first-trimester LTL and earlier gestational age at delivery, which warrants further investigation in a larger cohort.

  View details for DOI 10.1016/j.bbih.2022.100506

  View details for PubMedID 36110146

• ASSOCIATION BETWEEN INFERTILITY SUBTYPES AND ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AMONG POSTMENOPAUSAL PARTICIPANTS FROM THE WOMEN'S HEALTH INITIATIVE. Murugappan, G., Leonard, S., Lathi, R. B., Farland, L. V., Carmichael, S. L., Parikh, N. J., Stefanick, M. L. ELSEVIER SCIENCE INC. 2022: E4-E5

  View details for Web of Science ID 000891942500003

• Addressing postpartum contraception practices utilizing a multidisciplinary Pregnancy Heart Team approach. AJOG global reports Miller, H. E., Do, S. C., Cruz, G., Panelli, D. M., Leonard, S. A., Girsen, A., Lee, C. J., Khandelwal, A., Shaw, K. A., Bianco, K. 2022; 2 (4): 100100

  Abstract

  BACKGROUND: Cardiovascular disease has emerged as the leading cause of maternal morbidity and mortality, making planned pregnancy, and thereby reliable contraception among people with cardiovascular disease, vital.OBJECTIVE: This study aimed to compare postpartum contraceptive practices among people with cardiovascular disease (cardiac cohort) cared for by a Pregnancy Heart Team to people with other chronic comorbidities (high-risk cohort), and people without comorbidities (low-risk cohort). We hypothesized that the Pregnancy Heart Team influenced baseline contraception counseling and practices among those with cardiovascular disease.STUDY DESIGN: This was a retrospective cohort study comparing postpartum contraceptive practices between a cardiac cohort who received care by a multidisciplinary team between 2012 and 2020 and high-risk and low-risk cohorts delivering at a single academic center between 2016 and 2019. We investigated presence of a contraceptive plan (at birthing admission, discharge, and postpartum visit) and uptake of reliable contraception by 8 weeks postpartum.RESULTS: We included 1464 people: 189 with cardiovascular disease, 197 with other chronic comorbidities, and 1078 low-risk people. At birth hospitalization admission, reliable contraception was planned among 42% of the cardiac cohort, 40% of the high-risk cohort, and 31% of the low-risk cohort, with similar distributions at the time of discharge and at 8 weeks postpartum.Compared with the cardiac cohort, by 8 weeks postpartum,the high-risk cohort had similar odds of using highly reliable forms of contraception (39% vs 36%; adjusted odds ratio, 0.78; 95% confidence interval, 0.50-1.21) and similar odds of having a plan to use the most reliable forms of contraception (intrauterine device, implant, bilateral tubal ligation) at the time of birthing admission (42% vs 40%; adjusted odds ratio, 0.78; 95% confidence interval, 0.50-1.22), discharge (47% vs 45%; adjusted odds ratio, 0.95; 95% confidence interval, 0.61-1.48), and postpartum visit (35% vs 29%; adjusted odds ratio, 0.76; 95% confidence interval, 0.49-1.17).The low-risk cohort had lower odds of using a reliable form of contraception (39% vs 27%; adjusted odds ratio, 0.53; 95% confidence interval, 0.37-0.75) and was less likely to have a plan for reliable contraception at the time of birthing admission (42% vs 31%; adjusted odds ratio, 0.54; 95% confidence interval, 0.38-0.76), discharge (47% vs 33%; adjusted odds ratio, 0.58; 95% confidence interval, 0.4-0.82), and postpartum visit (35% vs 21%; adjusted odds ratio, 0.50; 95% confidence interval, 0.35-0.71).CONCLUSION: People with cardiovascular disease cared for by a Pregnancy Heart Team had higher odds of reliable postpartum contraception planning and uptake compared with a low-risk cohort and similar odds compared with a high-risk cohort. Pregnancy could serve as a critical period for contraception counseling and family planning among people with cardiovascular disease. A multidisciplinary team should be used to address postpartum contraception as a modifiable risk factor to reduce maternal morbidity and mortality among those with cardiovascular disease.

  View details for DOI 10.1016/j.xagr.2022.100100

  View details for PubMedID 36536840

• Early postpartum readmissions: identifying risk factors at birth hospitalization. AJOG global reports Girsen, A. I., Leonard, S. A., Butwick, A. J., Joudi, N., Carmichael, S. L., Gibbs, R. S. 2022; 2 (4): 100094

  Abstract

  BACKGROUND: The high maternal mortality and severe morbidity rates in the United States compared with other high-income countries have received national attention. Characterization of postpartum hospital readmissions within the first days after delivery hospitalization discharge could help to identify patients who need additional preparedness for discharge.OBJECTIVE: This study aimed to investigate conditions at birth associated with postpartum readmissions occurring within 0 to 6 days and at 7 to 29 days after discharge from the delivery hospitalization.STUDY DESIGN: We analyzed linked vital statistics and hospital discharge records of patients who gave birth in California during 2007 to 2018. We investigated hospital readmissions within 30 days after birth hospitalization discharge. We used multivariable logistic regression to investigate factors associated with early readmission (0-6 days) and later readmission (7-29 days) compared with no readmission within 30 days (reference). The risk factors assessed included maternal medical or obstetrical conditions before and at birth, birth hospitalization length of stay, and mode of delivery. Severe maternal morbidity was defined as the presence of any of the 21 indicators recommended by the Centers for Disease Control and Prevention.RESULTS: Among 5,248,746 pregnant patients, 23,636 (0.45%) had an early postpartum readmission, whereas 24,712 (0.47%) had a later postpartum readmission. After adjustments, early readmission was most strongly associated with sepsis (adjusted odds ratio, 4.63; 95% confidence interval, 3.87-5.53), severe maternal morbidity (adjusted odds ratio, 3.46; 95% confidence interval, 3.28-3.65) at birth hospitalization, or preeclampsia before birth hospitalization (adjusted odds ratio, 3.67; 95% confidence interval, 3.54-3.81). The associations between later readmission and sepsis and severe maternal morbidity were similar, whereas the association between preeclampsia and later readmission was less strong (adjusted odds ratio, 1.65; 95% confidence interval, 1.57-1.73).CONCLUSION: Pregnant patients with sepsis or severe maternal morbidity during delivery hospitalization or preeclampsia before birth hospitalization were at the highest risk for readmission within 6 days of discharge. These findings may be informative for efforts to improve postpartum care.

  View details for DOI 10.1016/j.xagr.2022.100094

  View details for PubMedID 36536841

• Effect of gestational age at first delivery and interpregnancy interval on the recurrence of clinical chorioamnionitis. AJOG global reports Sperling, M. M., Sie, L., Leonard, S. A., Girsen, A. I., Lee, H. C., Gibbs, R. S. 2022; 2 (4): 100116

  Abstract

  There is an increased odds of having a recurrence of clinical chorioamnionitis in patients with a diagnosis of clinical chorioamnionitis compared with those without clinical chorioamnionitis in a previous pregnancy. However, it is unclear how gestational age at delivery of the first pregnancy or interpregnancy interval may contribute to this increased risk.This study aimed to evaluate how gestational age of delivery in a first pregnancy and interpregnancy interval affect the odds of recurrent clinical chorioamnionitis.Using maternally linked birth record files, Nulliparous patients from California with at least 2 consecutive deliveries between the gestational ages of 20 and 44 weeks from 2007 to 2012 were identified. The rates of clinical chorioamnionitis in the second pregnancy for patients with clinical chorioamnionitis vs those without clinical chorioamnionitis in the first pregnancy, stratified by the gestational age at delivery of the first pregnancy were determined. As a secondary analysis, the analysis by interpregnancy interval (<18 months vs ≥18 months) was stratified. Corresponding crude and adjusted odds ratios for each stratum were calculated to assess the association of clinical chorioamnionitis in the first and second pregnancies.Among 31,571 nulliparous patients with clinical chorioamnionitis in the first pregnancy, the frequency of clinical chorioamnionitis in the next pregnancy was 4.0% (1257 cases). This was in comparison with the 1.0% (9177 of 896,154) of nulliparous patients without clinical chorioamnionitis in the first pregnancy who were diagnosed with clinical chorioamnionitis in the next pregnancy (adjusted odds ratio, 2.78; 95% confidence interval, 2.61-2.96). The absolute frequency of recurrence was the highest (54 cases [8.2%]) in those who delivered at 20 to 24 weeks of gestation in the first pregnancy with the diagnosis of clinical chorioamnionitis (adjusted odds ratio, 1.76; 95% confidence interval, 1.25-2.48). For pregnancies delivered at term in the first pregnancy, the frequency of clinical chorioamnionitis in the next pregnancy was higher in those diagnosed with clinical chorioamnionitis in the first pregnancy than in those without clinical chorioamnionitis in the first pregnancy (4.0% vs 1.0%; adjusted odds ratio, 2.85; 95% confidence interval, 2.66-3.05). An interpregnancy interval of <18 months was not associated with increased odds of recurrent clinical chorioamnionitis.The odds of recurrence of clinical chorioamnionitis were the strongest when a patient delivered in the term to postterm period in the first pregnancy, with the absolute risk being the highest when the first pregnancy was delivered in the periviable period (20-24 weeks of gestation). The interpregnancy interval did not seem to modify the risk of recurrent clinical chorioamnionitis.

