Objective:Maternal health in the United States is characterized by persistent racial and ethnic disparities, even among clinically low-risk patients. Health systems often report outcomes in aggregate, a practice that can obscure inequities. We examined adverse maternal outcomes (AMO) among clinically low-risk patients stratified by race/ethnicity and assessed whether area-level social vulnerability differed across geographic patterns of AMO. Study Design:We conducted a secondary analysis of 7,691 patients who received intrapartum care from certified nurse-midwives or obstetricians at a tertiary academic hospital between 2013 and 2018. We evaluated severe maternal morbidity (SMM), adapted from CDC criteria, and AMO which included SMM plus postpartum hemorrhage, intra-amniotic infection, obstetric anal sphincter injury, and unplanned cesarean delivery. We stratified outcomes by mutually exclusive, census-derived racial/ethnic categories based on patient self-report. We used chi-squared, Student's t-tests, and one-way ANOVA for comparisons, and logistic regression to assess AMO by racial/ethnic category. We used the Mann-Whitney U test to compare area-level social vulnerability indicators between zip codes with the highest and lowest AMO prevalence, and Geographic Information Systems (GIS) to map the zip code distribution. Results:AMO, but not SMM, differed by racial/ethnic category. Patients identifying as non-Hispanic Asian had the highest AMO (38%) and more than twice the odds compared with non-Hispanic White patients (aOR: 2.02; 95% CI: 1.63-2.51; p < 0.001). Zip code-level social vulnerability indicators did not differ by AMO prevalence. Conclusion:Racial and ethnic disparities in AMO persisted in a clinically low-risk cohort, underscoring the importance of disaggregated reporting to identify inequities that may be masked in aggregate analyses. Key Points:· Racial disparities exist even among low-risk patients.. · AMO, but not SMM, varied by race/ethnicity.. · Non-Hispanic Asian patients had the highest AMO rates.. · Zip code social vulnerability did not differ by AMO prevalence.. · Disaggregated reporting clarifies disparities..

Rheumatic disease significantly alters a child’s quality of life. Rheumatologists often apply a patient global assessment score (PGA) in real time to gauge quality of life, effectiveness of treatment, and disease activity for clinical and research purposes. Previous studies showed a discrepancy between the PGA and objective disease activity measures. This study explores patients’ self-reported reasons behind their PGA score, especially the role of anxiety and depression. This is a single-center, cross-sectional, survey-based study. Seventy-one patients 12–18 years old with JIA, SLE or JDM completed a survey including the PGA, Patient Health Questionnaire-9 (PHQ9) and Screen for Childhood Anxiety Related Disorders (SCARED). The associations of high (≥ 3) and low (< 3) PGA scores with mental health scores and reasons for selecting a PGA were analyzed using appropriate nonparametric tests. Twenty-seven participants (38.0

Background:The social vulnerability index (SVI) measures socioeconomic hardship, with high SVI indicating high susceptibility. We applied the SVI to characterize and compare patients who underwent abdominal versus minimally invasive hysterectomy. Objective:To evaluate whether high social vulnerability, as measured by SVI, was associated with a lower likelihood of undergoing minimally invasive hysterectomy compared to abdominal hysterectomy. Study Design:This was a retrospective cohort study conducted across 4 hospitals within a single health system in Colorado. The study included patients who underwent hysterectomy for any indication between 2013 and 2018. Patient addresses were geocoded to estimate overall SVI and its 4 sub-domains: Socioeconomic, Housing/Disability, Race/Minority, and Housing/Transportation. These data were analyzed to evaluate for an association between SVI and surgical approach to hysterectomy. Results:Among 2,619 patients, 86% underwent MIH (87.3% non-Hispanic White [NHW]; 76.6% non-Hispanic Black [NHB]; 82.5% Hispanic). Patients undergoing MIH were more likely to be NHW, ASA class I or II, and less likely to have diabetes, hypertension, or receive care within a tertiary referral center (P<.05). While MIH was not associated with high overall SVI (P=.07), patients undergoing abdominal hysterectomy were more likely to have high SVI in race/minority and housing/transportation sub-domains (P=.006 and P=.01, respectively). Significant differences in age, comorbidities, BMI class, hospital setting, route of hysterectomy were observed across all race/ethnic groups (P<.001).Multivariable logistic regression analysis showed that high overall SVI or high SVI in either race/minority or housing/transportation sub-domains was not significantly associated with MIH. However, age (aOR 0.97; [0.97-0.98]), NHW race/ethnicity (aOR 1.49; [1.14-1.94]), hospital setting within a tertiary referral center (aOR 0.29; [0.22-0.38]), and ASA class I (aOR 1.6; [1.05-2.46]) were independent predictors of MIH. Conclusion:Age, race/ethnicity, hospital setting, and ASA class were found to be stronger independent predictors of MIH than SVI. Because race/ethnicity and hospital setting are independently associated with SVI based on prior study, we suspect that including these variables in the analysis weakened the observed independent association between SVI and route of hysterectomy. Further research is required to understand the underlying mechanisms driving surgical disparities, which may include systemic, institutional, or provider-level factors.

