OBJECTIVE:To quantify associations of the community-level material deprivation index (CMDI) with asthma diagnosis by age 5 years among preterm infants with bronchopulmonary dysplasia (BPD). METHODS:We conducted a retrospective cohort study of preterm infants with BPD, born between 2010 and 2019, discharged from a single hospital system to a home address in the Philadelphia metropolitan area, with documented follow-up in the Children's Hospital of Philadelphia Care Network through 5 years of age. Patient charts were reviewed for asthma diagnoses, identified by ICD-10 codes. We geocoded each patient's address at time of neonatal intensive care unit (NICU) discharge to assign census tract CMDI values (range 0 to 1). Multivariable logistic regression models quantified associations of CMDI with asthma diagnosis by age 5 adjusting for patient-level factors. RESULTS:Of the 337 preterm infants with BPD and 5-year follow-up within the CHOP Care Network, 169 (50%) were diagnosed with asthma by age 5. CMDI was higher among infants diagnosed with asthma compared to those without asthma (0.43 vs 0.38, p = 0.002). Per standard deviation increment of CMDI, infants had 34% and 32% higher odds of asthma diagnosis in unadjusted (OR 1.34, 95% CI: 1.11, 1.62) and adjusted (aOR 1.32, 95%CI: 1.05-1.65) models, respectively. CONCLUSIONS:Among an urban population of former preterm infants with BPD, high rates of asthma by school age were noted and higher neighborhood deprivation was associated with asthma diagnosis by age 5 years.

Importance:In the setting of substantial maternal health disparities and poor outcomes, there has been increasing public and private investment in maternal health. While venture capital (VC) investing in pregnancy health can facilitate innovation, limited research exists. Objective:To describe VC-backed pregnancy health startups and assess how they address recognized problems in maternal health. Design, Setting, and Participants:This cross-sectional study analyzed VC-backed maternal health startups. Included companies were founded between January 1, 2014, and December 31, 2022, headquartered in the US and directly related to the perinatal period. Exclusion criteria included non-health care companies, companies focused on prepregnancy, infant health companies, companies using pregnancy genetics technology to diagnose cancer, companies whose target population was outside of the US, and companies where maternal health was only 1 of many services provided. Financial databases were used to identify startups and obtain descriptive characteristics. Dual-coder content analysis was performed using company websites. Data were analyzed March to June 2025. Exposure:Maternal health companies funded by VC. Main Outcomes and Measures:VC-backed companies were assessed for business model, mention of health equity and maternal mortality, acceptance of insurance and/or Medicaid, and health care category. Results:Among 439 identified companies, 183 met inclusion criteria, and 172 were funded by VC in their last funding round. Of the 172 companies, $977.5 million was collectively raised during the study period and 52% ($508.3 million) of all funds raised were raised by 3 companies. One hundred thirty-three companies were actively in business with VC funding. The most common category among companies actively in business was virtual or hybrid wraparound pregnancy care (46 of 133 companies [34.6%]). The health care category raising the most capital was maternal and fetal health diagnostics ($520.1 million). The number of startups and funds raised for startups increased annually. Few startups mentioned health equity (23 of 133 [17.3%]) or maternal mortality (24 of 133 [18.1%]). Less than half of startups that could reasonably accept insurance accepted insurance and even fewer accepted Medicaid. Conclusions and Relevance:In this study, VC-backed startups are filling gaps in pregnancy care delivery. Startups have the potential to facilitate needed innovation and improvement in maternal health, but few focus on low-income populations or mention health equity.

OBJECTIVE:To assess the validity of NICU admission reporting on birth certificates in a large dataset. STUDY DESIGN:We compared NICU admissions on birth certificates to actual NICU admissions for all potentially viable in-hospital deliveries in Pennsylvania and South Carolina from 2006 to 2018 (n = 2,470,917). We used data from linked birth certificate and hospital discharge records to identify actual NICU admissions and evaluated missed NICU admissions by gestational age, mother's race and ethnicity, and other factors. RESULTS:38% of infants who were truly admitted to a NICU did not have a NICU admission on their birth certificates. Missed NICU admission occurred across all gestational ages. Birth certificates missed more than half of NICU admissions among term infants (37+ weeks), including among those with conditions considered to be severe. CONCLUSIONS:NICU admission reporting on birth certificates grossly underestimates utilization of NICU care and can have serious implications for research, resource allocation, and policy.