  View details for DOI 10.1016/j.xagr.2022.100116

  View details for PubMedID 36316994

  View details for PubMedCentralID PMC9617201

• Postpartum Readmission for Hypertension After Discharge on Labetalol or Nifedipine. Obstetrics and gynecology Do, S. C., Leonard, S. A., Kan, P., Panelli, D. M., Girsen, A. I., Lyell, D. J., El-Sayed, Y. Y., Druzin, M. L., Herrero, T. 2022

  Abstract

  To assess whether readmission for hypertension by 6 weeks postpartum differed between patients discharged on nifedipine or labetalol.This cohort study included patients with delivery admissions from 2006 to 2017 who were discharged from the hospital on nifedipine or labetalol and were included in a large, national adjudicated claims database. We identified patients' discharge medication based on filled outpatient prescriptions. We compared rates of hospital readmission for hypertension between patients discharged postpartum on labetalol alone, nifedipine alone, or combined nifedipine and labetalol. Patients with chronic hypertension without superimposed preeclampsia were excluded. Comparisons based on medication were performed using logistic regression models with adjustment for prespecified confounders. Comparisons were also stratified by hypertensive disorder of pregnancy severity.Among 1,582,335 patients overall, 14,112 (0.89%) were discharged postpartum on labetalol, 9,001 (0.57%) on nifedipine, and 1,364 (0.09%) on both medications. Postpartum readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine (641 patients vs 185 patients, 4.5% vs 2.1%, adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine for both mild (4.5% vs 2.7%, aOR 1.57, 95% CI 1.29-1.93) and severe hypertensive disorders of pregnancy (261 patients vs 72 patients, 5.7% vs 3.2%, aOR 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent on combined nifedipine and labetalol compared with nifedipine (3.1% vs 2.1%), but the odds were lower after confounder adjustment (aOR 0.80, 95% CI 0.64-0.99).Postpartum discharge on labetalol was associated with increased risk of readmission for hypertension compared with discharge on nifedipine.

  View details for DOI 10.1097/AOG.0000000000004918

  View details for PubMedID 36075068

• Risk of Adverse Pregnancy Outcomes Among US Individuals With Gestational Diabetes by Race and Ethnicity. JAMA Gemmill, A., Leonard, S. A. 2022; 328 (4): 397

  View details for DOI 10.1001/jama.2022.9412

  View details for PubMedID 35881129

• Risk of Adverse Pregnancy Outcomes Among US Individuals With Gestational Diabetes by Race and Ethnicity JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Gemmill, A., Leonard, S. A. 2022; 328 (4): 397

  View details for Web of Science ID 000839108600023

• HMOX1 Genetic Polymorphisms Display Ancestral Diversity and May Be Linked to Hypertensive Disorders in Pregnancy. Reproductive sciences (Thousand Oaks, Calif.) Sun, T., Cruz, G. I., Mousavi, N., Maric, I., Brewer, A., Wong, R. J., Aghaeepour, N., Sayed, N., Wu, J. C., Stevenson, D. K., Leonard, S. A., Gymrek, M., Winn, V. D. 2022

  Abstract

  Racial disparity exists for hypertensive disorders in pregnancy (HDP), which leads to disparate morbidity and mortality worldwide. The enzyme heme oxygenase-1 (HO-1) is encoded by HMOX1, which has genetic polymorphisms in its regulatory region that impact its expression and activity and have been associated with various diseases. However, studies of these genetic variants in HDP have been limited. The objective of this study was to examine HMOX1 as a potential genetic contributor of ancestral disparity seen in HDP. First, the 1000 Genomes Project (1KG) phase 3 was utilized to compare the frequencies of alleles, genotypes, and estimated haplotypes of guanidine thymidine repeats (GTn; containing rs3074372) and A/T SNP (rs2071746) among females from five ancestral populations (Africa, theAmericas, Europe, East Asia, and South Asia, N=1271). Then, using genomic DNA from women with a history of HDP, we explored the possibility of HMOX1 variants predisposing women to HDP (N=178) compared with an equivalent ancestral group from 1KG (N=263). Both HMOX1 variants were distributed differently across ancestries, with African women having a distinct distribution and an overall higher prevalence of the variants previously associated with lower HO-1 expression. The two HMOX1 variants display linkage disequilibrium in all but the African group, and within EUR cohort, LL and AA individuals have a higher prevalence in HDP. HMOX1 variants demonstrate ancestral differences that may contribute to racial disparity in HDP. Understanding maternal genetic contribution to HDP will help improve prediction and facilitate personalized approaches to care for HDP.

  View details for DOI 10.1007/s43032-022-01001-1

  View details for PubMedID 35697922

• Leukocyte telomere dynamics across gestation in uncomplicated pregnancies and associations with stress. BMC pregnancy and childbirth Panelli, D. M., Leonard, S. A., Wong, R. J., Becker, M., Mayo, J. A., Wu, E., Girsen, A. I., Gotlib, I. H., Aghaeepour, N., Druzin, M. L., Shaw, G. M., Stevenson, D. K., Bianco, K. 2022; 22 (1): 381

  Abstract

  Short leukocyte telomere length is a biomarker associated with stress and morbidity in non-pregnant adults. Little is known, however, about maternal telomere dynamics in pregnancy. To address this, we examined changes in maternal leukocyte telomere length (LTL) during uncomplicated pregnancies and explored correlations with perceived stress.In this pilot study, maternal LTL was measured in blood collected from nulliparas who delivered live, term, singleton infants between 2012 and 2018 at a single institution. Participants were excluded if they had diabetes or hypertensive disease. Samples were collected over the course of pregnancy and divided into three time periods: < 200/7 weeks (Timepoint 1); 201/7 to 366/7 weeks (Timepoint 2); and 370/7 to 9-weeks postpartum (Timepoint 3). All participants also completed a survey assessing a multivariate profile of perceived stress at the time of enrollment in the first trimester. LTL was measured using quantitative polymerase chain reaction (PCR). Wilcoxon signed-rank tests were used to compare LTL differences within participants across all timepoint intervals. To determine whether mode of delivery affected LTL, we compared postpartum Timepoint 3 LTLs between participants who had vaginal versus cesarean birth. Secondarily, we evaluated the association of the assessed multivariate stress profile and LTL using machine learning analysis.A total of 115 samples from 46 patients were analyzed. LTL (mean ± SD), expressed as telomere to single copy gene (T/S) ratios, were: 1.15 ± 0.26, 1.13 ± 0.23, and 1.07 ± 0.21 for Timepoints 1, 2, and 3, respectively. There were no significant differences in LTL between Timepoints 1 and 2 (LTL T/S change - 0.03 ± 0.26, p = 0.39); 2 and 3 (- 0.07 ± 0.29, p = 0.38) or Timepoints 1 and 3 (- 0.07 ± 0.21, p = 0.06). Participants who underwent cesareans had significantly shorter postpartum LTLs than those who delivered vaginally (T/S ratio: 0.94 ± 0.12 cesarean versus 1.12 ± 0.21 vaginal, p = 0.01). In secondary analysis, poor sleep quality was the main stress construct associated with shorter Timepoint 1 LTLs (p = 0.02) and shorter mean LTLs (p = 0.03).In this cohort of healthy pregnancies, maternal LTLs did not significantly change across gestation and postpartum LTLs were shorter after cesarean than after vaginal birth. Significant associations between sleep quality and short LTLs warrant further investigation.

  View details for DOI 10.1186/s12884-022-04693-0

  View details for PubMedID 35501726

• Constructing a Pregnancy Loss Cohort From Electronic Health Records Callahan, A., Leonard, S., Druzin, M., Lathi, R. B., Murugappan, G. LIPPINCOTT WILLIAMS & WILKINS. 2022: 95S

  View details for Web of Science ID 000811070700328

• Sexual and/or Gender Minority Parental Structures among California Births, 2016-2020. American journal of obstetrics & gynecology MFM Berrahou, I. K., Leonard, S. A., Zhang, A., Main, E. K., Obedin-Maliver, J. 2022: 100653

  Abstract

  BACKGROUND: Sexual and/or gender minority (SGM) people account for roughly 7.1% of the U.S. population, and an estimated one-third are parents. Little is known about SGM people who become pregnant, despite this population having documented health care disparities that may impact pregnancy.OBJECTIVES: Our objective was to describe parental structures among birth parents and the pre-pregnancy characteristics of parents giving birth in likely sexual and/or gender minority (SGM) parental structures from California birth certificates.STUDY DESIGN: We conducted a population-based study using birth certificate data from all live births in California from 2016 through 2020 (n = 2,257,974). The state amended its birth certificate in 2016 to enable the recording of more diverse parental roles. Now, parents on birth certificates are classified as "parent giving birth" and "parent not giving birth" and people in either role can identify as "mother," "father," or "parent." We examined all potential combinations of parenting roles and grouped parental structures of "mother-mother" and all structures designating a "father" as the "parent giving birth" into likely SGM groups. We assessed the distribution of pre-pregnancy characteristics across parental structure groups ("mother-father," "SGM," "mother only," "unclassified," and "missing both parental roles").RESULTS: SGM parents accounted for 6,802 (0.3%) of live births in California over the 5-year study period. The most common SGM parental structures were "mother-mother" (n=4,310; 63% of the group) and "father-father" (n=1,486; 22% of the group). Compared with "parents giving birth" in the "mother-father" structure (n=2,055,038; 91%), a higher proportion of "parents giving birth" in the "SGM" group were 35 years or older, white, college-educated, and had commercial health insurance. In addition, a higher proportion had a high pre-pregnancy body mass index. Although likely underreported overall, the proportion who used assisted reproductive technology was much higher among those in the "SGM" group (1.4%) than in the "mother-father" group (0.05%). Cigarette smoking in the three months prior to pregnancy was similar in both groups.CONCLUSION: Changes to the California birth certificate have revealed a multiplicity of parental structures. Our findings suggest that SGM parents differ from other parental structures and from the general SGM population and warrant further research.

