Comparison of 2 Case Definitions for Ascertaining the Prevalence of Autism Spectrum Disorder Among 8-Year-Old Children

The Autism and Developmental Disabilities Monitoring (ADDM) Network conducts population-based surveillance of autism spectrum disorder (ASD) among 8-year-old children in multiple US communities. From 2000 to 2016, investigators at ADDM Network sites classified ASD from collected text descriptions of behaviors from medical and educational evaluations which were reviewed and coded by ADDM Network clinicians. It took at least 4 years to publish data from a given surveillance year. In 2018, we developed an alternative case definition utilizing ASD diagnoses or classifications made by community professionals. Using data from surveillance years 2014 and 2016, we compared the new and previous ASD case definitions. Compared with the prevalence based on the previous case definition, the prevalence based on the new case definition was similar for 2014 and slightly lower for 2016. Sex and race/ethnicity prevalence ratios were nearly unchanged. Compared with the previous case definition, the new case definition's sensitivity was 86% and its positive predictive value was 89%. The new case definition does not require clinical review and collects about half as much data, yielding more timely reporting. It also more directly measures community identification of ASD, thus allowing for more valid comparisons among communities, and reduces resource requirements while retaining measurement properties similar to those of the previous definition.

Potential Contributions of Clinical and Community Testing in Identifying Persons with Undiagnosed HIV Infection in the United States

BACKGROUND

An estimated 166,155 individuals in the United States have undiagnosed HIV infection. We modeled the numbers of HIV-infected individuals who could be diagnosed in clinical and community settings by broadly implementing HIV screening guidelines.

SETTING

United States.

METHODS

We modeled testing for general population (once lifetime) and high-risk populations (annual): men who have sex with men, people who inject drugs, and high-risk heterosexuals. We used published data on HIV infections, HIV testing, engagement in clinical care, and risk status disclosure.

RESULTS

In clinical settings, about 76 million never-tested low-risk and 2.6 million high-risk individuals would be tested, yielding 36,000 and 55,000 HIV diagnoses, respectively. In community settings, 30 million low-risk and 4.4 million high-risk individuals would be tested, yielding 75,000 HIV diagnoses.

CONCLUSION

HIV testing in clinical and community settings diagnoses similar numbers of individuals. Lifetime and risk-based testing are both needed to substantially reduce undiagnosed HIV.

Prevalence of intellectual disability among eight-year-old children from selected communities in the United States, 2014

BACKGROUND

Children with intellectual disability (ID), characterized by impairments in intellectual functioning and adaptive behavior, benefit from early identification and access to services. Previous U.S. estimates used administrative data or parent report with limited information for demographic subgroups.

OBJECTIVE

Using empiric measures we examined ID characteristics among 8-year-old children and estimated prevalence by sex, race/ethnicity, geographic area and socioeconomic status (SES) area indicators.

METHODS

We analyzed data for 8-year-old children in 9 geographic areas participating in the 2014 Autism and Developmental Disabilities Monitoring Network. Children with ID were identified through record review of IQ test data. Census and American Community Survey data were used to estimate the denominator.

RESULTS

Overall, 11.8 per 1,000 (1.2%) had ID (IQ ≤ 70), of whom 39% (n = 998) also had autism spectrum disorder. Among children with ID, 1,823 had adaptive behavior test scores for which 64% were characterized as impaired. ID prevalence per 1,000 was 15.8 (95% confidence interval [95% CI], 15.0-16.5) among males and 7.7 (95% CI, 7.2-8.2) among females. ID prevalence was 17.7 (95% CI, 16.6-18.9) among children who were non-Hispanic black; 12.0 (95% CI, 11.1-13.0), among Hispanic; 8.6 (95% CI, 7.1-10.4), among non-Hispanic Asian; and 8.0 (95% CI, 7.5-8.6), among non-Hispanic white. Prevalence varied across geographic areas and was inversely associated with SES.

CONCLUSIONS

ID prevalence varied substantively among racial, ethnic, geographic, and SES groups. Results can inform strategies to enhance identification and improve access to services particularly for children who are minorities or living in areas with lower SES.

National and State Estimates of Adults with Autism Spectrum Disorder

U.S. national and state population-based estimates of adults living with autism spectrum disorder (ASD) are nonexistent due to the lack of existing surveillance systems funded to address this need. Therefore, we estimated national and state prevalence of adults 18-84 years living with ASD using simulation in conjunction with Bayesian hierarchal models. In 2017, we estimated that approximately 2.21% (95% simulation interval (SI) 1.95%, 2.45%) or 5,437,988 U.S. adults aged 18 and older have ASD, with state prevalence ranging from 1.97% (95% SI 1.55%, 2.45%) in Louisiana to 2.42% (95% SI 1.93%, 2.99%) in Massachusetts. Prevalence and case estimates of adults living with ASD (diagnosed and undiagnosed) can help states estimate the need for diagnosing and providing services to those unidentified.

Factors Associated with State Variation in Mortality Among Persons Living with Diagnosed HIV Infection

In the United States, the all-cause mortality rate among persons living with diagnosed HIV infection (PLWH) is almost twice as high as among the general population. We aimed to identify amendable factors that state public health programs can influence to reduce mortality among PLWH. Using generalized estimating equations (GEE), we estimated age-group-specific models (24-34, 35-54, ≥ 55 years) to assess the association between state-level mortality rates among PLWH during 2010-2014 (National HIV Surveillance System) and amendable factors (percentage of Ryan White HIV/AIDS Program (RWHAP) clients with viral suppression, percentage of residents with healthcare coverage, state-enacted anti-discrimination laws index) while controlling for sociodemographic nonamendable factors. Controlling for nonamendable factors, states with 5% higher viral suppression among RWHAP clients had a 3-5% lower mortality rates across all age groups [adjusted Risk Ratio (aRR): 0.95, 95% Confidence Interval (CI): 0.92-0.99 for 24-34 years, aRR: 0.97, 95%CI: 0.94-0.99 for 35-54 years, aRR: 0.96, 95%CI: 0.94-0.99 for ≥ 55 years]; states with 5% higher health care coverage had 4-11% lower mortality rate among older age groups (aRR: 0.96, 95%CI: 0.93-0.99 for 34-54 years; aRR: 0.89, 95%CI: 0.81-0.97 for ≥ 55 years); and having laws that address one additional area of anti-discrimination was associated with a 2-3% lower mortality rate among older age groups (aRR: 0.98, 95%CI: 0.95-1.00 for 34-54 years; aRR: 0.97, 95%CI: 0.94-0.99 for ≥ 55 years). The mortality rate among PLWH was lower in states with higher levels of residents with healthcare coverage, anti-discrimination laws, and viral suppression among RWHAP clients. States can influence these factors through programs and policies.

Early Identification of Autism Spectrum Disorder Among Children Aged 4 Years - Early Autism and Developmental Disabilities Monitoring Network, Six Sites, United States, 2016

PROBLEM/CONDITION

Autism spectrum disorder (ASD).

PERIOD COVERED

2016.

DESCRIPTION OF SYSTEM

The Early Autism and Developmental Disabilities Monitoring (Early ADDM) Network, a subset of the overall ADDM Network, is an active surveillance program that estimates ASD prevalence and monitors early identification of ASD among children aged 4 years. Children included in surveillance year 2016 were born in 2012 and had a parent or guardian who lived in the surveillance area in Arizona, Colorado, Missouri, New Jersey, North Carolina, or Wisconsin, at any time during 2016. Children were identified from records of community sources including general pediatric health clinics, special education programs, and early intervention programs. Data from comprehensive evaluations performed by community professionals were abstracted and reviewed by trained clinicians using a standardized ASD surveillance case definition with criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

RESULTS

In 2016, the overall ASD prevalence was 15.6 per 1,000 (one in 64) children aged 4 years for Early ADDM Network sites. Prevalence varied from 8.8 per 1,000 in Missouri to 25.3 per 1,000 in New Jersey. At every site, prevalence was higher among boys than among girls, with an overall male-to-female prevalence ratio of 3.5 (95% confidence interval [CI] = 3.1-4.1). Prevalence of ASD between non-Hispanic white (white) and non-Hispanic black (black) children was similar at each site (overall prevalence ratio: 0.9; 95% CI = 0.8-1.1). The prevalence of ASD using DSM-5 criteria was lower than the prevalence using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria at one of four sites that used criteria from both editions. Among sites where ≥60% of children aged 4 years had information about intellectual disability (intelligence quotient ≤70 or examiner's statement of intellectual disability documented in an evaluation), 53% of children with ASD had co-occurring intellectual disability. Of all children aged 4 years with ASD, 84% had a first evaluation at age ≤36 months and 71% of children who met the surveillance case definition had a previous ASD diagnosis from a community provider. Median age at first evaluation and diagnosis for this age group was 26 months and 33 months, respectively. Cumulative incidence of autism diagnoses received by age 48 months was higher for children aged 4 years than for those aged 8 years identified in Early ADDM Network surveillance areas in 2016.