Objective:We investigated the utility of pre-operative computerized tomography (CT) abdomen and pelvis on clinical staging and surgical decision making for uterine carcinoma. Methods:This retrospective cohort study included patients treated surgically for uterine carcinoma between 2010 and 2021 at a single academic center. Data on patient demographics, tumor characteristics, CT imaging results, and surgical procedures were collected. Diagnostic accuracy metrics (sensitivity, specificity, positive predictive value [PPV], negative predictive value [NPV]) were analyzed to assess the predictive value of CT for determining extrauterine disease, lymphadenopathy, and omental involvement. The impact of CT imaging on surgical management decisions was also evaluated. Results:Of 409 patients meeting inclusion criteria, 68.9 % underwent pre-operative CT imaging. CT demonstrated moderate sensitivity (67.0 %, 61/91) and high specificity (87.4 %, 145/166) for detecting extrauterine disease, which was comparable across those with low grade endometrioid, high grade endometrioid, and non-endometrioid histotypes. Patients with abnormal CT findings were significantly more likely to have advanced stage disease (FIGO stage III/IV; p < 0.001), undergo tumor debulking (p < 0.001), and receive pelvic (p = 0.001) and para-aortic lymphadenectomy (p < 0.001). Conversely, patients with normal CT scans more frequently underwent minimally invasive surgery (MIS) and sentinel lymph node (SLN) procedures (p < 0.001). Conclusions:Preoperative CT shows moderate sensitivity but high specificity for identifying extrauterine disease in uterine carcinoma, supporting continued use for high risk histotypes. Among patients with low-grade histotypes, risk-adaptive use of CT may be valuable in determining eligibility for either MIS or SLN mapping. This is an increasingly relevant consideration as MIS and SLN are becoming more widely adopted.

The goal of this study is to evaluate whether adjuvant progesterone following cerclage affords a reduction in the rate of preterm delivery.This is a retrospective cohort review of all individuals who underwent transvaginal cerclage placement at a tertiary care academic medical center between 2005 and 2021. The rate of delivery prior to 37 weeks and several secondary maternal and neonatal outcomes were compared between patients with and without progesterone supplementation after cerclage. Multivariable regression, subgroup, and matched pairs analyses were performed in order to account for the formulation of progesterone, indication for cerclage, and other potential confounding variables. The study was powered a priori to detect a difference in our primary outcome.Among 451 patients, there were 163 history-, 135 ultrasound-, and 153 examination-indicated cerclages. Overall, 284 (63%) received adjuvant progesterone. Adjuvant progesterone was associated with an increased rate of preterm delivery before 37 weeks (45 vs. 34%, p = 0.03) with an adjusted odds ratio of 1.78 (95% confidence interval: 1.14 and 2.80) in our multivariable model. The median latency from cerclage placement to delivery was shorter when progesterone was used (119 vs. 139 days, p < 0.001). There was no benefit of adjuvant progesterone when analyzed by formulation of progesterone or indication for cerclage or when analyzing pairs matched based on propensity score matching. There were no differences in secondary outcomes for pregnant patients or their offspring.Adjuvant progesterone does not decrease the preterm delivery rate and may in fact cause harm by decreasing latency from cerclage to delivery. Maternal and neonatal outcomes do not vary with supplemental progesterone after cerclage. Our data do not support a synergistic benefit of cerclage and postcerclage progesterone. · There are currently no guidelines for the use of progesterone after cerclage.. · Adjuvant progesterone does not decrease the preterm birth rate.. · Secondary maternal and neonatal outcomes do not improve with adjuvant progesterone..