  View details for DOI 10.1016/j.ajogmf.2022.100653

  View details for PubMedID 35462057

• Association of infertility with atherosclerotic cardiovascular disease among postmenopausal participants in the Women's Health Initiative. Fertility and sterility Murugappan, G., Leonard, S. A., Farland, L. V., Lau, E. S., Shadyab, A. H., Wild, R. A., Schnatz, P., Carmichael, S. L., Stefanick, M. L., Parikh, N. I. 2022

  Abstract

  OBJECTIVE: To investigate the association of infertility with atherosclerotic cardiovascular disease (ASCVD) among postmenopausal participants in the Women's Health Initiative (WHI). We hypothesized that nulliparity and pregnancy loss may reveal more extreme phenotypes of infertility, enabling further understanding of the association of infertility with ASCVD.DESIGN: Prospective cohort study.SETTING: Forty clinical centers in the United States.PATIENT(S): A total of 158,787 postmenopausal participants in the Women's Health Initiative cohort.INTERVENTION(S): Infertility, parity, and pregnancy loss.MAIN OUTCOME MEASURE(S): The primary outcome was risk of ASCVD among women with and without a history of infertility, stratified by history of live birth and pregnancy loss. Cox proportional-hazards models were adjusted for demographics and risk factors for ASCVD.RESULT(S): Among 158,787 women, 25,933 (16.3%) reported a history of infertility; 20,427 (80%) had at least 1 live birth; and 9,062 (35%) had at least 1 pregnancy loss. There was a moderate overall association between infertility and ASCVD (adjusted hazard ratio, 1.02; 95% confidence interval [CI], 0.99-1.06) over 19 years of follow-up. Among nulliparous women, infertility was associated with a 13% higher risk of ASCVD (95% CI, 1.04-1.23). Among nulliparous women who had a pregnancy loss, infertility was associated with a 36% higher risk of ASCVD (95% CI, 1.09-1.71).CONCLUSION(S): Women with a history of infertility overall had a moderately higher risk of ASCVD compared with women without a history of infertility. Atherosclerotic cardiovascular disease risk was much higher among nulliparous infertile women and among nulliparous infertile women who also had a pregnancy loss, suggesting that in these more extreme phenotypes, infertility may be associated with ASCVD risk.

  View details for DOI 10.1016/j.fertnstert.2022.02.005

  View details for PubMedID 35305814

• Clinical and Hospital Factors Associated with Increased Cesarean Birth Rate Among People with Epilepsy Darmawan, K., Cruz, G., Leonard, S., Meador, K., McElrath, T., Carmichael, S., Lyell, D., El Sayed, Y., Herrero, T., Druzin, M., Panelli, D. SPRINGER HEIDELBERG. 2022: 216

  View details for Web of Science ID 000762765300443

• Cellular Aging and Stress in Pregnant and Non-Pregnant People During the COVID-19 Pandemic Panelli, D., Diwan, M., Cruz, G. I., Leonard, S. A., Chueh, J., Gotlib, I. H., Bianco, K. SPRINGER HEIDELBERG. 2022: 191

  View details for Web of Science ID 000762765300376

• Leukocyte Telomere Length in the First Trimester of Pregnancy and its Association with Perinatal Outcomes Panelli, D., Diwan, M., Cruz, G. I., Leonard, S. A., Chueh, J., Gotlib, I. H., Bianco, K. SPRINGER HEIDELBERG. 2022: 155

  View details for Web of Science ID 000762765300282

• The effect of severe maternal morbidity on infant costs and lengths of stay. Journal of perinatology : official journal of the California Perinatal Association Phibbs, C. M., Kozhimannil, K. B., Leonard, S. A., Lorch, S. A., Main, E. K., Schmitt, S. K., Phibbs, C. S. 2022

  Abstract

  OBJECTIVE: To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity.STUDY DESIGN: Secondary data analysis using California linked birth certificate-patient discharge data for 2009-2011 (N=1,260,457). Regression models were used to estimate the association between SMM and infant costs and LOS.RESULTS: The 16,687 SMM-exposed infants experienced a $6550 (33%) increase in costs and a 0.7 (18%) day increase in LOS. Preterm infants had ($11,258 (18%) added costs and 1.3 days (8.1%) longer LOS) than term infants ($2539 (38%) added costs and 0.5 days (22%) longer LOS).CONCLUSIONS: SMM was associated with increased infant costs and LOS, suggesting that SMM may have adverse health effects for infants, including term infants. The relatively larger effect on costs indicates an increase in treatment intensity (clinical severity) greater than additional LOS.

  View details for DOI 10.1038/s41372-022-01343-3

  View details for PubMedID 35184145

• Interpregnancy Weight Change: Associations with Severe Maternal Morbidity and Neonatal Outcomes. American journal of obstetrics & gynecology MFM Abrams, B. F., Leonard, S. A., Kan, P., Lyell, D. J., Carmichael, S. L. 2022: 100596

  Abstract

  INTRODUCTION: Prepregnancy body mass index (BMI) and gestational weight gain have been linked with severe maternal morbidity (SMM), suggesting that weight change between pregnancies may also play a role, as it does for neonatal outcomes. We assessed the association of changes in prepregnancy BMI between two consecutive singleton pregnancies with the outcomes of SMM, stillbirth, small for gestational age (SGA) and large for gestational age (LGA) in the subsequent pregnancy.METHODS: This observational study was based on birth records from 1,111,032 consecutive pregnancies linked to hospital discharge records in California (2007-2017). Interpregnancy BMI change between the beginning of an index pregnancy and the beginning of the subsequent pregnancy was calculated from self-reported weight and height. SMM was defined based on the CDC index, including and excluding transfusion-only cases. We used multivariable log-binomial regression models to estimate adjusted risks, overall and stratified by prepregnancy BMI at index birth.RESULTS: Substantial interpregnancy BMI gain (≥4 kg/m2) was associated with SMM in crude but not adjusted analyses. Substantial interpregnancy BMI loss (>2 kg/m2) was associated with increased risk of SMM (adjusted relative risk (aRR) 1.13, 95% CI (1.07-1.19), and both substantial loss (aRR 1.11 (1.02-1.19)) and gain (≥4 kg/m2; aRR 1.09 (1.02-1.17)) were associated with non-transfusion SMM. Substantial loss (aRR 1.17 (1.05-1.31)) and gain (1.26 (1.14-1.40)) were associated with stillbirth. BMI gain was positively associated with LGA, and inversely associated with SGA.CONCLUSIONS: Substantial interpregnancy BMI changes were associated with modestly increased risk of SMM, stillbirth, SGA and LGA.

  View details for DOI 10.1016/j.ajogmf.2022.100596

  View details for PubMedID 35181513

• A Comprehensive Analysis of the Costs of Severe Maternal Morbidity. Women's health issues : official publication of the Jacobs Institute of Women's Health Phibbs, C. M., Kozhimannil, K. B., Leonard, S. A., Lorch, S. A., Main, E. K., Schmitt, S. K., Phibbs, C. S. 1800

  Abstract

  INTRODUCTION: The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases.METHODS: California linked birth certificate-patient discharge data for 2009 through 2011 (n=1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS.RESULTS: Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME], $3,550) and a 33% increase in LOS (ME 0.9days). These increased to 70% (ME $5,806) and 46% (ME 1.3days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7days]).CONCLUSIONS: Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.

  View details for DOI 10.1016/j.whi.2021.12.006

  View details for PubMedID 35031196

• Fasting vs fed: A randomized trial assessing oral intake prior to the glucose tolerance test Sperling, M., Leonard, S. A., Miller, S. E., El Sayed, Y. Y., Herrero, T., Faig, J., Carter, S., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2022: S189

  View details for Web of Science ID 000737459400263

• Clinical factors associated with a positive postpartum depression screen in people with cardiac disease during pregnancy. Current research in psychiatry Panelli, D. M., Sherwin, E. B., Lee, C. J., Leonard, S. A., Miller, S. E., Miller, H. E., Tolani, A. T., Hoover, V., Ansari, J. R., Khandelwal, A., Bianco, K. 2022; 2 (2): 25-29

  Abstract

  Background: While people with cardiac disease are known to be at increased lifetime risk of depression, little is known about postpartum depression rates in this population. Describing rates of positive postpartum depression screens and identifying risk factors that are unique to cardiac patients may help inform risk reduction strategies.Methods: This retrospective cohort study included pregnant patients with congenital and/or acquired cardiac disease who delivered at a single institution between 2014 and 2020. The primary outcome was a positive postpartum depression screen, defined as Edinburgh Postpartum Depression Score (EPDS) ≥10. Potential exposures were selected a priori and compared between patients with and without a positive postpartum depression screen using Wilcoxon rank-sum and Fisher's exact tests. Secondary outcomes were responses to a longitudinal follow-up survey sent to English-speaking patients evaluating cardiac status, mental health, and infant development.Results: Of 126 eligible cardiac patients, 23 (18.3%) had a positive postpartum depression screen. Patients with a positive postpartum depression screen were more likely to have had antepartum anticoagulation with heparin or enoxaparin (56.5% versus 26.2%, p=0.007), blood transfusion during delivery (8.7% versus 0%, p=0.032), and maternal-infant separation postpartum (52.2% versus 28.2%, p=0.047) compared to patients with a negative screen. Among 29 patients with a positive screen who responded to the follow up survey, 50% reported being formally diagnosed with anxiety or depression and 33.3% reported child development problems.Conclusions: Our results highlight the importance of screening for postpartum depression in patients with cardiac disease, especially those requiring antepartum anticoagulation or maternal-infant separation postpartum.