ObjectiveTo evaluate changes in hospital outcomes for infants with neonatal opioid withdrawal syndrome (NOWS) assessed by the Finnegan Tool before (10/1/2019 to 12/31/2019;pre-epoch) and after (7/1/2021 to 3/31/2022;post-epoch) publication of the 2020 AAP NOWS clinical report.Study designThis subgroup analysis included infants with NOWS assessed with the Finnegan Tool and enrolled in the INFORM NOW study (pre- and post-epoch 183 and 267 infants respectively).ResultsNo differences were found between epochs in initiation or length of pharmacologic treatment(LOT), or length of stay(LOS). Outcomes were modified by opioid type: LOT was 20% shorter (aMR=0.80; 95%CI:[0.69,0.93]) and LOS was 16% shorter (aMR=0.84; 95%CI:[0.73,0.96]) for buprenorphine treated infants post- compared to pre-epoch, while LOT and LOS were longer in the post-epoch for those treated with methadone.ConclusionThere was no difference in outcomes before and after publication of the AAP report. However, the type of postnatal opioid did modify study results.

Importance:US territory nativity and/or residence may be associated with health because it affects environmental exposures, insurance coverage, prenatal care, and other factors. Investigations of preterm birth in the US territories are limited. Objective:To assess the association between maternal territory status and preterm birth, as well as whether insurance type modified associations. Design, Setting, and Participants:Cross-sectional study of restricted-use birth certificates of in-hospital, singleton births in the US and territories from 2014 to 2023. Exposures:Maternal territory status was defined for births in territories where data were available (Guam, Northern Mariana Islands, Puerto Rico, and Virgin Islands) for the following groups: (1) those with territory nativity and residence; (2) those with territory nativity and mainland residence; (3) those with mainland nativity and territory residence; and (4) those with mainland nativity and residence (reference group). Insurance type (private, Medicaid, or other) was evaluated as well. Main Outcomes and Measures:Preterm birth (live birth before 37 weeks' gestation). Results:Among 28 627 700 births, 465 291 (1.6%) had any maternal territory status (nativity or residence). This group had a mean (SD) age of 27.1 (6.0) years, and 297 593 (64.0%) had Medicaid insurance. The highest preterm birth rate was among those with territory nativity and residence (10.5%; 95% CI, 10.4%-10.7%); the lowest was among those with mainland nativity and residence (8.4%; 95% CI, 8.4%-8.5%). Individuals with territory nativity and residence had an adjusted relative risk (aRR) of 1.30 (95% CI, 1.29-1.32) for preterm birth compared with the reference group. There was significant interaction between territory residence and insurance. Compared with individuals with mainland residence and private insurance, those with territory residence and Medicaid had the highest preterm birth risk (aRR, 1.57; 95% CI, 1.55-1.59), followed by territory residence and private insurance (aRR, 1.42; 95% CI, 1.39-1.45). Conclusions and relevance:In this cross-sectional study, maternal territory nativity and residence were associated with preterm birth. Territory residence was associated with a higher risk of preterm birth, regardless of insurance type. Privately insured-individuals in US territories had a higher risk of preterm birth than Medicaid-insured individuals in the mainland. Given differential access to health care, health insurance, and other social exposures between territory and mainland populations, future work should explore causal effects and related policies that may improve birth outcomes in US territories.

Breastfeeding is increasingly recognized as a powerful biologic intervention associated with positive infant and maternal health outcomes. Emerging evidence continues to expand our understanding of the mechanisms through which human milk promotes health, including via immune system development and modulation of antimicrobial resistance. Yet despite the robust scientific evidence supporting breastfeeding as critical to public health, many families in the US face structural barriers to achieving their breastfeeding goals. In the US, paid family leave has been strongly associated with both the initiation of breastfeeding and its duration. Paid family leave has also been associated with improved maternal and infant health, including reduced infant mortality. These findings suggest that paid family leave should be viewed not solely as a labor policy, but as a maternal-child health policy. The US remains one of the few high-income nations without a federal paid family leave program, relying instead on a fragmented patchwork of state policies. State experiences demonstrate that paid family leave can be implemented without major labor market disruption, while public support for a national program remains high. As breastfeeding science continues to advance, federal paid family leave represents overdue public health infrastructure necessary to translate evidence into population-level health improvements. IMPACT: Paid family leave is one of the most effective and well-supported policy mechanisms for promoting breastfeeding success and improving maternal and infant health. This article synthesizes emerging breastfeeding science, including new evidence regarding human milk's influence on neonatal immunity and antimicrobial resistance. We then link breastfeeding research with research on the policy that most supports widespread breastfeeding at a population level: paid family leave. Translating the benefits of breastfeeding into improved public health will require national policies that enable families to achieve breastfeeding goals. Federal paid family leave is among the most evidence-based policy strategies to achieve such goals.