INTERPRETATION

In 2016, the overall prevalence of ASD in the Early ADDM Network using DSM-5 criteria (15.6 per 1,000 children aged 4 years) was higher than the 2014 estimate using DSM-5 criteria (14.1 per 1,000). Children born in 2012 had a higher cumulative incidence of ASD diagnoses by age 48 months compared with children born in 2008, which indicates more early identification of ASD in the younger group. The disparity in ASD prevalence has decreased between white and black children. Prevalence of co-occurring intellectual disability was higher than in 2014, suggesting children with intellectual disability continue to be identified at younger ages. More children received evaluations by age 36 months in 2016 than in 2014, which is consistent with Healthy People 2020 goals. Median age at earliest ASD diagnosis has not changed considerably since 2014.

PUBLIC HEALTH ACTION

More children aged 4 years with ASD are being evaluated by age 36 months and diagnosed by age 48 months, but there is still room for improvement in early identification. Timely evaluation of children by community providers as soon as developmental concerns have been identified might result in earlier ASD diagnoses, earlier receipt of evidence-based interventions, and improved developmental outcomes.

Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2016

PROBLEM/CONDITION

Autism spectrum disorder (ASD).

PERIOD COVERED

2016.

DESCRIPTION OF SYSTEM

The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance program that provides estimates of the prevalence of ASD among children aged 8 years whose parents or guardians live in 11 ADDM Network sites in the United States (Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin). Surveillance is conducted in two phases. The first phase involves review and abstraction of comprehensive evaluations that were completed by medical and educational service providers in the community. In the second phase, experienced clinicians who systematically review all abstracted information determine ASD case status. The case definition is based on ASD criteria described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

RESULTS

For 2016, across all 11 sites, ASD prevalence was 18.5 per 1,000 (one in 54) children aged 8 years, and ASD was 4.3 times as prevalent among boys as among girls. ASD prevalence varied by site, ranging from 13.1 (Colorado) to 31.4 (New Jersey). Prevalence estimates were approximately identical for non-Hispanic white (white), non-Hispanic black (black), and Asian/Pacific Islander children (18.5, 18.3, and 17.9, respectively) but lower for Hispanic children (15.4). Among children with ASD for whom data on intellectual or cognitive functioning were available, 33% were classified as having intellectual disability (intelligence quotient [IQ] ≤70); this percentage was higher among girls than boys (39% versus 32%) and among black and Hispanic than white children (47%, 36%, and 27%, respectively) [corrected]. Black children with ASD were less likely to have a first evaluation by age 36 months than were white children with ASD (40% versus 45%). The overall median age at earliest known ASD diagnosis (51 months) was similar by sex and racial and ethnic groups; however, black children with IQ ≤70 had a later median age at ASD diagnosis than white children with IQ ≤70 (48 months versus 42 months).

INTERPRETATION

The prevalence of ASD varied considerably across sites and was higher than previous estimates since 2014. Although no overall difference in ASD prevalence between black and white children aged 8 years was observed, the disparities for black children persisted in early evaluation and diagnosis of ASD. Hispanic children also continue to be identified as having ASD less frequently than white or black children.

PUBLIC HEALTH ACTION

These findings highlight the variability in the evaluation and detection of ASD across communities and between sociodemographic groups. Continued efforts are needed for early and equitable identification of ASD and timely enrollment in services.

Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2016

PROBLEM/CONDITION

Autism spectrum disorder (ASD).

PERIOD COVERED

2016.

DESCRIPTION OF SYSTEM

The Autism and Developmental Disabilities Monitoring (ADDM) Network is an active surveillance program that provides estimates of the prevalence of ASD among children aged 8 years whose parents or guardians live in 11 ADDM Network sites in the United States (Arizona, Arkansas, Colorado, Georgia, Maryland, Minnesota, Missouri, New Jersey, North Carolina, Tennessee, and Wisconsin). Surveillance is conducted in two phases. The first phase involves review and abstraction of comprehensive evaluations that were completed by medical and educational service providers in the community. In the second phase, experienced clinicians who systematically review all abstracted information determine ASD case status. The case definition is based on ASD criteria described in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

RESULTS

For 2016, across all 11 sites, ASD prevalence was 18.5 per 1,000 (one in 54) children aged 8 years, and ASD was 4.3 times as prevalent among boys as among girls. ASD prevalence varied by site, ranging from 13.1 (Colorado) to 31.4 (New Jersey). Prevalence estimates were approximately identical for non-Hispanic white (white), non-Hispanic black (black), and Asian/Pacific Islander children (18.5, 18.3, and 17.9, respectively) but lower for Hispanic children (15.4). Among children with ASD for whom data on intellectual or cognitive functioning were available, 33% were classified as having intellectual disability (intelligence quotient [IQ] ≤70); this percentage was higher among girls than boys (39% versus 32%) and among black and Hispanic than white children (47%, 36%, and 27%, respectively) [corrected]. Black children with ASD were less likely to have a first evaluation by age 36 months than were white children with ASD (40% versus 45%). The overall median age at earliest known ASD diagnosis (51 months) was similar by sex and racial and ethnic groups; however, black children with IQ ≤70 had a later median age at ASD diagnosis than white children with IQ ≤70 (48 months versus 42 months).

INTERPRETATION

The prevalence of ASD varied considerably across sites and was higher than previous estimates since 2014. Although no overall difference in ASD prevalence between black and white children aged 8 years was observed, the disparities for black children persisted in early evaluation and diagnosis of ASD. Hispanic children also continue to be identified as having ASD less frequently than white or black children.

PUBLIC HEALTH ACTION

These findings highlight the variability in the evaluation and detection of ASD across communities and between sociodemographic groups. Continued efforts are needed for early and equitable identification of ASD and timely enrollment in services.

HIV Testing, Access to HIV-Related Services, and Late-Stage HIV Diagnoses Across US States, 2013-2016

Objectives. To examine state-level factors associated with late-stage HIV diagnoses in the United States.Methods. We examined state-level factors associated with late-stage diagnoses by estimating negative binomial regression models. We used 2013 to 2016 data from the National HIV Surveillance System (late-stage diagnoses), the Behavioral Risk Factor Surveillance System (HIV testing), and the American Community Survey (sociodemographics).Results. Among individuals 25 to 44 years old, a 5% increase in the percentage of the state population tested for HIV in the preceding 12 months was associated with a 3% decrease in late-stage diagnoses. Among both individuals 25 to 44 years of age and those aged 45 years and older, a 5% increase in the percentage of the population living in a rural area was associated with a 2% to 3% increase in late-stage diagnoses.Conclusions. Increasing HIV testing may lower late-stage HIV diagnoses among younger individuals. Increasing HIV-related services may benefit both younger and older people in rural areas.

Number and cost of hospitalizations with principal and secondary diagnoses of tuberculosis, United States

OBJECTIVE

To estimate the number and cost of hospitalizations with a diagnosis of active tuberculosis (TB) disease in the United States.

METHODS

We analyzed the 2014 National In-Patient Sample using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes to identify hospitalizations with a principal (TB-PD) or any secondary discharge (TB-SD) TB diagnosis. We used a generalized linear model with log link and gamma distribution to estimate the cost per TB-PD and TB-SD episode adjusted for patient demographics, insurer, clinical elements, and hospital characteristics.

RESULTS

We estimated 4985 TB-PD and 6080 TB-SD hospitalizations nationwide. TB-PD adjusted averaged $16 695 per episode (95%CI $16 168-$17 221). The average for miliary/disseminated TB ($22 498, 95%CI $21 067-$23 929) or TB of the central nervous system ($28 338, 95%CI $25 836-$30 840) was significantly greater than for pulmonary TB ($14 819, 95%CI $14 284-$15 354). The most common principal diagnoses for TB-SD were septicemia (n = 965 hospitalizations), human immunodeficiency virus infection (n = 610), pneumonia (n = 565), and chronic obstructive pulmonary disease and bronchiectasis (COPD-B, n = 150). The adjusted average cost per TB-SD episode was $15 909 (95%CI $15 337-$16 481), varying between $8687 (95%CI $8337-$9036) for COPD-B and $23 335 (95%CI $21 979-$24 690) for septicemia. TB-PD cost the US health care system $123.4 million (95%CI $106.3-$140.5) and TB-SD cost $141.9 million ($128.4-$155.5), of which Medicaid/Medicare covered respectively 67.2% and 69.7%.