  View details for DOI 10.46439/Psychiatry.2.027

  View details for PubMedID 36570491

• Association of Neighborhood Income with Clinical Outcomes Among Pregnant Patients with Cardiac Disease Reproductive Sciences Carland, C., Panelli, D. M., Leonard, S. A., Bryant, E., Sherwin , E. B., Lee, C. J., Levin, E., Jimenez , S., Tremmel, J. A., Tsai , S., Heidenreich , P. A., Bianco , K., Khandelwal , A. 2022

  View details for DOI 10.1007/s43032-022-00978-z

• Constructing a cohort of nulliparous, term, singleton, vertex births from electronic health records Callahan, A., Murugappan, G., Main, E. K., Leonard, S. A. MOSBY-ELSEVIER. 2022: S521-S522

  View details for Web of Science ID 000737459401168

• Health Disparities in Antepartum Anemia: The Intersection of Race and Social Determinants of Health Igbinosa, I., Leonard, S. A., Noelette, F., Mujahid, M., Main, E. K., Lyell, D. J. MOSBY-ELSEVIER. 2022: S529-S530

  View details for Web of Science ID 000737459401182

• Provider utilization of gestational diabetes screening methods - Have practices changed since the HAPO trial? Miller, S. E., Sperling, M., Cruz, G., Schulkin, J., Leonard, S. A., Lyell, D. J., Herrero, T., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2022: S483-S484

  View details for Web of Science ID 000737459401108

• To Eat or not to Eat? Provider Recommendations Surrounding Oral Intake Before the 50g OGTT Miller, S. E., Sperling, M., Cruz, G., Schulkin, J., Leonard, S. A., Lyell, D. J., Herrero, T., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2022: S350-S351

  View details for Web of Science ID 000737459400522

• Hospital Readmissions after Postpartum Emergency Department Visit Girsen, A., Leonard, S. A., Carmichael, S. L., Gibbs, R. S., Butwick, A. MOSBY-ELSEVIER. 2022: S517-S518

  View details for Web of Science ID 000737459401161

• Obstetric ultrasound (US) quality improvement initiative: Long-term results of a quality assurance protocol Joudi, N., Leonard, S. A., Pugh, B., Chueh, J., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2022: S554-S555

  View details for Web of Science ID 000737459401226

• Validation of ICD-10-CM Diagnosis Codes for Gestational Age at Birth Leonard, S. A., Gould, J. B., Main, E. K. MOSBY-ELSEVIER. 2022: S429

  View details for Web of Science ID 000737459401022

• Does magnesium sulfate for hypertensive disease reduce the risk of neonatal hypoxic ischemic encephalopathy? Minor, K. C., Liu, J., El-Sayed, Y. Y., Druzin, M. L., Profit, J., Hintz, S., Bonifacio, S., Leonard, S. A., Karakash, S. MOSBY-ELSEVIER. 2022: S526

  View details for Web of Science ID 000737459401175

• Patient preferences, beliefs, and experiences regarding oral intake and the 1-hour oral glucose tolerance test Sperling, M., Leonard, S. A., Miller, S. E., El-Sayed, Y. Y., Herrero, T., Faig, J., Carter, S., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2022: S325-S326

  View details for Web of Science ID 000737459400479

• Ketonuria is associated with a positive 1-hour oral glucose tolerance test Sperling, M., Leonard, S. A., Miller, S. E., El-Sayed, Y. Y., Herrero, T., Faig, J., Carter, S., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2022: S574-S575

  View details for Web of Science ID 000737459401259

• Birth registration policies in the United States and their relevance to sexual and/or gender minority families: Identifying existing strengths and areas of improvement. Social science & medicine (1982) Zhang, A., Berrahou, I., Leonard, S. A., Main, E. K., Obedin-Maliver, J. 1800; 293: 114633

  Abstract

  Birth certificates are some of the most critical identity documents available to current residents of the United States, yet sexual and gender minority (SGM) parents frequently face barriers in obtaining accurate documents for their children. It is essential for SGM parents to have accurate birth certificates for their children at the time of birth registration so that they do not experience undue burden in raising their children and establishing their status as legal parents. In this analysis, we focused on the birth registration process in the US as they apply to SGM family-building and the assignation of parentage on birth certificates at the time of a child's birth. We utilized keyword-based search criteria to identify, collect, and tabulate official state policies related to birth registration. Birth registration policies rely on gendered, heteronormative assumptions about the sex and gender of a child's parents in all but three states when identifying the birthing person and in all but eight states when identifying the non-birthing person. We found additional barriers for SGM parents who give birth outside of a marriage or legal union. These barriers leave SGM parents particularly vulnerable to inaccuracies on their children's identity documents and incomplete recognition of their parental roles and rights. Existing birth registration policies also do little to ensure the inclusion of diverse family structures in administrative data collection. There are many ways to modify existing birth registration policies and enhance the inclusion of SGM parents within governmental administrative structures. We conclude with suggestions to improve upon existing birth registration systems by de-linking parental sex and gender from birthing role, parental role, and contribution to the pregnancy.

  View details for DOI 10.1016/j.socscimed.2021.114633

  View details for PubMedID 34933243

• Association of Epilepsy and Severe Maternal Morbidity. Obstetrics and gynecology Panelli, D. M., Leonard, S. A., Kan, P., Meador, K. J., McElrath, T. F., Darmawan, K. F., Carmichael, S. L., Lyell, D. J., El-Sayed, Y. Y., Druzin, M. L., Herrero, T. C. 2021

  Abstract

  OBJECTIVE: To evaluate severe maternal morbidity (SMM) among patients with epilepsy and patients without epilepsy.METHODS: We retrospectively examined SMM using linked birth certificate and maternal hospital discharge records in California between 2007 and 2012. Epilepsy present at delivery admission was the exposure and was subtyped into generalized, focal and other less specified, or unspecified. The outcomes were SMM and nontransfusion SMM from delivery up to 42 days' postpartum, identified using Centers for Disease Control and Prevention indicators. Multivariable logistic regression models were used to adjust for confounders, which were selected a priori. We also estimated the association between epilepsy and SMM independent of comorbidities by using a validated obstetric comorbidity score. Severe maternal morbidity indicators were then compared using the same multivariable logistic regression models.RESULTS: Of 2,668,442 births, 8,145 (0.3%) were to patients with epilepsy; 637 (7.8%) had generalized, 6,250 (76.7%) had focal or other less specified, and 1,258 (15.4%) had unspecified subtypes. Compared with patients without epilepsy, patients with epilepsy had greater odds of SMM (4.3% vs 1.4%, adjusted odds ratio [aOR] 2.91, 95% CI 2.61-3.24) and nontransfusion SMM (2.9% vs 0.7%, aOR 4.16, 95% CI 3.65-4.75). Epilepsy remained significantly associated with increased SMM and nontransfusion SMM after additional adjustment for the obstetric comorbidity score, though the effects were attenuated. When grouped by organ system, all SMM indicators were significantly more common among patients with epilepsy-most notably those related to hemorrhage and transfusion.CONCLUSION: Severe maternal morbidity was significantly increased in patients with epilepsy, and SMM indicators across all organ systems contributed to this.

  View details for DOI 10.1097/AOG.0000000000004562

  View details for PubMedID 34619720

• INFERTILITY AND RISK OF CARDIOVASCULAR DISEASE AMONG POSTMENOPAUSAL PARTICIPANTS IN THE WOMEN'S HEALTH INITIATIVE. Murugappan, G., Leonard, S. A., Carmichael, S. L., Stefanick, M. L., Parikh, N. I. ELSEVIER SCIENCE INC. 2021: E15

  View details for Web of Science ID 000699951500035

• The impact of the COVID-19 pandemic on postpartum contraception planning AMERICAN JOURNAL OF OBSTETRICS & GYNECOLOGY MFM Miller, H. E., Henkel, A., Leonard, S. A., Miller, S. E., Tran, L., Bianco, K., Shaw, K. A. 2021; 3 (5)

  View details for Web of Science ID 000711236400041

• Homelessness in pregnancy: perinatal outcomes. Journal of perinatology : official journal of the California Perinatal Association St Martin, B. S., Spiegel, A. M., Sie, L., Leonard, S. A., Seidman, D., Girsen, A. I., Shaw, G. M., El-Sayed, Y. Y. 2021

  Abstract

  OBJECTIVE: Investigate the association between maternal homelessness at the time of delivery and perinatal outcomes, with a focus on neonatal health outcomes.STUDY DESIGN: Population-based cohort using California's statewide database included 1,520,253 women with linked birth and maternal discharge data, 2008-2012. Multivariable analysis assessed homelessness at time of delivery on perinatal outcomes, preterm delivery, and neonatal intensive care unit admission.RESULT: A total of 672 women (0.05%) were homeless at the time of delivery. Homelessness was associated with premature delivery at multiple gestational age cutoffs (34w0d-36w6d; 32w0d-33w6d; 28w0d-31w6d; <28w0d) (range of aORs:1.62-2.19), and neonatal intensive care unit admission (aOR=1.66, 95% CI:1.31-2.09). Among term infants, homelessness remained associated with increased odds of neonatal intensive care unit admission (aOR=1.84, 95% CI:1.34-2.53), low birthweight (aOR=1.99, 95% CI:1.36-2.90), neonatal abstinence syndrome (aOR=2.13, 95% CI:1.35-2.53), hypoxic-ischemic encephalopathy (aOR=14.38, 95% CI:3.90-53.01), and necrotizing enterocolitis (aOR=14.94, 95% CI:2.68-83.20).CONCLUSION: Homelessness in pregnancy was associated with adverse perinatal outcomes including increased odds of preterm delivery across all gestational ages, and increased risk of neonatal intensive care unit admission and low birth weight independent of preterm delivery.

  View details for DOI 10.1038/s41372-021-01187-3

  View details for PubMedID 34404925

• Myocardial Bridge in Pregnancy: Beyond a 'Normal Anatomic Variant'. Joudi, N., Datoc, I., Leonard, S., Lee, C., Schnittger, I., Khandelwal, A., Bianco, K. SPRINGER HEIDELBERG. 2021: 267A

  View details for Web of Science ID 000675441000561

• A COST-EFFECTIVENESS ANALYSIS OF GESTATIONAL CARRIERS FOR INFERTILE WOMEN OF VERY ADVANCED MATERNAL AGE Bavan, B., Cheng, H., Phibbs, C., Leonard, S., Lyell, D., Murugappan, G. ELSEVIER SCIENCE INC. 2021: E43-E44

  View details for Web of Science ID 000680508800064

• Association of Preconception Paternal Health and Adverse Maternal Outcomes among Healthy Mothers. American journal of obstetrics & gynecology MFM Murugappan, G., Li, S., Leonard, S., Winnm, V. D., Druzin, M., Eisenberg, M. L. 2021: 100384

