David A. Goodman

Recombinant antigen-based antibody assays for the diagnosis and surveillance of lymphatic filariasis – a multicenter trial

The development of antifilarial antibody responses is a characteristic feature of infection with filarial parasites. It should be possible to exploit this fact to develop tools to monitor the progress of the global program to eliminate lymphatic filariasis (LF); however, assays based on parasite extracts suffer from a number of limitations, including the paucity of parasite material, the difficulty of assay standardization and problems with assay specificity. In principle, assays based on recombinant filarial antigens should address these limitations and provide useful tools for diagnosis and surveillance of LF. The present multicenter study was designed to compare the performance of antibody assays for filariasis based on recombinant antigens Bm14, WbSXP, and BmR1. Coded serum specimens were distributed to five participating laboratories where assays for each antigen were conducted in parallel. Assays based on Bm14, WbSXP, or BmR1 demonstrated good sensitivity (>90%) for field use and none of the assays demonstrated reactivity with specimens from persons with non-filarial helminth infections. Limitations of the assays are discussed. Well-designed field studies are now needed to assess sampling methodology and the application of antibody testing to the monitoring and surveillance of LF elimination programs.

Sensitivity of birth certificate reports of birth defects in Atlanta, 1995-2005: effects of maternal, infant, and hospital characteristics.

Objectives. We assessed variations in the sensitivity of birth defect diagnoses derived from birth certificate data by maternal, infant, and hospital characteristics. Methods. We compared birth certificate data for 1995–2005 births in Atlanta with data from the Metropolitan Atlanta Congenital Defects Program (MACDP). We calculated the sensitivity of birth certificates for reporting defects often discernable at birth (e.g., anencephaly, spina bifida, cleft lip, clubfoot, Down syndrome, and rectal atresia or stenosis). We used multivariable logistic regression models to examine associations with sociodemographic and hospital factors. Results. The overall sensitivity of birth certificates was 23% and ranged from 7% for rectal atresia/stenosis to 69% for anencephaly. Non-Hispanic black maternal race/ethnicity, less than a high school education, and preterm birth were independently associated with a lower probability of a birth defect diagnosis being reported on a birth certificate. Sensitivity also was lower for hospitals with >1,000 births per year. Conclusions. The underreporting of birth defects on birth certificates is influenced by sociodemographic and hospital characteristics. Interpretation of birth defects prevalence estimates derived from birth certificate reports should take these issues into account.

Female Genital Mutilation/Cutting in the United States: Updated Estimates of Women and Girls at Risk, 2012

Objectives. In 1996, the U.S. Congress passed legislation making female genital mutilation/cutting (FGM/C) illegal in the United States. CDC published the first estimates of the number of women and girls at risk for FGM/C in 1997. Since 2012, various constituencies have again raised concerns about the practice in the United States. We updated an earlier estimate of the number of women and girls in the United States who were at risk for FGM/C or its consequences. Methods. We estimated the number of women and girls who were at risk for undergoing FGM/C or its consequences in 2012 by applying country-specific prevalence of FGM/C to the estimated number of women and girls living in the United States who were born in that country or who lived with a parent born in that country. Results. Approximately 513,000 women and girls in the United States were at risk for FGM/C or its consequences in 2012, which was more than three times higher than the earlier estimate, based on 1990 data. The increase in the number of women and girls younger than 18 years of age at risk for FGM/C was more than four times that of previous estimates. Conclusion. The estimated increase was wholly a result of rapid growth in the number of immigrants from FGM/C-practicing countries living in the United States and not from increases in FGM/C prevalence in those countries. Scientifically valid information regarding whether women or their daughters have actually undergone FGM/C and related information that can contribute to efforts to prevent the practice in the United States and provide needed health services to women who have undergone FGM/C are needed.

Revival of a Core Public Health Function: State- and Urban-Based Maternal Death Review Processes

This article reviews some of the current challenges for maternal death review in the United States, describes key findings from an assessment of U.S. capacity for conducting maternal death reviews, and introduces a new Maternal Mortality Initiative that aims to develop standardized guidelines for state- or city-based maternal deaths review processes.