CONCLUSIONS

TB hospitalizations result in substantial costs within the US health care system.

Estimated cost of comprehensive syringe service program in the United States

OBJECTIVE

To estimate the cost of establishing and operating a comprehensive syringe service program (SSP) free to clients in the United States.

METHODS

We identified the major cost components of a comprehensive SSP: (one-time start-up cost, and annual costs associated with personnel, operations, and prevention/medical services) and estimated the anticipated total costs (2016 US dollars) based on program size (number of clients served each year) and geographic location of the service (rural, suburban, and urban).

RESULTS

The estimated costs ranged from $0.4 million for a small rural SSP (serving 250 clients) to $1.9 million for a large urban SSP (serving 2,500 clients), of which 1.6% and 0.8% is the start-up cost of a small rural and large urban SSP, respectively. Cost per syringe distributed varied from $3 (small urban SSP) to $1 (large rural SSP), and cost per client per year varied from $2000 (small urban SSP) to $700 (large rural SSP).

CONCLUSIONS

Estimates of the cost of SSPs in the United States vary by number of clients served and geographic location of service. Accurate costing can be useful for planning programs, developing policy, allocating funds for establishing and supporting SSPs, and providing data for economic evaluation of SSPs.

Increasing Syphilis Diagnoses Among Females Giving Birth in US Hospitals, 2010-2014

BACKGROUND

National trends in syphilis rates among females delivering newborns are not well characterized. We assessed 2010-2014 trends in syphilis diagnoses documented on discharge records and associated factors among females who have given birth in US hospitals.

METHODS

We calculated quarterly trends in syphilis rates (per 100,000 deliveries) by using International Classification of Diseases, Ninth Revision, Clinical Modification codes on delivery discharge records from the National Inpatient Sample. Changes in trends were determined by using Joinpoint software. We estimated relative risks (RR) to assess the association of syphilis diagnoses with race/ethnicity, age, insurance status, household income, and census region.

RESULTS

Overall, estimated syphilis rates decreased during 2010-2012 at 1.0% per quarter (P < 0.001) and increased afterward at 1.8% (P < 0.001). The syphilis rate increase was statistically significant across all sociodemographic groups and all US regions, with substantial increases identified among whites (35.2% per quarter; P < 0.001) and Medicaid recipients (15.1%; P < 0.001). In 2014, the risk of syphilis diagnosis was greater among blacks (RR, 13.02; 95% confidence interval [CI], 9.46-17.92) or Hispanics (RR, 4.53; 95% CI, 3.19-6.42), compared with whites; Medicaid recipients (RR, 4.63; 95% CI, 3.38-6.33) or uninsured persons (RR, 2.84; 95% CI, 1.74-4.63), compared with privately insured patients; females with the lowest household income (RR, 5.32; 95% CI, 3.55-7.97), compared with the highest income; and females in the South (RR, 2.42; 95% CI, 1.66-3.53), compared with the West.

CONCLUSIONS

Increasing syphilis rates among pregnant females of all backgrounds reinforce the importance of prenatal screening and treatment.

Centers for Disease Control and Prevention Funding for HIV Testing Associated With Higher State Percentage of Persons Tested

OBJECTIVES

To assess the association between state per capita allocations of Centers for Disease Control and Prevention (CDC) funding for HIV testing and the percentage of persons tested for HIV.

SETTING AND PARTICIPANTS

We examined data from 2 sources: 2011 Behavioral Risk Factor Surveillance System and 2010-2011 State HIV Budget Allocations Reports. Behavioral Risk Factor Surveillance System data were used to estimate the percentage of persons aged 18 to 64 years who had reported testing for HIV in the last 2 years in the United States by state. State HIV Budget Allocations Reports were used to calculate the state mean annual per capita allocations for CDC-funded HIV testing reported by state and local health departments in the United States.

DESIGN

The association between the state fixed-effect per capita allocations for CDC-funded HIV testing and self-reported HIV testing in the last 2 years among persons aged 18 to 64 years was assessed with a hierarchical logistic regression model adjusting for individual-level characteristics.

MAIN OUTCOME

The percentage of persons tested for HIV in the last 2 years.

RESULTS

In 2011, 18.7% (95% confidence interval = 18.4-19.0) of persons reported being tested for HIV in last 2 years (state range, 9.7%-28.2%). During 2010-2011, the state mean annual per capita allocation for CDC-funded HIV testing was $0.34 (state range, $0.04-$1.04). A $0.30 increase in per capita allocation for CDC-funded HIV testing was associated with an increase of 2.4 percentage points (14.0% vs 16.4%) in the percentage of persons tested for HIV per state.

CONCLUSIONS

Providing HIV testing resources to health departments was associated with an increased percentage of state residents tested for HIV.

Barriers and promoters of an evidenced-based smoking cessation counseling during prenatal care in Argentina and Uruguay

In Argentina and Uruguay, 10.3 and 18.3 %, respectively, of pregnant women smoked in 2005. Brief cessation counseling, based on the 5A's model, has been effective in different settings. This qualitative study aims to improve the understanding of factors influencing the provision of smoking cessation counseling during pregnancy in Argentina and Uruguay. In 2010, we obtained prenatal care providers', clinic directors', and pregnant smokers' opinions regarding barriers and promoters to brief smoking cessation counseling in publicly-funded prenatal care clinics in Buenos Aires, Argentina and Montevideo, Uruguay. We interviewed six prenatal clinic directors, conducted focus groups with 46 health professionals and 24 pregnant smokers. Themes emerged from three issue areas: health professionals, health system, and patients. Health professional barriers to cessation counseling included inadequate knowledge and motivation, perceived low self-efficacy, and concerns about inadequate time and large workload. They expressed interest in obtaining a counseling script. Health system barriers included low prioritization of smoking cessation and a lack of clinic protocols to implement interventions. Pregnant smokers lacked information on the risks of prenatal smoking and underestimated the difficulty of smoking cessation. Having access to written materials and receiving cessation services during clinic waiting times were mentioned as promoters for the intervention. Women also were receptive to non-physician office staff delivering intervention components. Implementing smoking cessation counseling in publicly-funded prenatal care clinics in Argentina and Uruguay may require integrating counseling into routine prenatal care and educating and training providers on best-practices approaches.

Pregnant women's secondhand smoke exposure and receipt of screening and brief advice by prenatal care providers in Argentina and Uruguay

Secondhand smoke (SHS) exposure has negative effects on maternal and infant health. SHS exposure among pregnant women in Argentina and Uruguay has not been previously described, nor has the proportion of those who have received screening and advice to avoid SHS during prenatal care. Women who attended one of 21 clusters of publicly-funded prenatal care clinics were interviewed regarding SHS exposure during pregnancy at their delivery hospitalization during 2011-2012. Analyses were conducted using SURVEYFREQ procedure in SAS version 9.3 to account for prenatal clinic clusters. Of 3,427 pregnant women, 43.4 % had a partner who smoked, 52.3 % lived with household members who smoked cigarettes, and 34.4 % had no or partial smoke-free home rule. Of 528 pregnant women who worked outside of the home, 21.6 % reported past month SHS exposure at work and 38.1 % reported no or partial smoke-free work policy. Overall, 35.9 % of women were exposed to SHS at home or work. In at least one prenatal care visit, 67.2 % of women were screened for SHS exposure, and 56.6 % received advice to avoid SHS. Also, 52.6 % of women always avoided SHS for their unborn baby's health. In summary, a third of pregnant women attending publicly-funded prenatal clinics were exposed to SHS, and only half of pregnant women always avoided SHS for their unborn baby's health. Provider screening and advice rates can be improved in these prenatal care settings, as all pregnant women should be screened and advised of the harms of SHS and how to avoid it.

HIV Testing among Outpatients with Medicaid and Commercial Insurance

Objective

To assess HIV testing and factors associated with receipt of testing among persons with Medicaid and commercial insurance during 2012.

Methods

Outpatient and laboratory claims were analyzed from two databases: all Medicaid claims from six states and all claims from Medicaid health plans from four other states and a large national convenience sample of patients with commercial insurance in the United States. We excluded those aged <13 years and >64 years, enrolled <9 of the 12 months, pregnant females, and previously diagnosed with HIV. We identified patients with new HIV diagnoses that followed (did not precede) the HIV test, using HIV ICD-9 codes. HIV testing percentages were assessed by patient demographics and other tests or diagnoses that occurred during the same visit.