  Abstract

  OBJECTIVE: To examine the association of preconception paternal health and risk of adverse maternal outcomes among healthy mothers.STUDY DESIGN: Retrospective analysis of live births from 2009-2016 among healthy women 20-45 years of age in the IBM Marketscan research database. Infants were linked to paired mothers and fathers using family ID. Preconception paternal health was assessed using the number of metabolic syndrome (MetS) components and the most common individual chronic disease diagnoses (hypertension, diabetes mellitus, obesity, hyperlipidemia, COPD, cancer, and depression). Women with MetS components were excluded to avoid potential confounding of maternal and paternal factors. Adverse maternal outcomes assessed included: 1) abnormal placentation including placenta accreta spectrum, placenta previa and placental abruption 2) pre-eclampsia with and without severe features including eclampsia, and 3) severe maternal morbidity (SMM), identified as any indicator from the CDC Index of life-threatening complications at the time of delivery through 6 weeks postpartum. The trend between preconception paternal health and each maternal outcome was determined using the Cochran-Armitage Trend test. The independent association of paternal health and maternal outcomes was also determined using generalized estimating equations (GEE) models accounting for some mothers contributing multiple births and adjusting for maternal age, paternal age, region of birth, year of birth, maternal smoking, and average number of outpatient visits per year.RESULTS: Among 669,256 births to healthy mothers, there was a significant trend of all adverse maternal outcomes with worsening preconception paternal health defined either as number of MetS components or number of chronic diseases (p<0.001, Cochran-Armitage Trend test). In the GEE model, the odds of pre-eclampsia without severe features increased in a dose-dependent fashion and were 21% higher (95% CI 1.17-1.26) among women whose partners had ≥2 MetS than for women whose partners had 0 MetS. The odds of pre-eclampsia with severe features and eclampsia increased in a dose-dependent fashion and were 19% higher (95% CI 1.09-1.30) for women whose partners had ≥2 MetS than for women whose partners had 0 MetS. The odds of SMM were 9% higher (95% CI 1.002-1.19) for women whose partners had ≥2 MetS components than for women whose partners had 0 MetS. The odds of abnormal placentation was similar between groups (aOR 0.96, 95% CI 0.89-1.03).CONCLUSIONS: Among healthy mothers, we report preconception paternal health is significantly associated with increased odds of pre-eclampsia with and without severe features and weakly associated with odds of SMM. These findings suggest that paternally derived factors may play significant roles in the development of adverse maternal outcomes in healthy women with a low a priori risk of obstetric complications.

  View details for DOI 10.1016/j.ajogmf.2021.100384

  View details for PubMedID 33895399

• Karyotype of first clinical miscarriage and prognosis of subsequent pregnancy outcome. Reproductive biomedicine online Murugappan, G., Leonard, S. A., Newman, H., Shahine, L., Lathi, R. B. 2021

  Abstract

  RESEARCH QUESTION: Is the karyotype of the first clinical miscarriage in an infertile patient predictive of the outcome of the subsequent pregnancy?DESIGN: Retrospective cohort study of infertile patients undergoing manual vacuum aspiration with chromosome testing at the time of the first (index) clinical miscarriage with a genetic diagnosis and a subsequent pregnancy. Patients treated at two academic-affiliated fertility centres from 1999 to 2018 were included; those using preimplantation genetic testing for aneuploidy were excluded. Main outcome was live birth in the subsequent pregnancy.RESULTS: One hundred patients with euploid clinical miscarriage and 151 patients with aneuploid clinical miscarriage in the index pregnancy were included. Patients with euploid clinical miscarriage in the index pregnancy had a live birth rate of 63% in the subsequent pregnancy compared with 68% among patients with aneuploid clinical miscarriage (adjusted odds ratio [aOR] 0.75, 95% CI 0.47-1.39, P=0.45, logistic regression model adjusting for age, parity, body mass index and mode of conception). In a multinomial logistic regression model with three outcomes (live birth, clinical miscarriage or biochemical miscarriage), euploid clinical miscarriage for the index pregnancy was associated with similar odds of clinical miscarriage in the subsequent pregnancy compared with aneuploid clinical miscarriage for the index pregnancy (32% versus 24%, respectively, aOR 1.49, 95% CI 0.83-2.70, P=0.19). Euploid clinical miscarriage for the index pregnancy was not associated with likelihood of biochemical miscarriage in the subsequent pregnancy compared with aneuploid clinical miscarriage (5% versus 8%, respectively, aOR 0.46, 95% CI 0.14-1.55, P=0.21).CONCLUSION: Prognosis after a first clinical miscarriage among infertile patients is equally favourable among patients with euploid and aneuploid karyotype, and independent of the karyotype of the pregnancy loss.

  View details for DOI 10.1016/j.rbmo.2021.03.021

  View details for PubMedID 33962906

• Outcomes in pregnancies complicated by IUGR before 32 weeks: does the degree of SGA matter? Minor, K., Bianco, K., Sie, L., Druzin, M. L., Lee, H. C., Leonard, S. A. MOSBY-ELSEVIER. 2021: S519

  View details for Web of Science ID 000621547401378

• Vaginal breech delivery: maternal and neonatal outcomes Joudi, N., Panelli, D. M., Leonard, S. A., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2021: S211

  View details for Web of Science ID 000621547400320

• Inflammatory bowel disease and the impact on rates of chorioamnionitis, sepsis, and severe maternal morbidity Igbinosa, I., Trepman, P., Sie, L., Leonard, S. A., Herrero, T. MOSBY-ELSEVIER. 2021: S441–S442

  View details for Web of Science ID 000621547401249

• Perceived stress and spontaneous preterm birth in twin gestations Blumenfeld, Y. J., Leonard, S. A., Wilson, H. W., Girsen, A., Datoc, I., Lyell, D. J. MOSBY-ELSEVIER. 2021: S418–S419

  View details for Web of Science ID 000621547401212

• Positive predictive value of ICD-10 codes for placenta accreta syndrome: a single center validation study Jotwani, A. R., Leonard, S. A., Butwick, A., Lyell, D. J. MOSBY-ELSEVIER. 2021: S523–S524

  View details for Web of Science ID 000621547401386

• Prepregnancy body mass index and gestational diabetes mellitus across asian subpopulations Sperling, M., Leonard, S. A., Waldrop, A. R., Miller, S., Blumenfeld, Y. J., Carmichael, S., Chueh, J. MOSBY-ELSEVIER. 2021: S118–S119

  View details for Web of Science ID 000621547400177

• To pull or not to pull: clinical factors associated with failed operative vaginal delivery Panelli, D. M., Leonard, S. A., Joudi, N., Girsen, A., Judy, A., Bianco, K., El-Sayed, Y. Y., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2021: S101

  View details for Web of Science ID 000621547400148

• Association between paternal health and severe maternal morbidity: analysis of US claims data Murugappan, G., Li, S., Leonard, S. A., Druzin, M. L., Eisenberg, M. L. MOSBY-ELSEVIER. 2021: S117–S118

  View details for Web of Science ID 000621547400175

• Stimulant medications for attention deficit/hyperactivity disorder and maternal and neonatal outcomes Johnson, C., Kan, P., Leonard, S. A., Lee, H. C., Jacobs, L., Lyell, D. J. MOSBY-ELSEVIER. 2021: S615

  View details for Web of Science ID 000621547401536

• Severe maternal and neonatal morbidity after attempted operative vaginal delivery. American journal of obstetrics & gynecology MFM Panelli, D. M., Leonard, S. A., Joudi, N. n., Girsen, A. I., Judy, A. E., El-Sayed, Y. Y., Gilbert, W. M., Lyell, D. J. 2021: 100339

  Abstract

  Operative vaginal delivery (OVD) is a critical tool in reducing primary cesarean birth, but declining OVD rates and concerns about provider skill necessitate a clear understanding of risks. These risks are ambiguous because most studies compare outcomes with OVD to spontaneous vaginal delivery, rather than to second stage cesarean which is usually the realistic alternative.Our objective was to compare severe maternal and neonatal morbidity by mode of delivery among patients with a prolonged second stage of labor who had a successful OVD, a cesarean birth after failed OVD, or a cesarean birth without an OVD attempt.We used a population-based database to evaluate nulliparous, term, singleton, vertex livebirths in California between 2007 and 2012 among patients with a prolonged second stage of labor. Birth certificate and ICD-9-CM coded diagnoses and procedures were used for ascertainment of exposure, outcome, and demographics. Exposure was mode of delivery among patients who had any OVD attempt versus cesarean without OVD attempt. The outcomes were severe maternal morbidity (SMM) and severe unexpected newborn morbidity (UNM), defined using established indices. Anticipating that the code for prolonged second stage of labor would represent only a fraction of true OVD candidates, a secondary analysis was conducted removing this restriction in order to explore granular outcomes in a larger cohort with unsuccessful labor. Multivariable logistic regression was used to compare outcomes by mode of delivery adjusted for measured confounders. Sensitivity analyses were done excluding patients with combined vacuum-forceps and birthweight >4000g.9,239 prolonged second stage births were included; 6,851 (74.1%) were successful OVDs, 301 (3.3%) were failed OVDs, and 2,087 (22.6%) were cesareans without OVD attempts. Of successful OVDs, 6,195 (90.4%) were vacuums and 656 (10.6%) were forceps. Of failed OVDs where OVD type was specified, 83 (47.4%) were vacuums, 38 (21.7%) were forceps, and 54 (30.9%) were combined vacuum-forceps. Of note, all 54 combined vacuum-forceps OVD attempts that we identified failed. Patients with failed OVD differed from those with successful OVD, with higher rates of comorbidities, use of combined OVD, and birthweight >4000 g. Successful OVD was associated with reduced SMM (aOR 0.55, 95% CI 0.39-0.78) without a difference in severe UNM (aOR 0.99, 95% CI 0.78-1.26). In contrast, failed OVD was associated with increased SMM (aOR 2.14, 95% CI 1.20-3.82) and severe UNM (aOR 1.78, 95% CI 1.09-2.86). Findings were similar in secondary analysis of 260,585 patients with unsuccessful labor.In this large cohort of nulliparous, term, singleton, vertex births, successful OVD was associated with a 45% reduction in SMM without differences in severe UNM when compared to cesarean birth after prolonged second stage of labor. OVD failed infrequently, but when it did it was associated with a 214% increase in SMM and a 78% increase in severe UNM; combined OVDs were major contributors to this, since all combined OVDs failed. Optimization of OVD success rates through means such as improved patient selection, enhanced provider skill, and dissuasion against combined OVD could reduce maternal and neonatal complications.