Perinatal regionalization: a geospatial view of perinatal critical care, United States, 2010–2013

BACKGROUND: Perinatal services exist today as a dyad of maternal and neonatal care. When perinatal care is fragmented or unavailable, excess morbidity and mortality may occur in pregnant women and newborns. OBJECTIVE: The objective of the study was to describe spatial relationships between women of reproductive age, individual perinatal subspecialists (maternal‐fetal medicine and neonatology), and obstetric and neonatal critical care facilities in the United States to identify gaps in health care access. STUDY DESIGN: We used geographic visualization and conducted surface interpolation, nearest neighbor, and proximity analyses. Source data included 2010 US Census, October 2013 National Provider Index, 2012 American Hospital Association, 2012 National Center for Health Statistics Natality File, and the 2011 American Academy of Pediatrics directory. RESULTS: In October 2013, there were 2.5 neonatologists for every maternal‐fetal medicine specialist in the United States. In 2012 there were 1.4 level III or higher neonatal intensive care units for every level III obstetric unit (hereafter, obstetric critical care unit). Nationally, 87% of women of reproductive age live within 50 miles of both an obstetric critical care unit and a neonatal intensive care unit. However, 18% of obstetric critical care units had no neonatal intensive care unit, and 20% of neonatal intensive care units had no obstetric critical care unit within a 10 mile radius. Additionally, 26% of obstetric critical care units had no maternal‐fetal medicine specialist practicing within 10 miles of the facility, and 4% of neonatal intensive care units had no neonatologist practicing within 10 miles. CONCLUSION: Gaps in access and discordance between the availability of level III or higher obstetric and neonatal care may affect the delivery of risk‐appropriate care for high‐risk maternal fetal dyads. Further study is needed to understand the importance of these gaps and discordance on maternal and neonatal outcomes.

Contributors to excess infant mortality in the U.S. South.

BACKGROUND Infant mortality rates (IMRs) are disproportionally high in the U.S. South; however, the proximate contributors that could inform regional action remain unclear. PURPOSE To quantify the components of excess infant mortality in the U.S. South by maternal race/ethnicity, underlying cause of death, and gestational age. METHODS U.S. Period Linked Birth/Infant Death Data Files 2007-2009 (analyzed in 2013) were used to compare IMRs between the South (U.S. Public Health Regions IV and VI) and all other regions combined. RESULTS Compared to other regions, there were 1.18 excess infant deaths per 1000 live births in the South, representing about 1600 excess infant deaths annually. New Mexico and Texas did not have elevated IMRs relative to other regions; excess death rates among other states ranged from 0.62 per 1000 in Kentucky to 3.82 per 1000 in Mississippi. Racial/ethnic compositional differences, generally the greater proportion of non-Hispanic black births in the South, explained 59% of the overall regional difference; the remainder was mostly explained by higher IMRs among non-Hispanic whites. The leading causes of excess Southern infant mortality were sudden unexpected infant death (SUID; 36%, range=12% in Florida to 90% in Kentucky) and preterm-related death (22%, range= -71% in Kentucky to 51% in North Carolina). Higher rates of preterm birth, predominantly <34 weeks, accounted for most of the preterm contribution. CONCLUSIONS To reduce excess Southern infant mortality, comprehensive strategies addressing SUID and preterm birth prevention for both non-Hispanic black and white births are needed, with state-level findings used to tailor state-specific efforts.

Working with State Health Departments on Emerging Issues in Maternal and Child Health: Immediate Postpartum Long-Acting Reversible Contraceptives

BACKGROUND Immediate postpartum long-acting reversible contraceptives (LARC) are highly effective in preventing unintended pregnancy. State health departments are in the process of implementing a systems change approach to better apply policies supporting the use of immediate postpartum LARC. METHODS Beginning in 2014, a group of national organizations, federal agencies, and six states have convened a LARC Learning Community to share strategies and best practices in immediate postpartum LARC policy development and implementation. Community activities consist of in-person meetings and a webinar series as forums to discuss systems change. RESULTS The Learning Community identified eight domains for discussion and development of resources: training, pay streams, stocking and supply, consent, outreach, stakeholder partnerships, service location, and data and surveillance. The community is currently developing resource materials and guidance for use by other state health departments. CONCLUSIONS To effectively implement policies on immediate postpartum LARC, states must engage a number of stakeholders in the process, raise awareness of the challenges to implementation, and communicate strategies across agencies during policy development.