Results

During 2012, 89,242 of 2,069,536 patients (4.3%) with Medicaid had at least one HIV test, and 850 (1.0%) of those tested received a new HIV diagnosis. Among 27,206,804 patients with commercial insurance, 757,646 (2.8%) had at least one HIV test, and 5,884 (0.8%) of those tested received a new HIV diagnosis. During visits that included an HIV test, 80.2% of Medicaid and 83.0% of commercial insurance claims also included a test or diagnosis for a sexually transmitted infection (STI), and/or Hepatitis B or C virus at the same visit.

Conclusions

HIV testing primarily took place concurrently with screening or diagnoses for STIs or Hepatitis B or C. We found little evidence to suggest routine screening for HIV infection was widespread.

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. Women's 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.

Epidemiology and risk factors for Ebola virus disease in Sierra Leone-23 May 2014 to 31 January 2015

BACKGROUND

Sierra Leone has the most cases of Ebola virus disease (EVD) ever reported. Trends in laboratory-confirmed EVD, symptom presentation, and risk factors have not been fully described.

METHODS

EVD cases occurring from 23 May 2014 to 31 January 2015 are presented by geography, demographics, and risk factors for all persons who had laboratory-confirmed EVD, which was identified by Ebola virus-specific reverse-transcription polymerase chain reaction-based testing.

RESULTS

During the study period, 8056 persons had laboratory-confirmed EVD. Their median age was 28 years; 51.7% were female. Common symptoms included fever (90.4%), fatigue (88.3%), loss of appetite (87.0%), headache (77.9%), joint pain (73.7%), vomiting (71.2%), and diarrhea (70.6%). Among persons with confirmed cases, 47.9% reported having had contact with someone with suspected EVD or any sick person, and 25.5% reported having attended a funeral, of whom 66.2% reported touching the body. The incidence of EVD was highest during 1-30 November 2014, at 7.5 per 100 000 population per week, and decreased to 2.1 per week during 1-31 January 2015. Between 23 May and 30 August 2014, two districts had the highest incidence of 3.8 and 7.0 per 100 000 population per week which decreased >97% by 1-31 January 2015. In comparison, the districts that include the capital city reported a 10-fold increase in incidence per week during the same time periods.

CONCLUSIONS

Almost half of patients with EVD in Sierra Leone reported physical contact with a person ill with EVD or a dead body, highlighting prevention opportunities.

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

INTRODUCTION

The 5A's (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 5A's 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 5A's. 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 5A's intervention to help pregnant women quit smoking.

Trends in gestational weight gain: the Pregnancy Risk Assessment Monitoring System, 2000-2009

OBJECTIVE

Achieving adequate gestational weight gain (GWG) is important for optimal health of the infant and mother. We estimate current population-based trends of GWG.

STUDY DESIGN

We analyzed data from the Pregnancy Risk Assessment Monitoring System for 124,348 women who delivered live infants in 14 states during 2000 through 2009. We examined prevalence and trends in GWG in pounds as a continuous variable, and within 1990 Institute of Medicine (IOM) recommendations (yes/no) as a dichotomous variable. We examined adjusted trends in mean GWG using multivariable linear regression and GWG within recommendations using multivariable multinomial logistic regression.

RESULTS

During 2000 through 2009, 35.8% of women gained within IOM GWG recommendations, 44.4% gained above, and 19.8% gained below. From 2000 through 2009, there was a biennial 1.0 percentage point decrease in women gaining within IOM GWG recommendations (P trend < .01) and a biennial 0.8 percentage point increase in women gaining above IOM recommendations (P trend < .01). The percentage of women gaining weight below IOM recommendations remained relatively constant from 2000 through 2009 (P trend = .14). The adjusted odds of gaining within IOM recommendations were lower in 2006 through 2007 (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) and 2008 through 2009 (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) relative to 2000 through 2001.

CONCLUSION

Overall, from 2000 through 2009 the percentage of women gaining within IOM recommendations slightly decreased while mean GWG slightly increased. Efforts are needed to develop and implement strategies to ensure that women achieve GWG within recommendations.

Ebola virus disease in health care workers--Sierra Leone, 2014

Health care workers (HCWs) are at increased risk for infection in outbreaks of Ebola virus disease (Ebola). To characterize Ebola in HCWs in Sierra Leone and guide prevention efforts, surveillance data from the national Viral Hemorrhagic Fever database were analyzed. In addition, site visits and interviews with HCWs and health facility administrators were conducted. As of October 31, 2014, a total of 199 (5.2%) of the total of 3,854 laboratory-confirmed Ebola cases reported from Sierra Leone were in HCWs, representing a much higher estimated cumulative incidence of confirmed Ebola in HCWs than in non-HCWs, based on national data on the number of HCW. The peak number of confirmed Ebola cases in HCWs was reported in August (65 cases), and the highest number and percentage of confirmed Ebola cases in HCWs was in Kenema District (65 cases, 12.9% of cases in Kenema), mostly from Kenema General Hospital. Confirmed Ebola cases in HCWs continued to be reported through October and were from 12 of 14 districts in Sierra Leone. A broad range of challenges were reported in implementing infection prevention and control measures. In response, the Ministry of Health and Sanitation and partners are developing standard operating procedures for multiple aspects of infection prevention, including patient isolation and safe burials; recruiting and training staff in infection prevention and control; procuring needed commodities and equipment, including personal protective equipment and vehicles for safe transport of Ebola patients and corpses; renovating and constructing Ebola care facilities designed to reduce risk for nosocomial transmission; monitoring and evaluating infection prevention and control practices; and investigating new cases of Ebola in HCWs as sentinel public health events to identify and address ongoing prevention failures.

Ohio primary health care providers' practices and attitudes regarding screening women with prior gestational diabetes for type 2 diabetes mellitus--2010

INTRODUCTION

Gestational diabetes mellitus (GDM) is associated with a 7-fold increased lifetime risk for developing type 2 diabetes mellitus. Early diagnosis of type 2 diabetes is crucial for preventing complications. Despite recommendations for type 2 diabetes screening every 1 to 3 years for women with previous diagnoses of GDM and all women aged 45 years or older, screening prevalence is unknown. We sought to assess Ohio primary health care providers' practices and attitudes regarding assessing GDM history and risk for progression to type 2 diabetes.

METHODS

During 2010, we mailed surveys to 1,400 randomly selected Ohio family physicians and internal medicine physicians; we conducted analyses during 2011-2013. Overall responses were weighted to adjust for stratified sampling. Chi-square tests compared categorical variables.

RESULTS

Overall response rate was 34% (380 eligible responses). Among all respondents, 57% reported that all new female patients in their practices are routinely asked about GDM history; 62% reported screening women aged 45 years or younger with prior GDM every 1 to 3 years for glucose intolerance; and 42% reported that screening for type 2 diabetes among women with prior GDM is a high or very high priority in their practice.

CONCLUSION

Because knowing a patient's GDM history is the critical first step in the prevention of progression to type 2 diabetes for women who had GDM, suboptimal screening for both GDM history and subsequent glucose abnormalities demonstrates missed opportunities for identifying and counseling women with increased risk for type 2 diabetes.

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%).

Evaluating universal education and screening for postpartum depression using population-based data

BACKGROUND

In 2006, New Jersey was the first state to mandate prenatal education and screening at hospital delivery for postpartum depression. We sought to evaluate provision of prenatal education and screening at delivery, estimate the prevalence of postpartum depressive symptoms, and identify venues where additional screening and education could occur.

METHODS

For women who delivered live infants during 2009 and 2010 in New Jersey, data on Edinburgh Postnatal Depression Scale scores assessed at hospital delivery and recorded on birth records were linked to survey data from the Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based survey of mothers completed 2-8 months postpartum (n=2,391). The PRAMS survey assesses postpartum depressive symptoms and whether the woman's prenatal care provider discussed the signs and symptoms of perinatal depression with her, used as a proxy for prenatal education on depression.

RESULTS

Two-thirds (67.0%) of women reported that a prenatal care provider discussed depression with them and 89.6% were screened for depression at hospital delivery. Among the 13% of women with depressive symptoms at hospital delivery or later in the postpartum period, over a third were Women, Infants, and Children program (WIC) participants, 13% to 32% had an infant in the neonatal intensive care unit (NICU), over 80% attended the maternal postpartum check-up, and over 88% of their infants attended ≥1 well baby visits.