  View details for DOI 10.1016/j.ajogmf.2021.100339

  View details for PubMedID 33631384

• The impact of the COVID-19 pandemic on postpartum contraception planning. American journal of obstetrics & gynecology MFM Miller, H. E., Henkel, A., Leonard, S. A., Miller, S. E., Tran, L., Bianco, K., Shaw, K. A. 2021: 100412

  View details for DOI 10.1016/j.ajogmf.2021.100412

  View details for PubMedID 34058421

• Lactate and Procalcitonin Levels in Peripartum Women with Intraamniotic Infection. American journal of obstetrics & gynecology MFM DO, S. C., Miller, H. n., Leonard, S. A., Datoc, I. A., Girsen, A. I., Kappagoda, S. n., Gibbs, R. S., Aziz, N. n. 2021: 100367

  Abstract

  Serum biomarkers are used to diagnose and manage severe infections, but data on their utility during labor are limited. We compared lactate and procalcitonin levels in women with and without intraamniotic infection to determine if they are useful biomarkers for infection during labor.We performed a prospective observational cohort study of term, singleton pregnancies admitted with planned vaginal delivery in 2019 at a university medical center. Lactate and procalcitonin levels were drawn in early labor, within 2 hours following delivery, and postpartum day 1. Women with intraamniotic infection additionally had lactate and procalcitonin levels drawn following intraamniotic infection diagnosis. Samples were processed immediately in the hospital clinical laboratory. Primary outcome was mean lactate level following delivery. Secondary outcomes were lactate and procalcitonin levels at other time points. Comparisons based on infection status were performed using multivariate linear regression.22 women with intraamniotic infection and 29 uninfected women were included. Early labor mean lactate level (1.47 vs 1.49 mmol/L) and mean procalcitonin level (0.048 vs 0.039 ng/mL) did not differ and were normal in uninfected and intraamniotic infection groups. Mean lactate level was highest following delivery for women in uninfected and intraamniotic infection groups (2.00 vs 2.33 mmol/L, adjusted p=0.08, 95% CI 0.98-1.53). Lactate level returned to normal by postpartum day 1 and did not significantly differ based on the infection status at any time point in adjusted models. Procalcitonin level following delivery was higher among women with intraamniotic infection versus without infection (0.142 vs 0.091 ng/mL, adjusted p=0.03). Procalcitonin level rose further in both intraamniotic infection and uninfected groups on postpartum day 1 (0.737 vs 0.408 ng/mL, adjusted p=0.05).Lactate level is not significantly elevated in intraamniotic infection above the physiologic increase at delivery observed in women without infection. Procalcitonin level is elevated at delivery in women with intraamniotic infection and warrants further investigation as a peripartum infection marker.

  View details for DOI 10.1016/j.ajogmf.2021.100367

  View details for PubMedID 33831586

• Association of Maternal Comorbidity With Severe Maternal Morbidity: A Cohort Study of California Mothers Delivering Between 1997 and 2014. Annals of internal medicine Main, E. K., Leonard, S. A., Menard, M. K. 2020; 173 (11_Supplement): S11–S18

  Abstract

  BACKGROUND: Rates of maternal mortality and severe maternal morbidity (SMM) are higher in the United States than in other high-resource countries and are increasing further.OBJECTIVE: To examine the association of maternal comorbid conditions, age, body mass index, and previous cesarean birth with occurrence of SMM.DESIGN: Population-based cohort study using linked delivery hospitalization discharge data and vital records.SETTING: California, 1997 to 2014.PATIENTS: All 9179472 mothers delivering in California during 1997 to 2014.MEASUREMENTS: SMM rate, total and without transfusion-only cases; 2019 maternal comorbidity index.RESULTS: Total SMM increased by 160% during this time, and SMM excluding transfusion-only cases increased by 53%. Medical comorbid conditions were associated with an increasing portion of SMM occurrences. Medical comorbid conditions increased over the study period by 111%, and obstetric comorbid conditions increased by 30% to 40%. Identified medical comorbid conditions had high relative risks ranging from 1.3 to 14.3 for total SMM and even higher relative risks for nontransfusion SMM (to 32.4). The obstetric comorbidity index that is most often used may be undervaluing the degree of association with SMM.LIMITATIONS: Hospital discharge diagnosis files and birth certificate records can have misclassifications and may not include all relevant clinical data or social determinants. The period for analysis ended in 2014 to avoid the transition to the International Classification of Diseases, 10th Revision, Clinical Modification, and therefore missed more recent years.CONCLUSION: Obstetric and, particularly, medical comorbid conditions are increasing among women who develop SMM. The maternal comorbidity index is a promising tool for patient risk assessment and case-mix adjustment, but refinement of factor weights may be indicated.PRIMARY FUNDING SOURCE: National Institutes of Health.

  View details for DOI 10.7326/M19-3253

  View details for PubMedID 33253023

• Racial and Ethnic Disparities in Maternal and Neonatal Adverse Outcomes in College-Educated Women OBSTETRICS AND GYNECOLOGY Leonard, S. A., Scott, K. A. 2020; 136 (5): 1062–63

  View details for Web of Science ID 000587823500037

• PRE-CONCEPTION RISK PREDICTION INDEX FOR SEVERE MATERNAL MORBIDITY AMONG INFERTILE WOMEN. Murugappan, G., Alvero, R. J., Lyell, D. J., Khandelwal, A., Leonard, S. A. ELSEVIER SCIENCE INC. 2020: E65

  View details for Web of Science ID 000579355300157

• Birth Hospital and Racial/Ethnic Differences in Severe Maternal Morbidity in the State of California. American journal of obstetrics and gynecology Mujahid, M. S., Kan, P., Leonard, S. A., Hailu, E. M., Wall-Wieler, E., Abrams, B., Main, E., Profit, J., Carmichael, S. L. 2020

  Abstract

  BACKGROUND: Birth hospital has recently emerged as a potentially key contributor to disparities in severe maternal morbidity, but investigations remain limited.OBJECTIVES: We leveraged state-wide data from California to examine whether birth hospital explained racial/ethnic differences in severe maternal morbidity.METHODS: This cohort study used data on all births ≥20 weeks in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least one of 21 diagnoses and procedures (e.g. eclampsia, blood transfusion, hysterectomy). Mixed effects logistic regression models (i.e. women nested within hospitals) were used to compare racial/ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, co-morbidities, and hospital characteristics. We also estimated risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percent reduction in severe maternal morbidity if each group of racially/ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic White women.RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian/Pacific Islander; 1.1% White; 1.6% American Indian/Alaska Native and Mixed Race referred to as "Other"). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, odds of severe maternal morbidity was greater among non-White women compared to Whites in a given hospital (Odds Ratios and 95% Confidence Intervals; Black =1.25 (1.19-1.31), US-born Hispanic=1.25 (1.20-1.29), Foreign-born Hispanic=1.17 (1.11-1.24), Asian/Pacific Islander=1.26 (1.21-1.32), "Other"=1.31 (1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of White women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared to 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and White women and accounted for 16.1-24.2% of the differences for all other racial/ethnic groups.CONCLUSION: In California, excess odds of severe maternal morbidity among racially/ethnically minoritized women was not fully explained by birth hospital. Structural causes of racial/ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

  View details for DOI 10.1016/j.ajog.2020.08.017

  View details for PubMedID 32798461

• Cellular Aging in Pregnancy: Telomere Dynamics Across Gestation. Panelli, D. M., Leonard, S. A., Wong, R. J., Girsen, A. I., Baskovic, M., Stevenson, D. K., Bianco, K. SPRINGER HEIDELBERG. 2020: 127A–128A

  View details for Web of Science ID 000525432600181

• Postpartum Depression Among Women with Cardiac Disease: Considerations During the Delivery Admission Panelli, D., Sherwin, E. B., Lee, C. J., Suharwardy, S., Miller, H. E., Tolani, A. T., Girsen, A. I., Leonard, S. A., Warshawsky, S., Judy, A., Khandel-Wal, A., Bianco, Y. K. SPRINGER HEIDELBERG. 2020: 246A

  View details for Web of Science ID 000525432601113

• Vaginal progesterone treatment is associated with intrahepatic cholestasis of pregnancy Tsur, A., Kan, P., Datoc, I., Leonard, S. A., Girsen, A., Shaw, G. M., Stevenson, D. K., El-Sayed, Y. Y., Druzin, M. L., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2020: S58–S59

  View details for DOI 10.1016/j.ajog.2019.11.084

  View details for Web of Science ID 000504997300069

• Placenta Accreta Spectrum Among Women With Twin Gestations. Obstetrics and gynecology Miller, H. E., Leonard, S. A., Fox, K. A., Carusi, D. A., Lyell, D. J. 2020

  Abstract

  To assess whether placenta accreta spectrum occurs more frequently among women with twin gestations compared with singleton gestations.All live births in California from 2016 to 2017 were identified from previously linked records of birth certificates and birth hospitalization discharges. The primary outcome was placenta accreta spectrum (which includes placenta accreta, increta, and percreta), identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes (O43.2x) for placenta accreta, increta, and percreta. We analyzed the association between twin gestation and placenta accreta spectrum by using multivariable logistic regression and assessed whether our findings were replicated by using a previously validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)-based approach.Among 918,452 live births, 1,126 were diagnosed with placenta accreta spectrum. The prevalence of placenta accreta spectrum was 11.8 per 10,000 among singleton pregnancies and 41.6 per 10,000 among twin pregnancies. In the unadjusted regression analysis, twin pregnancy was associated with higher relative risk of placenta accreta spectrum (RR 3.41, 95% CI 2.57-4.52). After adjusting the regression model for maternal age, previous cesarean birth, and sociodemographic factors, the association held with higher relative risk of placenta accreta spectrum (aRR 2.96, 95% CI 2.23-3.93). Women with twin compared with singleton gestations with placenta accreta spectrum were less likely to have placenta previa. When assessed using ICD-9-CM codes, placenta accreta spectrum was similarly more prevalent among twins than singletons, with an increase in the relative risk of placenta accreta spectrum (aRR 2.45, 95% CI 2.33-3.25).Twin gestation conferred an increased risk for placenta accreta spectrum independent of measured risk factors, which may contribute to increased maternal morbidity in twin gestation compared with singleton gestation. Clinicians should be aware of the increased risk for placenta accreta spectrum in twin gestation and should consider it during ultrasonographic screening.