BACKGROUND:Maternal level of care guidelines were published to facilitate risk-appropriate care and improve outcomes, yet evidence of benefit is lacking. All birth hospitals should be equipped to provide routine childbirth care and be prepared to manage common, treatable childbirth complications. Thus, our objective was to examine the association of maternal level of care with severe maternal morbidity (SMM) without transfusion among 1) all obstetric patients and 2) obstetric patients with common, treatable childbirth complications (e.g., hemorrhage and infection). METHODS:Using a retrospective observational cohort of hospital-based births, we analyzed linked vital statistic and hospital administrative data from Michigan (2010-2020), Oregon (2010-2020), Pennsylvania (2010-2018), and South Carolina (2010-2020). Maternal level of care (I [basic], II [specialty], III [subspecialty], and IV [regional perinatal health centers]) were empirically assigned using administrative data based on the care provided to patients who gave birth in each hospital annually. The primary outcome was SMM without blood product transfusion. We used modified Poisson regression to estimate adjusted risk ratios (aRRs), accounting for covariates present prior to admission for childbirth and associated with SMM. RESULTS:Among 3,296,520 births, the SMM rate rose with increasing level (I: 0.47%, II: 0.56%, III: 0.74%, IV: 0.94%). Compared to level IV care, the SMM aRR was lower in hospitals with level I care (aRR 0.87, 95% confidence interval [CI] 0.76-0.999). Whereas, among 245,604 patients with common, treatable childbirth complications the SMM aRR was higher in hospitals with level III care (aRR 1.21, 95% CI 1.04-1.40, reference level IV). CONCLUSION:We found differential associations between maternal levels of care and SMM among all obstetric patients and those with common, treatable complications that arise during childbirth. While unmeasured differences in patient triage, referral, and transfer patterns may influence associations, these findings suggest differences in how hospitals of varying levels of care assess patient risk, manage complications, and perceive their capabilities, illustrating the ongoing need to improve risk-appropriate obstetric care and optimize patient outcomes.

Importance:Antenatal opioid exposure is associated with adverse neurodevelopmental outcomes and smaller brain volumes, but the effects of opioids on newborn cortical folding maturation have not been defined. The Advancing Clinical Trials in Neonatal Opioid Withdrawal Outcomes of Babies With Opioid Exposure (OBOE) Study is a multisite prospective longitudinal cohort study examining the association of antenatal opioid exposure with brain maturation and outcomes in newborns. Objective:To compare cerebral cortical folding in newborns exposed to opioids vs nonexposed controls. Design, Setting, and Participants:In this cohort study, full-term newborns from the OBOE study with antenatal opioid exposure and nonexposed controls were recruited at 4 US sites, including obstetric clinics, maternal substance use treatment programs, and birth hospitals, from August 5, 2020, to December 28, 2023. Data analysis was performed from August 19, 2020, to March 25, 2026. Exposure:Newborn opioid exposure, including opioid-only and polysubstance exposure as well as exposure to specific opioids. Main Outcomes and Measures:Nonsedated T2-weighted magnetic resonance imaging (MRI) data were acquired via harmonized protocols, and 3D brain images were segmented and parcellated using the Developing Brain Region Annotation With Expectation-Maximization pipeline. The inner cortical gray matter surface was used to measure cortical folding across the frontal, parietal, temporal, and occipital lobes. Group differences between opioid-exposed and nonexposed newborns were compared via analysis of covariance, adjusting for postmenstrual age at MRI, sex, birth weight, maternal age, smoking status, and education level. Results:A total of 259 newborns (mean [SD] gestational age at birth, 39.1 [1.0] weeks; 145 [56.0%] male) were included in the analysis, of whom 164 had antenatal exposure to opioids and 95 were nonexposed controls (mean [SD] postmenstrual age at MRI, 42.8 [2.2] and 42.9 [2.0] weeks, respectively). Compared with nonexposed controls, newborns who had been exposed to opioids had significantly decreased sulcal depth in the frontal (difference, -0.11 mm [95% CI, -0.20 to -0.02 mm]), parietal (difference, -0.19 mm [95% CI, -0.31 to -0.07 mm]), and global (difference, -0.09 mm [95% CI, -0.18 to -0.01 mm]) regions, as well as decreased surface area in the frontal (difference, -1048 mm2 [95% CI, -1497 to -598 mm2]), parietal (difference, -501 mm2 [95% CI, -834 to -168 mm2]), temporal (difference, -422 mm2 [95% CI, -682 to -162 mm2]), occipital (difference, -232 mm2 [95% CI, -439 to -26 mm2]), and global (difference, -2185 mm2 [95% CI, -3327 to -1043 mm2]) surfaces. Compared with controls, newborns exposed to methadone showed larger reductions in frontal, parietal, and global surface areas than those exposed to buprenorphine, with parietal surface area significantly reduced only in the methadone-exposed group (difference, -656 mm2 [95% CI, -1111 to -202 mm2]). Newborns with polysubstance exposure had significantly reduced sulcal depth in the frontal, parietal, and global surfaces, as well as reduced surface area across all lobes compared with controls, whereas opioid-only exposed newborns showed fewer significant differences from controls, with reduced parietal sulcal depth and decreased frontal and global surface areas. Conclusions and Relevance:In this cohort study, newborns with antenatal exposure to opioids had reduced cerebral cortical sulcal depth and surface area compared with nonexposed controls, with greater reductions among newborns exposed to methadone compared with those exposed to buprenorphine, and in newborns with polysubstance exposure compared with those with opioid exposure only. Ongoing serial MRI and long-term follow-up are under way to assess the impact of these early cortical maturational differences on later neurodevelopment and behavior.

