Ruben A. Smith

Discharge Timing, Outpatient Follow-up, and Home Care of Late-Preterm and Early-Term Infants

OBJECTIVE: To compare the timing of hospital discharge, time to outpatient follow-up, and home care practices (breastfeeding initiation and continuation, tobacco smoke exposure, supine sleep position) for late-preterm (LPT; 34 0/7–36 6/7 weeks) and early-term (ET; 37 0/7–38/6/7 weeks) infants with term infants. METHODS: We analyzed 2000–2008 data from the Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System. χ2 Analyses were used to measure differences in maternal and infant characteristics, hospital discharge, outpatient care, and home care among LPT, ET, and term infants. We calculated adjusted risk ratios for the risk of adverse care outcomes among LPT and ET infants compared with term infants. RESULTS: In the adjusted analysis, LPT infants were less likely to be discharged early compared with term infants, whereas there was no difference for ET infants (odds ratio [OR; 95% confidence interval (CI)]: 0.65 [0.54–0.79]; 0.95 [0.88–1.02]). LPT and ET infants were more likely to have timely outpatient follow-up (1.07 [1.06–1.08]; 1.02 [1.02–1.03]), more likely to experience maternal tobacco smoke exposure (1.09 [1.05–1.14]; 1.08 [1.06–1.11]), less likely to be initially breastfed (0.95 [0.94–0.97]; 0.98 [0.97–0.98]), less likely to be breastfed for ≥10 weeks (0.88 [0.86–0.90]; 0.94 [0.93–0.96]), and less likely to be placed in a supine sleep position (0.95 [0.93–0.97]; 0.97 [0.96–0.98]). CONCLUSIONS: Given that LPT and ET infants bear an increased risk of morbidity and mortality, greater efforts are needed to ensure safe and healthy posthospitalization and home care practices for these vulnerable infants.

Low pregnancy weight gain and small for gestational age: a comparison of the association using 3 different measures of small for gestational age

OBJECTIVE The purpose of this study was to assess associations between pregnancy weight gain (PWG) and small for gestational age (SGA) defined by birthweight < 10th percentile and 2 more restrictive definitions and to assess the proportion of SGA attributed to low PWG. STUDY DESIGN This was a retrospective cohort study of 104,980 singleton, term births from the 2000-2005 Pregnancy Risk Assessment Monitoring System (PRAMS). RESULTS Compared with women who gained 15-25 lbs during pregnancy, women who gained 1-14 lbs had 1.5 greater odds (95% confidence interval, 1.2-1.8) of SGA for the most restrictive definition and 1.2 greater odds (95% confidence interval, 1.1-1.4) for the least restrictive definition, after adjustments for confounders. Depending upon the definition used, PWG below current Institute of Medicine recommendations contributed to 10-15% of SGA, representing 0.8-1.2% of all singleton term infants. CONCLUSION Associations between low PWG and SGA varied little by definition of SGA and contributed to only a small proportion of term SGA infants.

Recent Changes in the Trends of Teen Birth Rates, 1981–2006

PURPOSE To explore trends in teen birth rates by selected demographics. METHODS We used birth certificate data and joinpoint regression to examine trends in teen birth rates by age (10-14, 15-17, and 18-19 years) and race during 1981-2006 and by age and Hispanic origin during 1990-2006. Joinpoint analysis describes changing trends over successive segments of time and uses annual percentage change (APC) to express the amount of increase or decrease within each segment. RESULTS For teens younger than 18 years, the decline in birth rates began in 1994 and ended in 2003 (APC: -8.03% per year for ages 10-14 years; APC: -5.63% per year for ages 15-17 years). The downward trend for 18- and 19-year-old teens began earlier (1991) and ended 1 year later (2004) (APC: -2.37% per year). For each study population, the trend was approximately level during the most recent time segment, except for continuing declines for 18- and 19-year-old white and Asian/Pacific Islander teens. The only increasing trend in the most recent time segment was for 18- and 19-year-old Hispanic teens. During these declines, the age distribution of teens who gave birth shifted to slightly older ages, and the percentage whose current birth was at least their second birth decreased. CONCLUSIONS Teen birth rates were generally level during 2003/2004-2006 after the long-term declines. Rates increased among older Hispanic teens. These results indicate a need for renewed attention to effective teen pregnancy prevention programs in specific populations.

Accuracy of self‐reported smoking cessation during pregnancy

Evidence of bias of self‐reported smoking cessation during pregnancy is reported in high‐income countries but not elsewhere. We sought to evaluate self‐reported smoking cessation during pregnancy using biochemical verification and to compare characteristics of women with and without biochemically confirmed cessation in Argentina and Uruguay. In a cross‐sectional study from October 2011 to May 2012, women who attended one of 21 prenatal clinics and delivered at selected hospitals in Buenos Aires, Argentina and Montevideo, Uruguay, were surveyed about their smoking cessation during pregnancy. We tested saliva collected from women <12 h after delivery for cotinine to evaluate self‐reported smoking cessation during pregnancy. Overall, 10.0% (44/441) of women who self‐reported smoking cessation during pregnancy had biochemical evidence of continued smoking. Women who reported quitting later in pregnancy had a higher percentage of nondisclosure (17.2%) than women who reported quitting when learning of their pregnancy (6.4%).