  View details for DOI 10.1097/AOG.0000000000004204

  View details for PubMedID 33278284

• Racial and Ethnic Disparities in Maternal and Neonatal Adverse Outcomes in College-Educated Women. Obstetrics and gynecology Leonard, S. A., Scott, K. A. 2020; 136 (5): 1062–63

  View details for DOI 10.1097/AOG.0000000000004144

  View details for PubMedID 33093411

• Pre-pregnancy Obesity and the Risk of Peripartum Cardiomyopathy. American journal of perinatology Cho, S. H., Leonard, S. A., Lyndon, A. n., Main, E. K., Abrams, B. n., Hameed, A. B., Carmichael, S. L. 2020

  Abstract

   The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy. This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n = 2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m2) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (≥40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities. The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n = 320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00. Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period.· Pre-pregnancy obesity affects maternal health.. · Effects may extend to peripartum cardiomyopathy.. · The risk includes peripartum cardiomyopathy that emerges postpartum..

  View details for DOI 10.1055/s-0040-1712451

  View details for PubMedID 32512606

• Cervical insufficiency, cerclage, and early preterm birth: differences among racial/ethnic subgroups Miller, H. E., Suharwardy, S., Leonard, S. A., Girsen, A., Lyell, D. J. MOSBY-ELSEVIER. 2020: S540

  View details for DOI 10.1016/j.ajog.2019.11.879

  View details for Web of Science ID 000504997301190

• Early postpartum readmissions or emergency department visits: Identifying risk factors Girsen, A., Leonard, S. A., Carmichael, S. L., Gibbs, R. S. MOSBY-ELSEVIER. 2020: S351–S352

  View details for DOI 10.1016/j.ajog.2019.11.562

  View details for Web of Science ID 000504997300545

• Maternal genitourinary and wound infections: Early postpartum readmissions and emergency department visits Leonard, S. A., Girsen, A., Carmichael, S. L., Gibbs, R. S. MOSBY-ELSEVIER. 2020: S169

  View details for DOI 10.1016/j.ajog.2019.11.261

  View details for Web of Science ID 000504997300245

• Effect of an automated conversational agent on postpartum mental health: A randomized, controlled trial Suharwardy, S., Ramachandran, M., Leonard, S. A., Gunaseelan, A., Robinson, A., Darcy, A., Lyell, D. J., Judy, A. MOSBY-ELSEVIER. 2020: S91

  View details for DOI 10.1016/j.ajog.2019.11.132

  View details for Web of Science ID 000504997300116

• Acceptability of postnatal mood management through a smartphone-based automated conversational agent Ramachandran, M., Suharwardy, S., Leonard, S. A., Gunaseelan, A., Robinson, A., Darcy, A., Lyell, D. J., Judy, A. MOSBY-ELSEVIER. 2020: S62

  View details for DOI 10.1016/j.ajog.2019.11.090

  View details for Web of Science ID 000504997300075

• Antepartum iron-deficiency anemia: An opportunity to reduce severe maternal morbidity Leonard, S. A., Main, E. K., Lyell, D. J., Butwick, A. J., Carmichael, S. L. MOSBY-ELSEVIER. 2020: S168–S169

  View details for DOI 10.1016/j.ajog.2019.11.260

  View details for Web of Science ID 000504997300244

• Antepartum anemia and racial/ethnic disparities in blood transfusion in california Igbinosa, I., Leonard, S. A., Butwick, A. J., Lyell, D. J. MOSBY-ELSEVIER. 2020: S304

  View details for DOI 10.1016/j.ajog.2019.11.480

  View details for Web of Science ID 000504997300463

• Comparing insulin, metformin, and glyburide in treating diabetes in pregnancy and analyzing obstetric outcomes Sperling, M., Bentley, J., Girsen, A., Leonard, S. A., Sherwin, E. B., Panelli, D. M., Suharwardy, S., El Sayed, Y., Herrero, T. MOSBY-ELSEVIER. 2020: S481

  View details for DOI 10.1016/j.ajog.2019.11.773

  View details for Web of Science ID 000504997301086

• Sustaining the practice of operative vaginal delivery: Maternal and neonatal outcomes among a contemporary cohort Panelli, D. M., Leonard, S. A., Judy, A., El-Sayed, Y. Y., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2020: S568

  View details for DOI 10.1016/j.ajog.2019.11.929

  View details for Web of Science ID 000504997301240

• Pregnancy outcomes of american indian and alaskan native women residing in rural versus urban areas Estes, J., Girsen, A., Sie, L., Leonard, S. A., Carmichael, S. L., El-Sayed, Y. Y. MOSBY-ELSEVIER. 2020: S97

  View details for DOI 10.1016/j.ajog.2019.11.143

  View details for Web of Science ID 000504997300127

• Relationships of uterine fibroids to racial/ethnic disparities in severe maternal morbidity Igbinosa, I., Leonard, S. A., El-Sayed, Y. Y., Lyell, D. J. MOSBY-ELSEVIER. 2020: S170–S171

  View details for DOI 10.1016/j.ajog.2019.11.263

  View details for Web of Science ID 000504997300247

• Operative vaginal delivery in the modern obstetric era: How does it compare to the alternative? Panelli, D. M., Leonard, S. A., Judy, A., El-Sayed, Y. Y., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2020: S327–S328

  View details for DOI 10.1016/j.ajog.2019.11.519

  View details for Web of Science ID 000504997300502

• Prenatal and postnatal inflammation-related risk factors for retinopathy of prematurity JOURNAL OF PERINATOLOGY Goldstein, G. P., Leonard, S. A., Kan, P., Koo, E. B., Lee, H. C., Carmichael, S. L. 2019; 39 (7): 964–73

  View details for DOI 10.1038/s41372-019-0357-2

  View details for Web of Science ID 000472630200010

• Racial and ethnic disparities in severe maternal morbidity prevalence and trends ANNALS OF EPIDEMIOLOGY Leonard, S. A., Main, E. K., Scott, K. A., Profit, J., Carmichael, S. L. 2019; 33: 30–36

  View details for DOI 10.1016/j.annepidem.2019.02.007

  View details for Web of Science ID 000469160800004

• Morbidly Adherent Placenta Among Women With Twin Gestation Miller, H., Fox, K., Carusi, D. A., Leonard, S., Lyell, D. LIPPINCOTT WILLIAMS & WILKINS. 2019: 68S

  View details for Web of Science ID 000473810000232

• Invited Commentary: The Causal Association Between Obesity and Stillbirth-Strengths and Limitations of the Consecutive-Pregnancies Approach. American journal of epidemiology Snowden, J. M., Leonard, S. A. 2019

  Abstract

  There has been a resurgence in analyses of consecutive pregnancies (or similarly, sibling designs) in perinatal and pediatric epidemiology. These approaches have attractive qualities for estimating associations with complex multifactorial exposures like obesity. In an article appearing in this issue of the Journal, Yu et al. (Am J Epidemiol. 2019;000(00):000-000) apply a consecutive-pregnancies approach to characterize the risk of stillbirth among women who develop obesity between pregnancies ("incident obesity"). Working within a causal framework and using parametric and nonparametric estimation techniques, the authors find an increase in stillbirth risk associated with incident obesity. Risk differences varied between 0.4 per 1,000 births (95% confidence interval (CI): 0.1, 0.7) and 6.9 per 1,000 births (95% CI: 3.7, 10.0), and risk ratios ranged from 1.12 (95% CI: 1.02, 1.23) to 2.99 (95% CI: 2.19, 4.08). The strengths of this approach include starting from a clearly defined causal estimand and exploring the sensitivity of parameter estimates to model selection. In this commentary, we put these findings in the broader context of research on obesity and birth outcomes and highlight concerns regarding the generalizability of results derived from within-family designs. We conclude that while causal inference is an important goal, in some instances focusing on formulation of a causal question drives results away from broad applicability.

  View details for DOI 10.1093/aje/kwz079

  View details for PubMedID 31111943

• Prenatal and postnatal inflammation-related risk factors for retinopathy of prematurity. Journal of perinatology : official journal of the California Perinatal Association Goldstein, G. P., Leonard, S. A., Kan, P. n., Koo, E. B., Lee, H. C., Carmichael, S. L. 2019

  Abstract

  To evaluate the relationship between prenatal and postnatal inflammation-related risk factors and severe retinopathy of prematurity (ROP).The study included infants born <30 weeks in California from 2007 to 2011. Multivariable log-binomial regression was used to assess the association between prenatal and postnatal inflammation-related exposures and severe ROP, defined as stage 3-5 or surgery for ROP.Of 14,816 infants, 10.8% developed severe ROP. Though prenatal inflammation-related risk factors were initially associated with severe ROP, after accounting for the effect of these risk factors on gestational age at birth through mediation analysis, the association was non-significant (P = 0.6). Postnatal factors associated with severe ROP included prolonged oxygen exposure, sepsis, intraventricular hemorrhage, and necrotizing enterocolitis.Postnatal inflammation-related factors were associated with severe ROP more strongly than prenatal factors. The association between prenatal inflammation-related factors and ROP was explained by earlier gestational age in infants exposed to prenatal inflammation.