Importance:Infants with neonatal opioid withdrawal syndrome (NOWS) who receive pharmacologic treatment are traditionally treated with a scheduled opioid taper. An alternate approach, symptom-based dosing, may better align treatment with withdrawal severity. Objective:To compare time from birth to medical readiness for discharge for infants with moderate to severe withdrawal treated with either a symptom-based dosing or scheduled opioid taper approach. Design, Setting, and Participants:In this cluster, crossover randomized clinical trial with run-in period, 23 US hospitals cared for infants using the Eat, Sleep, Console approach (ESC) or Finnegan-based care (a comprehensive scoring system to quantify severity of symptoms; 15 ESC and 8 Finnegan hospitals) and their preferred primary opioid. Opioid dosing was guided by study-approved, site-specific algorithms. Infants with NOWS with a gestational age at birth of at least 36 weeks and at risk for pharmacologic treatment were enrolled between March 25, 2024, and April 9, 2025, with the last 3-month assessment on July 15, 2025. Sample size analyses were conducted between August 1, 2024, and September 23, 2024. Intervention:Sites were randomized to 1 of 2 sequences: (1) symptom-based dosing followed by scheduled opioid taper or (2) scheduled opioid taper followed by symptom-based dosing. Main Outcome and Measure:Time from birth to medical readiness for discharge. Results:Of the 626 enrolled infants (mean [SD] gestational age, 38 [1] weeks; 49% male), 383 were cared for with ESC (primary outcome cohort). The mean time to medical readiness for discharge was significantly shorter in the symptom-based dosing group compared with the scheduled opioid taper group (9.18 vs 11.61 days; adjusted mean ratio [aMR], 0.79 [95% CI, 0.65-0.96]). There was no difference in the risk for initiation of pharmacologic treatment (0.4 vs 0.41; adjusted risk ratio, 0.99 [95% CI, 0.77-1.27]) or length of stay (10.91 vs 12.09 days; aMR, 0.9 [95% CI, 0.72-1.13]) between groups. For infants in the symptom-based group, 35% (95% CI, 25%-45%) required scheduled opioid dosing due to withdrawal severity that was not controlled with intermittent dosing. In the Finnegan cohort (n = 243; planned secondary outcome), there were no significant differences in time to medical readiness for discharge (15.99 vs 17.56 days; aMR, 0.91 [95% CI, 0.72-1.15]) or length of stay (17.38 vs 19.39 days; aMR, 0.9 [95% CI, 0.69-1.16]). The inpatient composite safety outcome occurred rarely (in the ESC cohort, 3 of 188 in the symptom-based dosing vs 2 of 195 in the scheduled opioid taper groups). Conclusions and Relevance:Symptom-based dosing decreased time to medical readiness for discharge compared with a scheduled opioid taper approach among infants cared for with ESC. Trial Registration:ClinicalTrials.gov Identifier: NCT05980260.