CONCLUSIONS

Prenatal education and screening for depression at hospital delivery is feasible and results in the majority of women being educated and screened. However, missed opportunities for education and screening exist. More information is needed on how to utilize WIC, NICU, and well baby and postpartum encounters to ensure effective education, accurate diagnosis, and treatment for depressed mothers.

Routine HIV screening in two health-care settings--New York City and New Orleans, 2011-2013

Approximately 16% of the estimated 1.1 million persons living with human immunodeficiency virus (HIV) in the United States are unaware of their infection and thus unable to benefit from effective treatment that improves health and reduces transmission risk. Since 2006, CDC has recommended that health-care providers screen for HIV all patients aged 13-64 years unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. This report describes novel HIV screening programs at the Urban Health Plan (UHP), Inc. in New York City and the Interim Louisiana Hospital (ILH) in New Orleans. Data were provided by the two programs. UHP screened a monthly average of 986 patients for HIV during January 2011-September 2013. Of the 32,534 patients screened, 148 (0.45%) tested HIV-positive, of whom 147 (99%) received their test result and 43 (29%) were newly diagnosed. None of the 148 patients with HIV infection were previously receiving medical care, and 120 (81%) were linked to HIV medical care. The ILH emergency department (ED) and the urgent-care center (UCC) screened a monthly average of 1,323 patients from mid-March to December 2013. Of the 12,568 patients screened, 102 (0.81%) tested HIV-positive, of whom 100 (98%) received their test result, 77 (75%) were newly diagnosed, and five (5%) had acute HIV infection. Linkage to HIV medical care was successful for 67 (74%) of 91 patients not already in care. Routine HIV screening identified patients with new and previously diagnosed HIV infection and facilitated their linkage to medical care. The two HIV screening programs highlighted in this report can serve as models that could be adapted by other health-care settings.

Clinical interventions to reduce secondhand smoke exposure among pregnant women: a systematic review

OBJECTIVE

To conduct a systematic review of clinical interventions to reduce secondhand smoke (SHS) exposure among non-smoking pregnant women.

DATA SOURCES

We searched 16 databases for publications from 1990 to January 2013, with no language restrictions.

STUDY SELECTION

Papers were included if they met the following criteria: (1) the study population included non-smoking pregnant women exposed to SHS, (2) the clinical interventions were intended to reduce SHS exposure at home, (3) the study included a control group and (4) outcomes included either reduced SHS exposure of non-smoking pregnant women at home or quit rates among smoking partners during the pregnancy of the woman.

DATA EXTRACTION

Two coders independently reviewed each abstract or full text to identify eligible papers. Two abstractors independently coded papers based on US Preventive Services Task Force criteria for study quality (good, fair, poor), and studies without biochemically-verified outcome measures were considered poor quality.

DATA SYNTHESIS

From 4670 papers, we identified five studies that met our inclusion criteria: four focused on reducing SHS exposure among non-smoking pregnant women, and one focused on providing cessation support for smoking partners of pregnant women. All were randomised controlled trials, and all reported positive findings. Three studies were judged poor quality because outcome measures were not biochemically-verified, and two were considered fair quality.

CONCLUSIONS

Clinical interventions delivered in prenatal care settings appear to reduce SHS exposure, but study weaknesses limit our ability to draw firm conclusions. More rigorous studies, using biochemical validation, are needed to identify strategies for reducing SHS exposure in pregnant women.

Validation of obstetric estimate of gestational age on US birth certificates

OBJECTIVE

The birth certificate variable obstetric estimate of gestational age (GA) has not been previously validated against GA based on estimated date of delivery from medical records.

STUDY DESIGN

We estimated sensitivity, specificity, positive predictive value, negative predictive value and the corresponding 95% confidence intervals (CIs) for preterm delivery (<37 weeks' gestation) based on obstetric estimate using estimated date of delivery-based GA as the gold standard. Trained abstractors obtained the estimated date of delivery from the prenatal record (64.8% in New York City, and 94.6% in Vermont), or, when not available, from the hospital delivery record for 2 population-based samples: 586 live births delivered in New York City and 649 live births delivered in Vermont during 2009. Weights were applied to account for nonresponse and sampling design.

RESULTS

In New York City, the preterm delivery rate based on estimated date of delivery was 9.7% (95% CI, 7.6-12.4) and 8.2% (95% CI, 6.3-10.6) based on obstetric estimate; in Vermont, it was 6.8% (95% CI, 5.4-8.4) based on estimated date of delivery and 6.3% (95% CI, 5.1-7.8) based on obstetric estimate. In New York City, sensitivity of obstetric estimate-based preterm delivery was 82.5% (95% CI, 69.4-90.8), specificity 98.1% (95% CI, 96.4-99.1), positive predictive value 98.0% (95% CI, 95.2-99.2), and negative predictive value 98.8% (95% CI, 99.6-99.9). In Vermont, sensitivity of obstetric estimate-based preterm delivery was 93.8% (95% CI, 81.8-98.1), specificity 99.6% (95% CI, 98.5-99.9), positive predictive value 100%, and negative predictive value 100%.

CONCLUSION

Obstetric estimate-based preterm delivery had excellent specificity, positive predictive value and negative predictive value. Sensitivity was moderate in New York City and excellent in Vermont. These results suggest obstetric estimate-based preterm delivery from the birth certificate is useful for the surveillance of preterm delivery.

History of preterm birth and subsequent cardiovascular disease: a systematic review

A history of preterm birth (PTB) may be an important lifetime risk factor for cardiovascular disease (CVD) in women. We identified all peer-reviewed journal articles that met study criteria (English language, human studies, female, and adults ≥19 years old), that were found in the PubMed/MEDLINE databases, and that were published between Jan. 1, 1995, and Sept. 17, 2012. We summarized 10 studies that assessed the association between having a history of PTB and subsequent CVD morbidity or death. Compared with women who had term deliveries, women with any history of PTB had increased risk of CVD morbidity (variously defined; adjusted hazard ratio [aHR] ranged from 1.2-2.9; 2 studies), ischemic heart disease (aHR, 1.3-2.1; 3 studies), stroke (aHR, 1.7; 1 study), and atherosclerosis (aHR, 4.1; 1 study). Four of 5 studies that examined death showed that women with a history of PTB have twice the risk of CVD death compared with women who had term births. Two studies reported statistically significant higher risk of CVD-related morbidity and death outcomes (variously defined) among women with ≥2 pregnancies that ended in PTBs compared with women who had at least 2 births but which ended in only 1 PTB. Future research is needed to understand the potential impact of enhanced monitoring of CVD risk factors in women with a history of PTB on risk of future CVD risk.

Telephone smoking cessation quitline use among pregnant and non-pregnant women

To describe characteristics, referrals, service utilization, and self-reported quit rates among pregnant and non-pregnant women enrolled in a smoking cessation quitline. This information can be used to improve strategies to increase pregnant and non-pregnant smokers' use of quitlines. We examined tobacco use characteristics, referral sources, and use of services among 1,718 pregnant and 24,321 non-pregnant women aged 18-44 years enrolled in quitline services in 10 states during 2006-2008. We examined self-reported 30-day quit rates 7 months after enrollment among 246 pregnant and 4,123 non-pregnant women and, within groups, used Chi-square tests to compare quit rates by type of service received. The majority of pregnant and non-pregnant callers, respectively, smoked ≥10 cigarettes per day (62 %; 83 %), had recently attempted to quit (55 %; 58 %), smoked 5 or minutes after waking (59 %; 55 %), and lived with a smoker (63 %; 48 %). Of callers, 24.3 % of pregnant and 36.4 % of non-pregnant women were uninsured. Pregnant callers heard about the quitline most often from a health care provider (50 %) and non-pregnant callers most often through mass media (59 %). Over half of pregnant (52 %) and non-pregnant (57 %) women received self-help materials only, the remainder received counseling. Self-reported quit rates at 7 months after enrollment in the subsample were 26.4 % for pregnant women and 22.6 % for non-pregnant women. Quitlines provide needed services for pregnant and non-pregnant smokers, many of whom are uninsured. Smokers should be encouraged to access counseling services.

