Candice Belanoff

Perinatal outcomes associated with assisted reproductive technology: the Massachusetts Outcomes Study of Assisted Reproductive Technologies (MOSART)

OBJECTIVE To compare on a population basis the birth outcomes of women treated with assisted reproductive technologies (ART), women with indicators of subfertility but without ART, and fertile women. DESIGN Longitudinal cohort study. SETTING Not applicable. PARTICIPANT(S) A total of 334,628 births and fetal deaths to Massachusetts mothers giving birth in a Massachusetts hospital from July 1, 2004, to December 31, 2008, subdivided into three subgroups for comparison: ART 11,271, subfertile 6,609, and fertile 316,748. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Four outcomes-preterm birth, low birth weight, small for gestational age, and perinatal death-were modeled separately for singletons and twins with the use of logistic regression for the primary comparison between ART births and those to the newly created population-based subgroup of births to women with indicators of subfertility but no ART. RESULT(S) For singletons, the risks for both preterm birth and low birth weight were higher for the ART group (adjusted odds ratios [AORs] 1.23 and 1.26, respectively) compared with the subfertile group, and risks in both the ART and the subfertile groups were higher than those among the fertile births group. For twins, the risk of perinatal death was significantly lower among ART births than fertile (AOR 0.55) or subfertile (AOR 0.15) births. CONCLUSION(S) The use of a population-based comparison group of subfertile births without ART demonstrated significantly higher rates of preterm birth and low birth weight in ART singleton births, but these differences are smaller than differences between ART and fertile births. Further refinement of the measurement of subfertile births and examination of the independent risks of subfertile births is warranted.

Identifying women with indicators of subfertility in a statewide population database: operationalizing the missing link in assisted reproductive technology research

OBJECTIVE To identify a group of deliveries to mothers with indicators of subfertility (SUBFERTILITY). DESIGN Longitudinal cohort study. SETTING Hospital. PATIENT(S) A total of 334,152 deliveries to Massachusetts mothers in a Massachusetts hospital between July 1, 2004, and December 31, 2008. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Subfertility was defined by an indication on a current or past birth certificate or hospital utilization data of infertility or assisted reproductive technology (ART) cycle before index delivery and no indication of ART use with index delivery. RESULT(S) Initially, 12,367 deliveries met the inclusion criteria for SUBFERTILITY (8,019 from birth certificates, 2,777 from hospital data, 1,571 from prior ART treatment). Removing deliveries from more than one data source resulted in 10,764 unique deliveries. Removing deliveries resulting from ART treatments left 6,238 deliveries in the SUBFERTILITY category. Demographic analysis indicated that deliveries in SUBFERTILITY were more similar to those in the ART population than to those in the fertile population. CONCLUSION(S) We have demonstrated the feasibility of using existing population-based linked public health data sets to identify SUBFERTILITY deliveries, and we have used ART data to distinguish ART and SUBFERTILITY births. The SUBFERTILITY category can serve as a comparison group of subfertile patients for studies of ART delivery and longitudinal health outcomes.

Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact

Objective We examined the extent to which differences in hospital-level cesarean delivery rates in Massachusetts were attributable to hospital-level, rather than maternal, characteristics. Methods Birth certificate and maternal in-patient hospital discharge records for 2004–06 in Massachusetts were linked. The study population was nulliparous, term, singleton, and vertex births (NTSV) (n = 80,371) in 49 hospitals. Covariates included mothers age, race/ethnicity, education, infant birth weight, gestational age, labor induction (yes/no), hospital shift at time of birth, and preexisting health conditions. We estimated multilevel logistic regression models to assess the likelihood of a cesarean delivery Results Overall, among women with NTSV births, 26.5% births were cesarean, with a range of 14% to 38.3% across hospitals. In unadjusted models, the between-hospital variance was 0.103 (SE 0.022); adjusting for demographic, socioeconomic and preexisting medical conditions did not reduce any hospital-level variation 0.108 (SE 0.023). Conclusion Even after adjusting for both socio-demographic and clinical factors, the chance of a cesarean delivery for NTSV pregnancies varied according to hospital, suggesting the importance of hospital practices and culture in determining a hospitals cesarean rate.

Severe Maternal Morbidity and the Use of Assisted Reproductive Technology in Massachusetts.

