Michelle Macheras

Trends in childbirth before 39 weeks' gestation without medical indication.

Background:There is increasing attention to labor induction and cesarean delivery occurring at 37 0/7–38 6/7 weeks’ gestation (early-term) without medical indication. Objective:To measure prevalence, change over time, patient characteristics, and infant outcomes associated with early-term nonindicated births. Research Design and Subjects:Retrospective analysis using linked hospital discharge and birth certificate data for the 7,296,363 uncomplicated births (>37 0/7 wk’ gestation) between 1995 and 2009 in 3 states. Measures:Early-term nonindicated birth is calculated using diagnosis codes and birth certificate records. Secondary outcomes included infant prolonged length of stay and respiratory distress. Results:Across uncomplicated term births, the early-term nonindicated birth rate was 3.18%. After adjustment, the risk of nonindicated birth before 39 0/7 weeks was 86% higher in 2009 than in 1995 [hazard ratio (HR)=1.86; 95% confidence interval (CI), 1.81–1.90], peaking in 2006 (HR=2.03; P<0.001). Factors independently associated with higher odds included maternal age, higher education levels, private health insurance, and delivering at smaller-volume or nonteaching hospitals. Black women had higher risk of nonindicated cesarean birth (HR=1.29; 95% CI, 1.27–1.32), which was associated with greater odds of prolonged length of stay [adjusted odds ratio (AOR)=1.60; 95% CI, 1.57–1.64] and infant respiratory distress (AOR=2.44; 95% CI, 2.37–2.50) compared with births after 38 6/7 weeks. Early-term nonindicated induction was also associated with comparatively greater odds of prolonged length of stay (AOR=1.20; 95% CI, 1.17–1.23). Conclusions:Nearly 4% of all uncomplicated births to term infants occurred before 39 0/7 weeks’ gestation without medical indication. These births were associated with adverse infant outcomes.

Preterm Infant Attendance at Health Supervision Visits.

OBJECTIVES: To assess the adherence of premature infants with the American Academy of Pediatrics health supervision visit schedule, factors affecting adherence, and the association of adherence with preventive care. METHODS: Retrospective cohort of all infants ≤35 weeks’ gestation, born 2005 to 2009, receiving care at a 30-site primary care network for at least 24 months (n = 1854). Adherence was defined as having a health supervision visit within each expected time period during the first 18 months of life. Logistic regression identified sociodemographic and medical factors associated with nonadherence and risk-adjusted association between nonadherence and outcomes. RESULTS: Only 43% received all expected health supervision visits. Those with Medicaid insurance (adjusted odds ratio [AOR] 0.46, 95% confidence interval [CI] 0.35–0.60), a visit without insurance (AOR 0.46, 95% CI 0.32–0.67), chronic illness (AOR 0.7, 95% CI 0.51–0.97), and black race (AOR 0.7, 95% CI 0.50–0.98) were less adherent, whereas provider continuity of care (AOR 2.89, 95% CI 1.92–4.37) and lower birth weight (AOR 1.67, 95% CI 1.02–2.73) increased adherence. Infants <100% adherent were less likely to be up to date with immunizations and receive recommended preventive care. In nearly half of missed visit windows, no health supervision visit was scheduled. CONCLUSIONS: Fewer than half of premature infants were fully adherent with the preventive health schedule with associated gaps in health monitoring and immunization delays. These data suggest the importance of health supervision visits and the need to explore scheduling facilitators for those at risk for nonadherence.