Health care utilization in the first year of life among small- and large- for-gestational age term infants

The objective of the study was to assess if small- and large-for gestational age term infants have greater health care utilization during the first year of life. The sample included 28,215 singleton term infants (37-42 weeks) without major birth defects delivered from 1998 through 2007 and continuously enrolled at Kaiser Permanente Northwest for 12 months after delivery. Birth weight for gestational age was categorized into 3 levels: <10th percentile (SGA), 10-90th percentile (AGA), >90th percentile (LGA). Length of delivery hospitalization, re-hospitalizations and sick/emergency room visits were obtained from electronic records. Logistic regression models estimated associations between birth weight category and re-hospitalization. Generalized linear models estimated adjusted mean number of sick/emergency visits. Among term infants, 6.2 % were SGA and 13.9 % were LGA. Of infants born by cesarean section, SGA infants had 2.7 higher odds [95 % 1.9, 3.8] than AGA infants of staying ≥5 nights during the delivery hospitalization; of those born vaginally, SGA infants had 1.5 higher adjusted odds [95 % 1.1, 2.1] of staying ≥4 nights. LGA compared to AGA infants had higher odds of re-hospitalization within 2 weeks of delivery [OR 1.25, 95 % CI 0.99, 1.58] and of a length of stay ≥4 days during that hospitalization [OR 2.6, 95 % CI 1.3, 5.0]. The adjusted mean number of sick/emergency room visits was slightly higher in SGA (7.8) than AGA (7.5) infants (P < .05). Term infants born SGA or LGA had greater health care utilization than their counterparts, although the increase in utilization beyond the initial delivery hospitalization was small.

Validation of obstetric estimate using early ultrasound: 2007 California birth certificates

BACKGROUND

Obstetric estimate (OE) of gestational age, recently added to the standard US birth certificate, has not been validated. Using early ultrasound-based gestational age (prior to 20 weeks gestation) as the criterion standard, we estimated the prevalence of preterm delivery and the sensitivity and positive predictive value (PPV) of gestational age estimates based on OE.

METHODS

We analyzed 165 148 singleton livebirth records (38% of California livebirths during the study period) with linked early ultrasound information from a statewide California prenatal screening programme. OE of gestational age estimates was obtained from birth certificates.

RESULTS

Prevalence of preterm delivery (<37 weeks gestation) was higher based on early ultrasound (8.1%) compared with preterm delivery based on OE (7.1%). Sensitivity for preterm birth when using OE for gestational age was 74.9% (95% confidence interval [CI] [74.1, 75.6]), and PPV was 85.1% (95% CI [84.4, 85.7]). Incongruence, defined as a ≥ 14-day difference between early-ultrasound-derived gestational age and OE, was 3.4%.

CONCLUSIONS

OE reported on the birth certificate may underestimate the prevalence of preterm delivery, particularly among women of non-Hispanic non-white race and ethnicity and women with lower educational attainment, public insurance at time of delivery, and missing prepregnancy BMI. Additional validation studies in other samples of births are needed.

Preconception care: the perfect opportunity for health care providers to advise lifestyle changes for hypertensive women

PURPOSE

To provide estimates for prevalence of health care provider advice offered to reproductive-aged women and to assess their association with behavior change.

DESIGN

Cross-sectional study using the 2009 Behavioral Risk Factor Surveillance System. Setting. Nineteen states/areas.

SUBJECTS

Women aged 18 to 44 years with a self-reported history of hypertension or current antihypertensive medication use (n = 2063).

MEASURES

Self-reported hypertension; sociodemographic and health care access indicators; and provider advice and corresponding self-reported behavior change to improve diet, limit salt intake, exercise, and reduce alcohol use.

ANALYSIS

We estimated prevalence and prevalence ratios for receipt of provider advice and action to change habits. We calculated 95% confidence interval (CI) and used χ(2) tests to assess associations.

RESULTS

Overall, 9.8% of reproductive-aged women had self-reported hypertension; most reported receiving advice to change eating habits (72.9%), reduce salt intake (74.6%), and exercise (82.1%), and most reported making these changes. Only 44.7% reported receiving advice to reduce alcohol intake. Women who received provider advice were more likely to report corresponding behavior change compared to those who did not (prevalence ratios ranged from 1.3 [95% CI, 1.2-1.5, p < .05] for exercise to 1.6 [95% CI, 1.4-1.8, p < .05] for reducing alcohol use.

CONCLUSION

Health care providers should routinely advise hypertensive reproductive-aged women about lifestyle changes to reduce blood pressure and improve pregnancy outcomes.

Trends in smoking before, during, and after pregnancy--Pregnancy Risk Assessment Monitoring System, United States, 40 sites, 2000-2010

PROBLEM

Smoking during pregnancy increases the risk for complications such as fetal growth restriction, preterm delivery, and infant death. In 2002, 5%-8% of preterm deliveries, 13%-19% of term infants with growth restriction, 5%-7% of preterm-related deaths, and 23%-34% of deaths from sudden infant death syndrome were attributable to prenatal smoking in the United States.

REPORTING PERIOD COVERED

2000-2010.

DESCRIPTION OF SYSTEM

The Pregnancy Risk Assessment Monitoring System (PRAMS) was initiated in 1987 and is an ongoing state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and after pregnancy among females who deliver live-born infants in the United States. Self-reported questionnaire data are linked to selected birth certificate data and are weighted to represent all women delivering live infants in the state. Self-reported smoking data were obtained from the PRAMS questionnaire and birth certificates. This report provides data on trends (aggregated and site-specific estimates) in smoking before, during, and after pregnancy from 40 PRAMS sites during 2000-2010.

RESULTS

For the majority of sites, smoking prevalence before, during, or after pregnancy did not change over time. During 2000-2010, smoking prevalence decreased in three sites (Minnesota, New York state, and Utah) for all three measures and in eight sites (Colorado, Illinois, New Jersey, New Mexico, New York City, Washington, Wisconsin and Wyoming) for one or two of the measures. Smoking prevalence increased for all three measures in three sites (Louisiana, Mississippi, and West Virginia); an increase in prevalence before pregnancy (only) occurred in Oklahoma, and an increase during and after pregnancy occurred in Maine. For a subgroup of 10 sites for which data were available for the entire 11-year study period (Alaska, Arkansas, Colorado, Hawaii, Maine, Nebraska, Oklahoma, Utah, Washington, and West Virginia), the prevalence of smoking before pregnancy remained unchanged, with approximately one in five women reporting smoking before pregnancy (23.6% in 2000 to 24.7% in 2010). The prevalence of smoking during pregnancy decreased (p = 0.04; linear trend assessed with logistic regression) from 13.3% in 2000 to 12.3% in 2010, and the prevalence of smoking after delivery decreased (p<0.01) from 18.6% in 2000 to 17.2% in 2010.

INTERPRETATION

The results indicate that efforts to reduce smoking prevalence among female smokers before pregnancy have not been effective; however, tobacco-control efforts have been minimally effective in reducing smoking prevalence during and after pregnancy. Current tobacco-control efforts in most sites might be insufficient to reach national objectives related to reducing prevalence of smoking during pregnancy.

PUBLIC HEALTH ACTION

States with no change in or increasing smoking prevalence before, during, and after pregnancy can help reduce prevalence through sustained and comprehensive tobacco-control efforts (e.g., mass media campaigns, coverage of tobacco cessation, 100% smoke-free policies, and tobacco excise taxes).

Postpartum anxiety and comorbid depression in a population-based sample of women

BACKGROUND

Population-based estimates of prevalence of anxiety and comorbid depression are lacking. Therefore, we estimated the prevalence and risk factors for postpartum anxiety and comorbid depressive symptoms in a population-based sample of women.

METHODS

Using multinomial logistic regression, we examined the prevalence and risk factors for postpartum anxiety and depressive symptoms using 2009-2010 data from the Illinois and Maryland Pregnancy Risk Assessment Monitoring System, a population-based survey of mothers who gave birth to live infants. Survey participants are asked validated screening questions on anxiety and depressive symptoms.

RESULTS

Among 4451 postpartum women, 18.0% reported postpartum anxiety symptoms, of whom 35% reported postpartum depressive symptoms (6.3% overall). In the multivariable model, higher numbers of stressors during pregnancy (adjusted odds ratio [aOR] range: 1.3-9.7) and delivering an infant at ≤27 weeks gestation (aOR range: 2.0-5.7) were associated with postpartum anxiety and postpartum depressive symptoms, experienced individually or together. Smoking throughout pregnancy was associated with postpartum anxiety symptoms only (aOR=2.3) and comorbid anxiety and depressive symptoms (aOR=2.9).

CONCLUSIONS

Given the possible adverse effects of postpartum anxiety and comorbid depression on maternal health and infant development, clinicians should be aware of the substantial prevalence, comorbidity, and risk factors for both conditions and facilitate identification, referral, and/or treatment.

Tobacco cessation intervention for pregnant women in Argentina and Uruguay: study protocol

BACKGROUND

Argentina and Uruguay are among the countries with the highest proportion of pregnant women who smoke. The implementation of an effective smoking cessation intervention would have a significant impact on the health of mothers and infants. The "5 A's" (Ask, Advise, Assess, Assist, Arrange) is a strategy consisting of a brief cessation counseling session of 5-15 minutes delivered by a trained provider. The "5 A's" is considered the standard of care worldwide; however, it is under used in Argentina and Uruguay.