OBJECTIVE:To identify novel genetic loci associated with differences in serum etonogestrel concentrations among contraceptive implant users. METHODS:We conducted a cross-sectional analysis in which we enrolled healthy, reproductive-aged (age 18-45 years) participants who had been using etonogestrel implants for 12-48 months. Participants underwent a single-time blood draw for measurement of serum etonogestrel concentrations by liquid chromatography-tandem mass spectrometry and the extraction of DNA from whole blood. We genotyped participants using the Illumina Infinium Global Diversity Array with Enhanced PGx and imputed genotyping results using the TOPMed imputation server. We performed genome-wide complex trait analysis using a linear mixed model leave-one-chromosome-out association analysis to identify genetic variants associated with serum etonogestrel concentrations. RESULTS:We enrolled 900 etonogestrel implant users, with a median age of 22.3 years (range 18.0-41.5 years), median body mass index (BMI) 26.0 (range 18.5-52.0), and median duration of implant use 27 months (range 12-48 months). Most participants self-reported their race as White (49.3%) and ethnicity as Hispanic or Latina (52.9%). Participants had a median serum etonogestrel concentration of 126.9 pg/mL (range 39.4-695.1 pg/mL). Including BMI, duration of implant use, and three principal components as covariates in the genome-wide complex trait analysis, we identified no genetic variants with minor allele frequencies at or above 5% that were associated with serum etonogestrel concentrations at genome-wide significance (P<5.0×10-8). When including rare genetic variants (minor allele frequencies at or above 1%), we discovered 10 genetic loci of interest (RNF114; LINC02405; SYNE1; TSPAN14; CRYZL2P-SEC16B; CHRNA9; RIMS1; CCDC88C; and CBL), all containing genetic variants associated with increased serum etonogestrel concentrations. Among these novel genetic loci associated with serum etonogestrel concentrations, only one (CRYZL2P-SEC16B) has potential, albeit limited, physiologic plausibility. CONCLUSION:Despite enhanced coverage for known pharmacogenomic variants, we found no significant associations between interindividual variability in contraceptive implant pharmacokinetics and genetic loci directly involved in exogenous steroid hormone metabolism. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov, NCT03092037.

STUDY OBJECTIVE:To assess knowledge and perceptions of abortion and emergency contraception (EC) among adolescents and young adults (AYA) in a state with protected abortion access following the Dobbs v. Jackson Women's Health Organization decision. METHODS:We conducted a cross-sectional survey of patients aged 14-24 presenting to a Title X-supported sexual health clinic in Colorado between April 2023 and January 2024. A 50-item anonymous survey measured knowledge of abortion and EC laws, beliefs about abortion myths, and sociodemographic characteristics. Knowledge scores were categorized as high (≥50% correct) or low (<50% correct). RESULTS:Among 244 respondents, most were female (94.2%) and aged 18 or older (85%). While 83.3% were familiar with the Dobbs decision, 64.6% were unaware of any changes to abortion laws in Colorado. Less than half (45%) demonstrated high knowledge of abortion laws. Gaps were particularly notable regarding parental consent and gestational limits. In contrast, 76% demonstrated high EC knowledge, though 58.8% either believed EC could end an early pregnancy or were unsure. High abortion knowledge was associated with higher education, prior pregnancy, and awareness of Dobbs. Belief in abortion myths was more common among those with lower knowledge. CONCLUSION:Despite living in a state with legal abortion protections, many AYA remain unclear about abortion laws and hold common misconceptions, which may delay care. EC knowledge was higher, but misunderstandings persist. Targeted efforts are needed to improve reproductive health literacy among youth and ensure access to accurate, state-specific information.

Objective To examine factors associated with cesarean birth by race and ethnicity in a health system with a large proportion of midwife-attended births. Design Retrospective cohort study using electronic heath record data. Setting A multihospital regional health system of community and academic hospitals on the Colorado Front Range. Participants Data from the births of women admitted for labor and birth from January 1, 2018 to January 31, 2020 (N = 10,473). Methods We identified cesarean births and categorized them by maternal race and ethnicity and the type of provider who managed the labor. We used descriptive statistics to characterize the sample. We used multivariable logistic regression to examine associations among cesarean birth, maternal race and ethnicity, and provider type accounting for hospital geographic location, maternal age, and insurance status by parity. Results Cesareans accounted for 13% of total births and 22.4% of births among nulliparous women with term singleton pregnancies with the fetus in vertex position. Nearly 33% of total births were attended by midwives. Compared with non-Hispanic White women, odds of cesarean birth were significantly higher for nulliparous Black/African American women (odds ratio (OR) = 1.55, 95% confidence interval (CI) [1.13, 2.13], p < .05), Asian women (OR = 1.54, 95% CI [1.02, 2.32], p < .05), Hispanic women (OR = 1.36, 95% CI [1.11, 1.65], p > .05), and women of all other races (OR = 1.70, 95% CI [1.27, 2.27], p < .001) as well as multiparous Hispanic women (OR = 1.60, 95% CI [1.18, 2.25], p < .05) and multiparous women of all other races (OR = 2.60, 95% CI [1.64, 4.13], p < .001). Cesarean birth was more likely when a physician compared with a midwife managed the labor course in nulliparous births (OR = 1.38, 95% CI [1.30, 1.50], p < .001) and multiparous births (OR = 1.60, 95% CI [1.36, 1.90], p < .001). Conclusion Although overall rates of cesarean birth were low in comparison with state and national averages, racial disparities persisted. Our study findings are aligned with those from previous studies in which researchers demonstrated lower use of cesarean birth with midwifery care and reinforce the importance of examining multilevel influences on cesarean birth.