Application of Implementation Science Methodology to Immediate Postpartum Long-Acting Reversible Contraception Policy Roll-Out Across States

Purpose Providing long-acting reversible contraception (LARC) in the immediate postpartum period is an evidence-based strategy for expanding women’s access to highly effective contraception and for reducing unintended and rapid repeat pregnancy. The purpose of this article is to demonstrate the application of implementation science methodology to study the complexities of rolling-out policies that promote immediate postpartum LARC use across states. Description The Immediate Postpartum LARC Learning Community, sponsored by the Association of State and Territorial Health Officials (ASTHO), is made up of multi-disciplinary, multi-agency teams from 13 early-adopting states with Medicaid reimbursement policies promoting immediate postpartum LARC. Partners include federal agencies and maternal and child health organizations. The Learning Community discussed barriers, opportunities, strategies, and promising practices at an in-person meeting. Implementation science theory and methods, including the Consolidated Framework for Implementation Research (CFIR), and a recent compilation of implementation strategies, provide useful tools for studying the complexities of implementing immediate postpartum LARC policies in birthing facilities across early adopting states. Assessment To demonstrate the utility of this framework for guiding the expansion of immediate postpartum LARC policies, illustrative examples of barriers and strategies discussed during the in-person ASTHO Learning Community meeting are organized by the five CFIR domains—intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and process. Conclusion States considering adopting policies can learn from ASTHO’s Immediate Postpartum LARC Learning Community. Applying implementation science principles may lead to more effective statewide scale-up of immediate postpartum LARC and other evidence-based strategies to improve women and children’s health.

Developing a Standard Approach to Examine Infant Mortality: Findings from the State Infant Mortality Collaborative (SIMC)

States can improve pregnancy outcomes by using a standard approach to assess infant mortality. The State Infant Mortality Collaborative (SIMC) developed a series of analyses to describe infant mortality in states, identify contributing factors to infant death, and develop the evidence base for implementing new or modifying existing programs and policies addressing infant mortality. The SIMC was conducted between 2004 and 2006 among five states: Delaware, Hawaii, Louisiana, Missouri, and North Carolina. States used analytic strategies in an iterative process to investigate contributors to infant mortality. Analyses were conducted within three domains: data reporting (quality, reporting, definitional criteria, and timeliness), cause and timing of infant death (classification of cause and fetal, neonatal, and postneonatal timing), and maturity and weight at birth/maturity and birth weight-specific mortality. All states identified the SIMC analyses as useful for examining infant mortality trends. In each of the three domains, SIMC results were used to identify important direct contributors to infant mortality including disparities, design or implement interventions to reduce infant death, and identify foci for additional analyses. While each state has unique structural, political, and programmatic circumstances, the SIMC model provides a systematic approach to investigating increasing or static infant mortality rates that can be easily replicated in all other states and allows for cross-state comparison of results.

United States and territory policies supporting maternal and neonatal transfer: review of transport and reimbursement

Objective:Summarize policies that support maternal and neonatal transport among states and territories.Study Design:Systematic review of publicly available, web-based information on maternal and neonatal transport for each state and territory in 2014. Information was abstracted from published rules, statutes, regulations, planning documents and program descriptions. Abstracted information was summarized within two categories: transport and reimbursement.Results:Sixty-eight percent of states and 25% of territories had a policy for neonatal transport; 60% of states and one territory had a policy for maternal transport. Sixty-two percent of states had a reimbursement policy for neonatal transport, whereas 20% reimbursed for maternal transport. Thirty-two percent of states had an infant back-transport policy while 16% included back-transport for both. No territories had reimbursement or back-transport policies.Conclusion:The lack of development of maternal transport reimbursement and neonatal back-transport policies negatively impacts the achievements of risk-appropriate care, a strategy focused on improving perinatal outcomes.