METHODS

We will conduct a two-arm, parallel cluster randomized controlled trial of an implementation intervention in 20 prenatal care settings in Argentina and Uruguay. Prenatal care settings will be randomly allocated to either an intervention or a control group after a baseline data collection period. Midwives' facilitators in the 10 intervention prenatal clinics (clusters) will be identified and trained to deliver the "5 A's" to pregnant women and will then disseminate and implement the program. The 10 clusters in the control group will continue with their standard in-service activities. The intervention will be tailored by formative research to be readily applicable to local prenatal care services at maternity hospitals and acceptable to local pregnant women and health providers. Our primary hypothesis is that the intervention is feasible in prenatal clinics in Argentina and Uruguay and will increase the frequency of women receiving tobacco use cessation counseling during pregnancy in the intervention clinics compared to the control clinics. Our secondary hypotheses are that the intervention will decrease the frequency of women who smoke by the end of pregnancy, and that the intervention will increase the attitudes and readiness of midwives towards providing counseling to women in the intervention clinics compared to the control clinics.

Estimates of smoking before and during pregnancy, and smoking cessation during pregnancy: comparing two population-based data sources

OBJECTIVES

We compared three measures of maternal smoking status--prepregnancy, during pregnancy, and smoking cessation during pregnancy-between the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire and the 2003 revised birth certificate (BC).

METHODS

We analyzed data from 10,485 women with live births in eight states from the 2008 PRAMS survey, a confidential, anonymous survey administered in the postpartum period that is linked to select BC variables. We calculated self-reported prepregnancy and prenatal smoking (last trimester only) prevalence based on the BC, the PRAMS survey, and the two data sources combined, and the percentage of smoking cessation during pregnancy based on the BC and PRAMS survey. We used two-sided t-tests to compare BC and PRAMS estimates.

RESULTS

Prepregnancy smoking prevalence estimates were 17.3% from the BC, 24.4% from PRAMS, and 25.4% on one or both data sources. Prenatal smoking prevalence estimates were 11.3% from the BC, 14.0% from PRAMS, and 15.2% on one or both data sources. The percentages of prepregnancy smokers who indicated that they quit smoking by the last trimester were 35.1% from the BC and 42.6% from PRAMS. The PRAMS estimates of prepregnancy and prenatal smoking, and smoking cessation during pregnancy were statistically higher than the corresponding BC estimates (t-tests, p<0.05).

CONCLUSIONS

PRAMS captured more women who smoked before and during the last trimester than the revised BC. States implementing PRAMS and the revised BC should consider information from both sources when developing population-based estimates of smoking before pregnancy and during the last trimester of pregnancy.

Strategies associated with higher postpartum glucose tolerance screening rates for gestational diabetes mellitus patients

BACKGROUND

Most women with histories of gestational diabetes mellitus do not receive a postpartum screening test for type 2 diabetes, even though they are at increased risk. The objective of this study was to identify factors associated with high rates of postpartum glucose screening.

METHODS

This cross-sectional analysis assessed characteristics associated with postpartum diabetes screening for patients with gestational diabetes mellitus (GDM)-affected pregnancies self-reported by randomly sampled licensed obstetricians/gynecologists (OBs/GYNs) in Ohio in 2010.

RESULTS

Responses were received from 306 OBs/GYNs (56.5% response rate), among whom 69.9% reported frequently (always/most of the time) screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Compared to infrequent screeners, OBs/GYNs who frequently screen for postpartum glucose tolerance were statistically (p<0.05) more likely to have a clinical protocol addressing postpartum testing (67.2% vs. 26.7%), an electronic reminder system for providers (10.8% vs. 2.2%) and provide reminders to patients (16.4% vs. 4.4%). Frequent screeners were more likely to use recommended fasting blood glucose or 2-hour oral glucose tolerance test (61.8% vs. 34.6%, p<0.001) than infrequent screeners.

CONCLUSIONS

Strategies associated with higher postpartum glucose screening for GDM patients included clinical protocols for postpartum testing, electronic medical records to alert providers of the need for testing, and reminders to patients.

Expansion of Medicaid covered smoking cessation services: maternal smoking and birth outcomes

OBJECTIVE

To assess whether Medicaid coverage of smoking cessation services reduces maternal smoking and improves birth outcomes.

METHODS

Pooled, cross-sectional data for 178,937 women with live births from 1996 to 2008, who were insured by Medicaid in 34 states plus New York City, were used to analyze self-reported smoking before pregnancy (3 months), smoking during the last 3 months of pregnancy, smoking after delivery (3-4 months), infant birth weight, and gestational age at delivery. Maternal socio-demographic and behavior variables from survey data and birth outcomes from vital records were merged with annual state data on Medicaid coverage for nicotine replacement therapies (NRT), medications and cessation counseling. Probit and OLS regression models were used to test for effects of states' Medicaid cessation coverage on mother's smoking and infant outcomes relative to mothers in states without coverage.

RESULTS

Medicaid coverage of NRT and medications is associated with 1.6 percentage point reduction (p<.05) in smoking before pregnancy among Medicaid insured women relative to no coverage. Adding counseling coverage to NRT and medication coverage is associated with a 2.5 percentage point reduction in smoking before pregnancy (p<.10). Medicaid cessation coverage during pregnancy was associated with a small increase (<1 day) in infant gestation (p<.05).

CONCLUSIONS

In this sample, Medicaid coverage of smoking cessation only affected women enrolled prior to pregnancy. Expansions of Medicaid eligibility to include more women prior to pregnancy in participating states, and mandated coverage of some cessation services without co-pays under the Affordable Care Act (ACA) should reduce the number of women smoking before pregnancy.

Cholesterol screening for women: who is "at-risk"?

BACKGROUND

High cholesterol often precedes cardiovascular disease (CVD) and guidelines recommend cholesterol screening among at-risk women. Definitions of CVD risk vary and prevalence of dyslipidemia (abnormal total cholesterol, high-density lipoprotein (HDL-C), or non-HDL-C) among at-risk women may vary by age and definition of CVD risk.

METHODS

This study used 2007-2008 National Health and Nutrition Examination Survey data (n=1,781), a representative sample of the U.S. civilian, non-institutionalized population, to estimate the proportion of women without previous dyslipidemia diagnosis who are U.S. Preventive Services Task Force (USPSTF) at-risk and American Heart Association (AHA) at-risk. We also report dyslipidemia prevalence stratified by age.

RESULTS

Over half (55.0%) of younger women (20-44 years) and 74.2% of older women (≥45 years) were USPSTF at-risk, while nearly all younger and older women had at least one AHA risk factor (99.5% and 99.6%, respectively). Dyslipidemia prevalence among younger women was 47.3% (95% confidence interval [CI]: 42.2-52.5) for USPSTF-at-risk and 39.5% (95% CI: 35.7-43.4) for AHA at-risk. Among older women, it was 65.5% (95% CI: 60.8-69.9) for USPSTF at-risk and 63.3% (95% CI: 59.0-67.4) for AHA at-risk.

CONCLUSIONS

The AHA risk definition identified 45% more young women and 25% more older women than the USPSTF risk definition; however, both definitions of at-risk identified similar prevalence estimates of dyslipidemia among women. Given a high prevalence of dyslipidemia among younger women, future research is needed to assess whether identification and treatment of young women with dyslipidemia will decrease CVD mortality among them later in life.

Smoke-free-home rules among women with infants, 2004-2008

Introduction

Exposure to secondhand smoke increases risk for infant illness and death. The objective of this study was to estimate the prevalence of complete smoke-free–home rules (smoking not allowed anywhere in the home) among women with infants in the United States.

Methods

We analyzed 2004–2008 data from the Pregnancy Risk Assessment Monitoring System on 41,535 women who had recent live births in 5 states (Arkansas, Maine, New Jersey, Oregon, and Washington). We calculated the prevalence of complete smoke-free–home rules and partial or no rules by maternal smoking status, demographic characteristics, delivery year, and state of residence. We used adjusted prevalence ratios (APRs) to estimate associations between complete rules and partial or no rules and variables.

Results

During 2004–2008, the overall prevalence of complete rules was 94.6% (95% confidence interval [CI], 94.4–94.9), ranging from 85.4% (Arkansas) to 98.1% (Oregon). The prevalence of complete rules increased significantly in 3 states from 2004 to 2008. It was lowest among women who smoked during pregnancy and postpartum, women younger than 20 years, non-Hispanic black women, women with fewer than 12 years of education, women who had an annual household income of less than $10,000, unmarried women, and women enrolled in Medicaid during pregnancy.