To assess providers’ substance use screening/testing practices in patient care and identify disparities in their application. We hypothesized that patient race and social vulnerability (SV) are independently and jointly associated with increased rates of provider self-reported substance use screening/testing. A 2 × 2 factorial vignette design was used to survey OB/GYN, Midwifery, and Family Medicine providers. The patients’ age and medical characteristics were identical in each vignette, but two elements varied dichotomously: (1) the patient’s race (Black vs. White) and (2) the patient’s level of SV. Descriptive statistics were computed to assess respondent characteristics. Chi-square or Fisher’s exact tests were performed to assess disparities in substance use screening/testing practices. Providers shown the SV patient vignette, compared to providers shown the vignette for a non-SV patient, reported that the patient’s housing (41

The objective was to compare first-pass and overall removal rates of manual vacuum aspiration (MVA) versus alligator forceps for intrauterine devices (IUDs) with no visible strings. We enrolled people seeking IUD removal with no visible strings into a randomized, single-blind trial. Participants were randomized to removal with alligator forceps (standard of care) or MVA. If removal with MVA was unsuccessful after three attempts, alligator forceps were used. The primary outcome was successful first-pass removal. Secondary outcomes included successful removal, post-procedure recall of maximum pain (100-mm visual analog scale), need for cervical dilation, procedure time, satisfaction, and complications. We required 46 participants to detect a 40 percentage-point difference in first-pass removal success rates with a two-sided α=0.05 and 80% power. We stopped enrollment after 13 participants (6 alligator forceps, 7 MVA) due to significant concerns with patient-reported pain in the MVA group. First-pass removal was successful in 33% in the alligator forceps group versus 14.2% in the MVA group (P=.55), and overall success rates were 100% with alligator forceps and 33.3% for MVA (P=.07). Intention-to-treat analysis demonstrated maximum pain = 31.5 mm (±17.5) for alligator forceps versus 61.7 mm (±17.6) for MVA (P=.01). Procedure time, need for dilation, and participant satisfaction were similar between groups, and there were no complications. In a high-resource setting, alligator forceps remains the standard of care to remove IUDs without visible strings, as removal with MVA may be more painful. Further strategies are needed for IUD removal with no strings in low-resource settings, including those without ultrasound guidance.

Purpose : The study sought to identify differences in use of elective induction of labor (IOL) post-ARRIVE trial, by race and ethnicity, and contributions of multilevel contextual factors to induction use. Background : Racial disparities in birth outcomes have been attributed to community and provider (ie, multilevel contextual) factors. The varied use of elective induction, a common obstetric procedure, can provide insights on how racial biases are evidenced in care delivery. Methods : A retrospective cohort study, 2018 from 2020, utilized health record data from a multi-hospital regional health system to identify the sample of term, singleton gestations without maternal or fetal indications for induction. Multivariate logistic regression was used to test associations between race/ethnicity and odds of labor induction. Results : Labor induction occurred in 26.8% of 10 473 births. Use varied by reported race or ethnicity; non-Hispanic-White (31.1%), -Asian (22.2%), -Black or African American (22.1%), and -all other races (24.1%) and Hispanic (19.3%). Hispanic women had significantly fewer labor inductions compared to non-Hispanic White women (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.55-0.70, P < .001). Physician care was associated with higher use compared to midwifery care (OR: 1.48, 95% CI: 1.33-1.65, P < .001); hospital geographic location and older maternal age were associated with higher induction use. Hispanic women had significantly higher rate of cesarean birth after IOL. Conclusions : Provider type, hospital geographic location, and maternal age predicted differences in elective IOL use between racial and ethnic groups. Implications for practice and research : Future research should focus on additional contextual factors affecting use of elective induction and resultant mode of birth, particularly between racial and ethnic groups.