Maternity Care Practices and Breastfeeding Among Adolescent Mothers Aged 12-19 Years--United States, 2009-2011.

The American Academy of Pediatrics recommends that infants be breastfed exclusively for the first 6 months of life, and that mothers continue breastfeeding for at least 1 year. However, in 2011, only 19.3% of mothers aged ≤20 years in the United States exclusively breastfed their infants at 3 months, compared with 36.4% of women aged 20-29 years and 45.0% of women aged ≥30 years. Hospitals play an essential role in providing care that helps mothers establish and continue breastfeeding. The U.S. Surgeon General and numerous health professional organizations recommend providing care aligned with the Baby-Friendly Hospital Initiative (BFHI), including adherence to the Ten Steps to Successful Breastfeeding (Ten Steps), as well as not providing gift packs containing infant formula. Implementing BFHI-aligned maternity care improves duration of any and exclusive breastfeeding among mothers; however, studies have not examined associations between BFHI-aligned maternity care and breastfeeding outcomes solely among adolescent mothers (for this report, adolescents refers to persons aged 12-19 years). Therefore, CDC analyzed 2009-2011 Pregnancy Risk Assessment Monitoring System (PRAMS) data and determined that among adolescent mothers who initiated breastfeeding, self-reported prevalence of experiencing any of the nine selected BFHI-aligned maternity care practices included in the PRAMS survey ranged from 29.2% to 95.4%. Among the five practices identified to be significantly associated with breastfeeding outcomes in this study, the more practices a mother experienced, the more likely she was to be breastfeeding (any amount or exclusively) at 4 weeks and 8 weeks postpartum. Given the substantial health advantages conferred to mothers and children through breastfeeding, and the particular vulnerability of adolescent mothers to lower breastfeeding rates, it is important for hospitals to provide evidence-based maternity practices related to breastfeeding as part of their routine care to all mothers, including adolescent mothers.

Vital Signs: Trends and Disparities in Infant Safe Sleep Practices — United States, 2009–2015

INTRODUCTION There have been dramatic improvements in reducing infant sleep-related deaths since the 1990s, when recommendations were introduced to place infants on their backs for sleep. However, there are still approximately 3,500 sleep-related deaths among infants each year in the United States, including those from sudden infant death syndrome, accidental suffocation and strangulation in bed, and unknown causes. Unsafe sleep practices, including placing infants in a nonsupine (on side or on stomach) sleep position, bed sharing, and using soft bedding in the sleep environment (e.g., blankets, pillows, and soft objects) are modifiable risk factors for sleep-related infant deaths.

A Multifaceted Strategy to Implement Brief Smoking Cessation Counseling During Antenatal Care in Argentina and Uruguay: A Cluster Randomized Trial.

INTRODUCTION Argentina and Uruguay have a high prevalence of smoking during pregnancy. However, and despite national recommendations, pregnant women are not routinely receiving cessation counseling during antenatal care (ANC). We evaluated a multifaceted strategy designed to increase the frequency of pregnant women who received a brief smoking cessation counseling based on the 5As (Ask, Advise, Assess, Assist, and Arrange). METHODS We randomly assigned (1:1) 20 ANC clusters in Buenos Aires, Argentina and Montevideo, Uruguay to receive a multifaceted intervention to implement brief smoking cessation counseling into routine ANC, or to receive no intervention. The primary outcome was the frequency of women who recalled receiving the 5As during ANC at more than one visit. Frequency of women who smoked until the end of pregnancy, and attitudes and readiness of ANC providers towards providing counseling were secondary outcomes. Womens outcomes were measured at baseline and at the end of the 14- to 18-month intervention, by administering questionnaires at the postpartum hospital stay. Self-reported cessation was verified with saliva cotinine. The trial took place between October 03, 2011 and November 29, 2013. RESULTS The rate of women who recalled receiving the 5As increased from 14.0% to 33.6% in the intervention group (median rate change, 22.1%), and from 10.8% to 17.0% in the control group (median rate change, 4.6%; P = .001 for the difference in change between groups). The effect of the intervention was larger in Argentina than in Uruguay. The proportion of women who continued smoking during pregnancy was unchanged at follow-up in both groups and the relative difference between groups was not statistically significant (ratio of odds ratios 1.16, 95% CI: 0.98-1.37; P = .086). No significant changes were observed in knowledge, attitudes, and self-confidence of ANC providers. CONCLUSIONS The intervention showed a moderate effect in increasing the proportion of women who recalled receiving the 5As, with a third of women receiving counseling in more than one visit. However, the frequency of women who smoked until the end of the pregnancy was not significantly reduced by the intervention. IMPLICATIONS No implementation trials of smoking cessation interventions for pregnant women have been carried out in Latin American or in middle-income countries where health care systems or capacities may differ. We evaluated a multifaceted strategy designed to increase the frequency of pregnant women who receive brief smoking cessation counseling based on the 5As in Argentina and Uruguay. We found that the intervention showed a moderate effect in increasing the proportion of women receiving the 5As, with a third of women receiving counseling in more than one visit. However, the frequency of women who smoked until the end of the pregnancy was not significantly reduced by the intervention.