OBJECTIVES:Level III NICUs share one AAP level of care designation. We characterized variation, identified sub-classes, and compared sub-class outcomes. STUDY DESIGN:This retrospective cohort analysis of level III NICUs in Florida, Michigan, Oregon, Pennsylvania, and South Carolina used linked hospital discharge-vital statistics data (2010-2020). Included hospitals had ≥10 births annually and infants had gestational age <32 weeks and/or birth weight <1500 g. We characterized NICU-level heterogeneity; used latent class analysis (LCA) to obtain sub-classes; and compared risk-adjusted outcomes with multivariable Poisson regression. RESULTS:Among 163 NICUs (1518 hospital-years) there was significant variation. LCA identified five sub-classes (3a-e). Preterm volume and procedural intensity rose with acuity (3a lowest, 3d/3e highest). Higher acuity was associated with lower mortality but higher morbidity (3d vs. 3a: death: IRR 0.59 [95% CI 0.54-0.65]; morbidity: 2.84 [2.43-3.31]). CONCLUSIONS:Level III NICUs are heterogeneous and comprise five sub-classes with divergent outcomes. Sub-classification may facilitate risk-appropriate care.

Objective:Furosemide is commonly prescribed in hospitalized infants with grade 2-3 bronchopulmonary dysplasia (BPD). Intravenous (IV), gastric, and duodenal administrations are common, with a 1:2 IV-to-enteral conversion often used despite uncertain bioavailability. Our objective was to compare diuretic responses between routes in infants with BPD. Study Design:Single-center observational cohort of very preterm infants with grade 2-3 BPD prescribed furosemide. The association between route (exposure) and diuretic response (change in net fluid balance after administration, outcome) was evaluated using multivariable regression adjusting for dosing and infant characteristics. Results:Among 153 infants (median postmenstrual age of 43.3 weeks at exposure), furosemide reduced fluid balance by -25.6 (29.8) ml/kg/d. Adjusted mean changes were similar across routes: IV, -25.3 (-35.8, -14.7), gastric, -25.8 (-32.2, -19.4), and duodenal, -25.8 (-34.2, -17.4). Conclusions:Our data suggest a 1:2 IV-to-enteralconversion leads to comparable diuretic effects in infants with established BPD, supporting this common clinical practice.

BACKGROUND AND OBJECTIVES:Enhanced premium tax credits (PTCs) for Affordable Care Act Marketplace plans expired in 2026. We described families across income groups potentially affected by PTC policy changes and simulated net premiums. METHODS:We performed a cross-sectional simulation using the 2023 National Survey of Children's Health, classifying families by federal poverty level (FPL) into the following income groups: ineligible (above state Medicaid threshold, <100% FPL), Medicaid (below state threshold), 100-<250% FPL, 250-<400% FPL, and ≥400% FPL. We estimated family premiums using scaled state benchmarks and modeled net premium costs under (1) enhanced PTCs, (2) enhanced PTC expiration, and (3) PTC repeal using ordinary least squares regression adjusting for state fixed effects and family sociodemographics. RESULTS:Families in PTC-relevant income groups had greater material hardship and children with more health conditions but less access than higher-income families. With typical family ages, adjusted net premiums as a percentage of income would be 1.8% (100-<250% FPL), 6.3% (250-<400% FPL), and 8.4% (≥400% FPL) with enhanced PTCs; 6.2%, 9.5%, and 15.2% post-expiration; and 27.1%, 17.8%, and 13.7% with repealed PTCs. In 2023 dollars, net premiums would be $1,335, $6,137, and $9,705 with enhanced PTCs; $4,100, $9,056, and $17,711 post-expiration; and $15,963, $17,069, and $16,903 with no PTCs. CONCLUSIONS AND POLICY IMPLICATIONS:Enhanced PTC expiration would increase net premiums substantially, particularly for ≥400% FPL families; full PTC repeal would produce large, regressive premium burdens for lower-income families with children. PTCs should be re-enhanced and not repealed to support American families.