  View details for PubMedID 30932029

• Gestational Weight Gain and Severe Maternal Morbidity at Delivery Hospitalization. Obstetrics and gynecology Leonard, S. A., Carmichael, S. L., Abrams, B. n. 2019; 134 (2): 420

  View details for DOI 10.1097/AOG.0000000000003389

  View details for PubMedID 31348212

• Prepregnancy maternal body mass index and venous thromboembolism: A population based cohort study. BJOG : an international journal of obstetrics and gynaecology Butwick, A. J., Bentley, J., Leonard, S. A., Carmichael, S. L., El-Sayed, Y. Y., Stephansson, O., Guo, N. 2018

  Abstract

  OBJECTIVE: To assess the relationship between maternal body mass index (BMI) and pregnancy-related venous thromboembolism (VTE).DESIGN: Cross-sectional study.SETTING & POPULATION: 2,449,133 women with singleton pregnancies who underwent delivery hospitalization in California between 2008 and 2012.METHODS: Association of prepregnancy BMI and the risk of an antepartum and postpartum VTE was examined using logistic regression, with normal BMI as reference.MAIN OUTCOME MEASURES: Antepartum and postpartum VTE related hospitalization.RESULTS: The prevalences of antepartum and postpartum VTE increased with increasing BMI (antepartum: 2.3, 3.0, 3.8, 4.2, 4.7, and 10.6 per 10 000 women for underweight, normal BMI, overweight, obesity class I, II, and III, P<0.001. postpartum: 2.0, 3.1, 3.9, 5.6, 9.0, and 13.2 per 10 000 women, P<0.01). The adjusted odds of antepartum and postpartum VTE increased progressively with increasing BMI, and obese class III women being at highest risk of pregnancy-related VTE compared with normal BMI women: adjusted odds ratio (OR) for antepartum VTE: 2.9; 95% CI 2.2-3.8 and adjusted OR for postpartum VTE: 3.6; 95% CI 2.9-4.6.CONCLUSIONS: Our findings clearly demonstrate an increasing risk of pregnancy-related VTE with increasing BMI. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30500109

• Do the health benefits of education vary by sociodemographic subgroup? Differential returns to education and implications for health inequities. Annals of epidemiology Vable, A. M., Cohen, A. K., Leonard, S. A., Glymour, M. M., Duarte, C. D., Yen, I. H. 2018; 28 (11): 759-766.e5

  Abstract

  Evidence suggests education is an important life course determinant of health, but few studies examine differential returns to education by sociodemographic subgroup.Using National Longitudinal Survey of Youth 1979 (n = 6158) cohort data, we evaluate education attained by age 25 years and physical health (PCS) and mental health component summary scores (MCS) at age 50 years. Race / ethnicity, sex, geography, immigration status, and childhood socioeconomic status (cSES) were evaluated as effect modifiers in birth year adjusted linear regression models.The association between education and PCS was large among high cSES respondents (β = 0.81 per year of education, 95% CI: 0.67, 0.94), and larger among low cSES respondents (interaction β = 0.39, 95% CI: 0.06, 0.72). The association between education and MCS was imprecisely estimated among White men (β = 0.44; 95% CI: -0.03, 0.90), while, Black women benefited more from each year of education (interaction β = 0.91; 95% CI: 0.19, 1.64). Similarly, compared to socially advantaged groups, low cSES Blacks, and low and high cSES women benefited more from each year of education, while immigrants benefited less from each year of education.If causal, increases in educational attainment may reduce some social inequities in health.

  View details for DOI 10.1016/j.annepidem.2018.08.014

  View details for PubMedID 30309690

  View details for PubMedCentralID PMC6215723

• Maternal body mass index and risk of intraventricular hemorrhage in preterm infants. Pediatric research Pai, V. V., Carmichael, S. L., Kan, P., Leonard, S. A., Lee, H. C. 2018

  Abstract

  BACKGROUND: Intraventricular hemorrhage (IVH) and pre-pregnancy obesity and underweight have been linked to inflammatory states. We hypothesize that IVH in preterm infants is associated with pre-pregnancy obesity and underweight due to an inflammatory intrauterine environment.METHODS: Population-based study of infants born between 22 and 32 weeks' gestation from 2007 to 2011. Data were extracted from vital statistics and the California Perinatal Quality Care Collaborative. Results were examined for all cases (any IVH) and for severe IVH.RESULTS: Among 20,927 infants, 4,818 (23%) had IVH and 1,514 (7%) had severe IVH. After adjustment for confounders, there was an increased risk of IVH associated with pre-pregnancy obesity, relative risk 1.14 (95% CI 1.06, 1.32) for any IVH, and 1.25 (85% CI 1.10, 1.42) for severe IVH. The direct effect of pre-pregnancy obesity on any IVH was significant (P<0.001) after controlling for antenatal inflammation-related conditions, but was not significant after controlling for gestational age (P=0.56).CONCLUSION: Pre-pregnancy obesity was found to be a risk factor for IVH in preterm infants; however, this relationship appeared to be largely mediated through the effect of BMI on gestational age at delivery. The etiology of IVH is complex and it is important to understand contributing maternal factors.Pediatric Research accepted article preview online, 06 April 2018. doi:10.1038/pr.2018.47.

  View details for PubMedID 29624572

• Healthier vending machines in a university setting: Effective and financially sustainable. Appetite Viana, J., Leonard, S. A., Kitay, B., Ansel, D., Angelis, P., Slusser, W. 2018; 121: 263-267

  View details for DOI 10.1016/j.appet.2017.11.094

  View details for PubMedID 29137969

• Breastfeeding Is Associated With Reduced Obesity in Hispanic 2- to 5-Year-Olds Served by WIC. Journal of nutrition education and behavior Whaley, S. E., Koleilat, M., Leonard, S., Whaley, M. 2017; 49 (7S2): S144-S150.e1

  Abstract

  To examine the relationship between breastfeeding (BF) and odds of childhood obesity in a large, primarily Hispanic Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) population.A large urban WIC program in California.Infants enrolled in WIC born between 2004 and 2007 and observed to age 5 years (N = 39,801; 88.6% Hispanic).Level of BF: fully BF, fully formula feeding, or combination feeding.Obesity at age 2-5 years, measured by body mass index (BMI) ≥ 95th percentile.Logistic regression analyses to evaluate the association between initiation, duration, and exclusivity of BF and odds of obesity at age 2-5 years, controlling for ethnicity, preferred language, family size, poverty level, and maternal BMI.Infants exclusively formula fed at birth were significantly more likely than fully breastfed infants to be obese at age 2-5 years (χ(2) [2, N = 39,801] = 123.31; P < .001). For every additional month of any BF, obesity risk at age 2-5 years decreased by 1%. Every additional month of full BF conferred a 3% decrease in obesity risk. Ethnicity, preferred language, family size, poverty level, and maternal BMI were also significantly related to obesity risk.Breastfeeding may have a role in the attenuation of obesity in early childhood among Hispanic children. The BF promotion and support offered at WIC may have a significant role in reducing rates of early childhood obesity.

  View details for DOI 10.1016/j.jneb.2017.03.007

  View details for PubMedID 28689551

• Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Galin, J., Abrams, B., Leonard, S. A., Matthay, E. C., Goin, D. E., Ahern, J. 2017; 31 (1): 37-46

  Abstract

  During pregnancy, most women do not meet gestational weight gain (GWG) guidelines, potentially resulting in adverse maternal and infant health consequences. Social environment determinants of GWG have been identified, but evidence on the relationship between neighbourhood violence and GWG is scant. Our study aims to examine the relationship between neighbourhood violence and GWG outside the recommended range.We used statewide vital statistics and health care utilization data from California for 2006-12 (n = 2 364 793) to examine the relationship of neighbourhood violence (quarters of zip-code rates of homicide and assault) in the first 37 weeks of pregnancy with GWG (categorized using the Institute of Medicine's pregnancy weight gain guidelines). We estimated risk ratios (RR) and marginal risk differences, and analyses were stratified by maternal race/ethnicity and prepregnancy body mass index.Residence in neighbourhoods with the highest quartile of violence was associated with more excessive GWG (adjusted RR 1.04, 95% confidence interval CI 1.03, 1.05), compared to the lowest quartile of violence; violence was not associated with inadequate GWG. On the difference scale, this association translates to 2.3% more women gaining weight excessively rather than adequately if all women were exposed to high violence compared to if all women were exposed to low violence. Additionally, associations between neighbourhood violence and excessive GWG were larger in non-white women than in white women.These findings support the hypothesis that violence can affect weight gain during pregnancy, emphasizing the importance of neighbourhood violence as a public health issue.

  View details for DOI 10.1111/ppe.12331

  View details for Web of Science ID 000392509800007

  View details for PubMedID 27921300

  View details for PubMedCentralID PMC5195875

• Associations of maternal obesity and psychosocial factors with breastfeeding intention, initiation, and duration(1-4) AMERICAN JOURNAL OF CLINICAL NUTRITION Hauff, L. E., Leonard, S. A., Rasmussen, K. M. 2014; 99 (3): 524-534

  Abstract

  Psychosocial factors influence breastfeeding outcomes, but little is known about these characteristics and how they influence breastfeeding behavior of obese women, who are a group that experiences poor breastfeeding outcomes.Our objectives were to determine whether 1) maternal prepregnancy body mass index (BMI) is associated with social knowledge of, social influence toward, maternal confidence in, and behavioral beliefs about breastfeeding; 2) BMI and these psychosocial factors predict outcomes of intention to breastfeed, ever breastfed, and the duration of breastfeeding; and 3) BMI and psychosocial factors are associated with these breastfeeding outcomes independent of each other.Participants (n = 2824) in the Infant Feeding Practices Study II provided data on psychosocial characteristics and breastfeeding outcomes. In this prospective cohort study, data were analyzed by using logistic and proportional hazards regression models.Prepregnancy BMI was associated with confidence in (P < 0.0001), social influence toward (P = 0.02), and social knowledge of (P < 0.0001) breastfeeding but not with behavioral beliefs about breastfeeding (P = 0.45). Obese women did not differ from under- and normal-weight women in the intention to breastfeed (P = 0.07) but had lower odds of ever breastfeeding (P = 0.04) and were at greater risk of an earlier cessation of exclusive (P = 0.0009) and any (P = 0.03) breastfeeding. Only the association with exclusive breastfeeding remained significant after controlling for psychosocial factors (P = 0.01). All psychosocial factors were positively associated with each breastfeeding outcome.Despite their intentions to breastfeed, women with high prepregnancy BMI had psychosocial characteristics associated with poor breastfeeding outcomes. However, these characteristics did not fully explain the association between maternal obesity and breastfeeding outcomes.

  View details for DOI 10.3945/ajcn.113.071191

  View details for Web of Science ID 000332143900015

  View details for PubMedID 24401717

  View details for PubMedCentralID PMC3927688