Neonatal Withdrawal Syndrome, Michigan, 2000–2009

BACKGROUND Neonatal withdrawal syndrome, which is associated most frequently with opioid use in pregnancy, is an emerging public health concern, with recent studies documenting an increase in the rate of U.S. infants diagnosed. PURPOSE This study examined neonatal withdrawal syndrome diagnosis among Michigan infants from 2000 to 2009 and hospital length of stay (LOS) between infants with and without the syndrome for a subset of years (2006-2009). METHODS Michigan live birth records from 2000 to 2009 were linked with hospital discharge data to identify infants with neonatal withdrawal syndrome. Linked data were restricted to infants born between 2006 and 2009 to examine the difference in hospital LOS between infants with and without the syndrome. Multivariable regression models were constructed to examine the adjusted impact of syndrome diagnosis on infant LOS and fit using negative binomial distribution. Data were analyzed from July 2011 to February 2012. RESULTS From 2000 to 2009, the overall birth rate of infants with neonatal withdrawal syndrome increased from 41.2 to 289.0 per 100,000 live births (p<0.0001). Among infants born from 2006 to 2009, the average hospital LOS for those with the syndrome was between 1.36 (95% CI=1.24, 1.49) and 5.75 (95% CI=5.41, 6.10) times longer than for infants without it. CONCLUSIONS Diagnosis of neonatal withdrawal syndrome increased significantly in Michigan with infants who had the syndrome requiring a significantly longer LOS compared to those without it.

Disparities in Fetal Death and First Day Death: The Influence of Risk Factors in 2 Time Periods

OBJECTIVES We examined how changes in risk factors over time influence fetal, first day, and combined fetal-first day mortality and subsequent racial/ethnic disparities. METHODS We selected deliveries to US resident non-Hispanic White and Black mothers from the linked live birth-infant death cohort and fetal deaths files (1995-1996; 2001-2002) and calculated changes over time of mortality rates, odds, and relative odds ratios (RORs) overall and among mothers with modifiable risk factors (smoking, diabetes, or hypertensive disorders). RESULTS Adjusted odds ratios (AORs) for fetal mortality overall (AOR=0.99; 95% confidence interval [CI]=0.96, 1.01) and among Blacks (AOR=0.98; 95% CI=0.93, 1.03) indicated no change over time. Among women with modifiable risk factors, the RORs indicated no change in disparities. The ROR was not significant for fetal mortality (ROR=0.96; 95% CI=0.83, 1.01) among smokers, but there was evidence of some decline. There was evidence of increase in RORs in fetal death among mothers with diabetes and hypertensive disorders, but differences were not significant. CONCLUSIONS Disparities in fetal, first day, and combined fetal-first day mortality have persisted and reflect discrepancies in care provision or other factors more challenging to measure.

Smoking Patterns and Receipt of Cessation Services Among Pregnant Women in Argentina and Uruguay

INTRODUCTION The 5As (Ask, Advise, Assess, Assist, and Arrange) strategy, a best-practice approach for cessation counseling, has been widely implemented in high-income countries for pregnant women; however, no studies have evaluated implementation in middle-income countries. The study objectives were to assess smoking patterns and receipt of 5As among pregnant women in Buenos Aires, Argentina and Montevideo, Uruguay. METHODS Data were collected through administered questionnaires to women at delivery hospitalizations during October 2011-May 2012. Eligible women attended one of 12 maternity hospitals or 21 associated prenatal care clinics. The questionnaire included demographic data, tobacco use/cessation behaviors, and receipt of the 5As. Self-reported cessation was verified with saliva cotinine. RESULTS Overall, of 3400 pregnant women, 32.8% smoked at the beginning of pregnancy; 11.9% quit upon learning they were pregnant or later during pregnancy, and 20.9% smoked throughout pregnancy. Smoking prevalence varied by country with 16.1% and 26.7% who smoked throughout pregnancy in Argentina and Uruguay, respectively. Among pregnant smokers in Argentina, 23.8% reported that a provider asked them about smoking at more than one prenatal care visit; 18.5% were advised to quit; 5.3% were assessed for readiness to quit, 4.7% were provided assistance, and 0.7% reported follow-up was arranged. In Uruguay, those percentages were 36.3%, 27.9%, 5.4%, 5.6%, and 0.2%, respectively. CONCLUSIONS Approximately, one in six pregnant women smoked throughout pregnancy in Buenos Aires and one in four in Montevideo. However, a low percentage of smokers received any cessation assistance in both countries. Healthcare providers are not fully implementing the recommended 5As intervention to help pregnant women quit smoking.