OBJECTIVE: To assess whether risk of severe maternal morbidity at delivery differed for women who conceived using assisted reproductive technology (ART), those with indicators of subfertility but no ART (“subfertile”), and those who had neither ART nor subfertility (“fertile”). METHODS: This retrospective cohort study was part of the larger Massachusetts Outcomes Study of Assisted Reproductive Technology. To construct the Massachusetts Outcomes Study of Assisted Reproductive Technology database and identify ART deliveries, we linked ART treatment records to birth certificates and maternal and infant hospitalization records occurring in Massachusetts between 2004 and 2010. An algorithm of International Classification of Diseases, 9th Revision, Clinical Modification diagnosis and procedure codes identified severe maternal morbidity. We used logistic generalized estimating equations to estimate odds of severe maternal morbidity associated with fertility status, adjusting for maternal demographic and health factors and gestational age, stratifying on plurality and method of delivery. RESULTS: The prevalence of severe maternal morbidity among this population (n=458,918) was 1.16%. The overall, crude prevalences of severe maternal morbidity among fertile, subfertile, and ART deliveries were 1.09%, 1.44%, and 3.14%, respectively. The most common indicator of severe maternal morbidity was blood transfusion. In multivariable analyses, among singletons, ART was associated with increased odds of severe maternal morbidity compared with both fertile (vaginal: adjusted odds ratio [OR] 2.27, 95% confidence interval [CI] 1.78–2.88; cesarean: adjusted OR 1.67, 95% CI 1.40–1.98, respectively) and subfertile (vaginal: adjusted OR 1.97, 95% CI 1.30–3.00; cesarean: adjusted OR 1.75, 95% CI 1.30–2.35, respectively) deliveries. Among twins, only cesarean ART deliveries had significantly greater severe maternal morbidity compared with cesarean fertile deliveries (adjusted OR 1.48, 95% CI 1.14–1.93). CONCLUSION: Women who conceive through ART may have elevated risk of severe maternal morbidity at delivery, largely indicated by blood transfusion, even when compared with a subfertile population. Further research should elucidate mechanisms underlying this risk.

Racial/ethnic differences in hospital use and cost among a statewide population of children with Down syndrome

Children with Down syndrome (DS) use hospital services more often than children without DS, but data on racial/ethnic variations are limited. This study generated population-based estimates of hospital use and cost to 3 years of age by race/ethnicity among children with DS in Massachusetts using birth certificates linked to birth defects registry and hospital discharge data from 1999 to 2004. Hospital use (≥ 1 post-birth hospitalization and median days hospitalized birth and post-birth) and reasons for hospitalization were compared across maternal race/ethnicity using relative risk (RR) and Wilcoxon rank sums tests, as appropriate. Costs were calculated in 2011 United States dollars. Greater hospital use was observed among children with DS with Hispanic vs. Non-Hispanic White (NHW) mothers (post-birth hospitalization: RR 1.4; median days hospitalized: 20.0 vs. 11.0, respectively). Children with DS and congenital heart defects of Non-Hispanic Black (NHB) mothers had significantly greater median days hospitalized than their NHW counterparts (24.0 vs. 16.0, respectively). Respiratory diagnoses were listed more often among children with Hispanic vs. NHW mothers (50.0% vs. 29.1%, respectively), and NHBs had more cardiac diagnoses (34.1% vs. 21.5%, respectively). The mean total hospital cost was nine times higher among children with DS (

Refining Measurement of Substance Use Disorders Among Women of Child-Bearing Age Using Hospital Records: The Development of the Explicit-Mention Substance Abuse Need for Treatment in Women (EMSANT-W) Algorithm

40,075) than among children without DS (

Prepregnancy Obesity and Primary Cesareans among Otherwise Low-Risk Mothers in 38 U.S. States in 2012

4053), and total costs attributable to DS were almost

Assisted Reproductive Technology and Early Intervention Program Enrollment.

18 million. Median costs were

Racial and Ethnic Differences in the Likelihood of Vaginal Birth After Cesarean Delivery

22,781 for Hispanics,

The association of injury with substance use disorder among women of reproductive age: an opportunity to address a major contributor to recurrent preventable emergency department visits?

18,495 for NHBs, and