Conclusion

The prevalence of complete smoke-free–home rules among women with infants was high overall and increased in 3 of 5 states, signifying a public health success. Sustained and targeted efforts among groups of women who are least likely to have complete smoke-free–home rules are needed to protect infants from exposure to secondhand smoke.

Screening low-income women of reproductive age for cardiovascular disease risk factors

Abstract Background: Identifying and treating chronic diseases, their precursors, and other cardiovascular disease (CVD) risk factors during family planning visits may improve long-term health and reproductive outcomes among low-income women. A cross-sectional study design was used to describe the prevalence of chronic diseases (hypertension, high cholesterol, and diabetes), their precursors (pre-hypertension, borderline high cholesterol, and pre-diabetes), and related CVD risk factors (such as obesity, smoking, and physical inactivity) among low-income women of reproductive age.

METHODS

Prevalence of chronic diseases, their precursors, and related CVD risk factors were assessed for 462 out of 859 (53.8%) female family planning patients, ages 18-44 years, who attended a Title X clinic in eastern North Carolina during 2011 and 2012 and consented to participate. Data were obtained from clinical measurements, blood test results, and questionnaire. Differences in distribution of demographic and health care characteristics and CVD risk factors by presence of prehypertension and pre-diabetes were assessed by Pearson chi-square tests.

RESULTS

The prevalence of hypertension was 12%, high cholesterol 16%, and diabetes 3%. Nearly two-thirds of women with hypertension were newly diagnosed (62%) as were 75% of women with diabetes. The prevalence of pre-hypertension was 35%, pre-diabetes 31%, obesity 41%, smoking 32%, and physical inactivity 42%. The majority of participants (87%) had one or more chronic disease or related cardiovascular disease risk factor.

CONCLUSIONS

CVD screening during family planning visits can identify significant numbers of women at risk for poor pregnancy outcomes and future chronic disease and can provide prevention opportunities if effective interventions are available and acceptable to this population.

Assessing cardiovascular disease risk among young women with a history of delivering a low-birth-weight infant

OBJECTIVE

To assess the prevalence and risk factors of cardiovascular disease (CVD) among younger women by pregnancy history.

METHODS

Cross-sectional study using 1999 to 2006 National Health and Nutrition Examination Survey including women aged 20 to 64 years who had delivered at least one infant (n = 4820). Women self-reported pregnancy history and a clinician diagnosed CVD; CVD risk factors included hypertension (mean systolic blood pressure [BP] ≥140 mm Hg or mean diastolic BP ≥90 mm Hg, or currently treated), high cholesterol (total cholesterol ≥240 mg/dL or currently treated), diabetes (self-report or hemoglobin A1c ≥6.5), and smoking (self-report or cotinine-verified). Multivariable logistic regression was used to assess the association between pregnancy history and CVD.

RESULTS

Of the women we studied, 4.6% had CVD; 3.1% had delivered a term low-birth-weight infant (TLBWI). Women with a history of TLBWI had an adjusted odds ratio (AOR) of 2.07 (95% confidence intervals [CI] 1.08 to 3.99) for CVD compared with women without a history of LBWI. Adjustment for hypertension and high cholesterol mildly attenuated the association (AOR 1.85, 95% CI 0.89 to 3.83). Among women without CVD (n = 4555), 23.1% with a history of TLBWI had two risk factors compared with 14.0% of those without a history of LBWI (p = 0.0016).

CONCLUSION

Women with a history of TLBWI should be informed of a possible increased risk of CVD and encouraged to receive screenings as recommended.

Gestational diabetes mellitus and postpartum care practices of nurse-midwives

INTRODUCTION

Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement.

METHODS

From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening.

RESULTS

Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care.

DISCUSSION

CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies.

Health care utilisation in the first year of life among infants of mothers with perinatal depression or anxiety

BACKGROUND

Limited information is available on associations between maternal depression and anxiety and infant health care utilisation.

METHODS

We analysed data from 24 263 infants born between 1998 and 2007 who themselves and their mothers were continuously enrolled for the infant's first year in Kaiser Permanente Northwest. We used maternal depression and anxiety diagnoses during pregnancy and postpartum to categorise infants into two depression and anxiety groups and examined effect modification by timing of diagnosis (pregnancy only, postpartum only, pregnancy and postpartum). Using generalised estimating equations in multivariable log-linear regression, we estimated adjusted risk ratios (RR) between maternal depression and anxiety and well baby visits (<5 and ≥ 5), up to date immunisations (yes/no), sick/emergency visits (<6 and ≥ 6) and infant hospitalisation (any/none).

RESULTS

Infants of mothers with perinatal depression or anxiety were as likely to attend well baby visits and receive immunisations as their counterparts (RR = 1.0 for all). Compared with no depression or anxiety, infants of mothers with prenatal and postpartum depression or anxiety, or postpartum depression or anxiety only were 1.1 to 1.2 times more likely to have ≥ 6 sick/emergency visits. Infants of mothers with postpartum depression only had marginally increased risk of hospitalisation (RR = 1.2 [95% confidence interval 1.0, 1.4]); 70% of diagnoses occurred after the infant's hospitalisation.

CONCLUSIONS

An understanding of the temporality of the associations between maternal depression and anxiety and infant acute care is needed and will guide strategies to decrease maternal mental illness and improve infant care for this population.

A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes

OBJECTIVE

We sought to determine whether our process improvement program led to increased postpartum diabetes screening rates among women with gestational diabetes mellitus (GDM).

STUDY DESIGN

In early 2009, we conducted obstetrics department staff education sessions, revised GDM patient care protocols, and developed an electronic system to trigger reminder calls to patients who had not completed diabetes mellitus screening by 3 months postpartum. We then evaluated the rates of postpartum glucose test order entry and completion for women with GDM delivering from July 2009 through June 2010 (n = 179) and July 2007 through June 2008 (n = 200).

RESULTS

After the program's implementation, the proportion of women receiving an order for a postpartum glucose test within 3 months of delivery increased from 77.5-88.8% (P = .004), and test completion increased from 59.5-71.5% (hazard ratio, 1.37; 95% confidence interval, 1.07-1.75).

CONCLUSION

Rates of postpartum diabetes testing can be improved with system changes and reminders.

"Smoking cessation for pregnancy and beyond: a virtual clinic," an innovative web-based training for healthcare professionals

This article provides an overview of an interactive online training designed for healthcare professionals to hone their skills in assisting pregnant women to quit smoking and to remain quit postpartum. The curriculum teaches a best practice approach for smoking cessation, the 5A's, and is based on current clinical recommendations. The program offers five interactive case simulations and comprehensive discussions of patient visits, short lectures on relevant topics from leading experts, interviews with real patients who have quit, and a dedicated website of pertinent links and office resources. The training is accredited for up to 4.5 hours of continuing education credits. To access the training, please visit www.smokingcessationandpregnancy.org.

Early term delivery and health care utilization in the first year of life

OBJECTIVE

To assess health care utilization during the first year of life among early term-born infants.

STUDY DESIGN

We assessed health care utilization of 22420 singleton term infants (37-42 weeks gestational age [GA]) without major birth defects, fetal growth restriction, or exposure to diabetes or hypertension in utero, delivered between 1998 and 2007 and continuously enrolled at Kaiser Permanente Northwest for 12 months after delivery. GA, duration of delivery hospitalization, and postdelivery rehospitalizations and sick/emergency room visits in the first year of life were obtained from electronic medical records. Logistic regression models were used to estimate associations between GA and number of hospitalizations and length of stay. Generalized linear models were used to estimate the adjusted mean number of sick/emergency visits.

RESULTS

Overall, 20.9% of term infants were born early. Infants delivered vaginally at 37 weeks GA had a 2.2 greater odds (95% CI, 1.6-3.1) of staying 4 or more days compared with those born at 39-40 weeks GA. Similar association was found among infants delivered by cesarean delivery at 37 or 38 weeks GA. Infants born at 37 weeks GA had increased odds of being rehospitalized within 2 weeks of delivery (OR, 2.6; 95% CI, 1.9-3.6). The adjusted mean number of sick/emergency room visits was higher for infants born at 37 and 38 weeks GA than for those born at 39-40 weeks GA (8.1, 7.7, and 7.3, respectively; P < .0001).

CONCLUSIONS

Early term-born infants had greater health care utilization during their entire first year of life than infants born at 39-40 weeks GA.