Importance Infants with neonatal opioid withdrawal syndrome (NOWS) who receive pharmacologic treatment are traditionally treated with a scheduled opioid taper. An alternate approach, symptom-based dosing, may better align treatment with withdrawal severity. Objective To compare time from birth to medical readiness for discharge for infants with moderate to severe withdrawal treated with either a symptom-based dosing or scheduled opioid taper approach. Design, Setting, and Participants In this cluster, crossover randomized clinical trial with run-in period, 23 US hospitals cared for infants using the Eat, Sleep, Console approach (ESC) or Finnegan-based care (a comprehensive scoring system to quantify severity of symptoms; 15 ESC and 8 Finnegan hospitals) and their preferred primary opioid. Opioid dosing was guided by study-approved, site-specific algorithms. Infants with NOWS with a gestational age at birth of at least 36 weeks and at risk for pharmacologic treatment were enrolled between March 25, 2024, and April 9, 2025, with the last 3-month assessment on July 15, 2025. Sample size analyses were conducted between August 1, 2024, and September 23, 2024. Intervention Sites were randomized to 1 of 2 sequences: (1) symptom-based dosing followed by scheduled opioid taper or (2) scheduled opioid taper followed by symptom-based dosing. Main Outcome and Measure Time from birth to medical readiness for discharge. Results Of the 626 enrolled infants (mean [SD] gestational age, 38 [1] weeks; 49% male), 383 were cared for with ESC (primary outcome cohort). The mean time to medical readiness for discharge was significantly shorter in the symptom-based dosing group compared with the scheduled opioid taper group (9.18 vs 11.61 days; adjusted mean ratio [aMR], 0.79 [95% CI, 0.65-0.96]). There was no difference in the risk for initiation of pharmacologic treatment (0.4 vs 0.41; adjusted risk ratio, 0.99 [95% CI, 0.77-1.27]) or length of stay (10.91 vs 12.09 days; aMR, 0.9 [95% CI, 0.72-1.13]) between groups. For infants in the symptom-based group, 35% (95% CI, 25%-45%) required scheduled opioid dosing due to withdrawal severity that was not controlled with intermittent dosing. In the Finnegan cohort (n = 243; planned secondary outcome), there were no significant differences in time to medical readiness for discharge (15.99 vs 17.56 days; aMR, 0.91 [95% CI, 0.72-1.15]) or length of stay (17.38 vs 19.39 days; aMR, 0.9 [95% CI, 0.69-1.16]). The inpatient composite safety outcome occurred rarely (in the ESC cohort, 3 of 188 in the symptom-based dosing vs 2 of 195 in the scheduled opioid taper groups). Conclusions and Relevance Symptom-based dosing decreased time to medical readiness for discharge compared with a scheduled opioid taper approach among infants cared for with ESC. Trial Registration ClinicalTrials.gov Identifier: NCT05980260

OBJECTIVE:Determine the association of infant mortality (IM) and gentrification, a composite measure of rising neighborhood income, education, and housing costs. STUDY DESIGN:Retrospective cohort analysis of 672,432 infants born 2010-2019 across metropolitan Michigan. Multilevel multivariable regression models examined the association of gentrification and IM. Gentrification components were evaluated in separate models. RESULTS:Gentrification was not associated with IM, but some of its components were. Living in a census tract with an above median rise in income or education attainment was associated with lower odds of IM, compared to below median change (Income: aOR=0.88; 95% CI: 0.82-0.95; Education: aOR=0.93; 95% CI: 0.86-0.997). Rent increases above the median were linked to higher IM among term infants and lower IM among infants <32 weeks' gestation. The association of IM with rising home values varied by maternal insurance status. CONCLUSIONS:Indicators of increasing community affluence, often combined to define gentrification, have opposing relationships with IM.

Importance:There is limited research examining the association of antenatal opioid exposure with neonatal brain microstructure, particularly within the limbic system, which contains high concentrations of opioid receptors. Prior studies investigating microstructural changes in major white matter tracts were underpowered and lacked matched controls. Objective:To compare limbic system microstructure between neonates who were opioid exposed and unexposed. Design, Setting, and Participants:This case-control study assessed diffusion tensor imaging of neonates enrolled in the Outcomes of Babies With Opioid Exposure (OBOE) study and scanned between August 2020 and December 2023 at 4 US sites. Participants were term neonates with antenatal exposure and unexposed controls. Data were analyzed from July 2024 to April 2026. Exposure:Neonates were antenatally exposed to methadone, buprenorphine, oxycodone, hydromorphone, fentanyl, hydrocodone, heroin, morphine, or some combination of these opioids. Main Outcomes and Measures:The primary outcome was limbic system diffusion metric comparisons between neonates who were exposed and unexposed. Diffusion tensor imaging data in term neonates were acquired using harmonized protocols on Siemens and Philips 3T magnetic resonance imaging scanners, preprocessed using a neonatal-optimized pipeline, and analyzed. Using analysis of covariance, fractional anisotropy, mean diffusivity, radial diffusivity, and axial diffusivity were compared in the limbic system of neonates who were unexposed vs opioid exposed. In secondary, exploratory analyses, diffusion metrics in the limbic system were compared between subgroups of opioid exposure (methadone, buprenorphine, and other opioids) and controls. False discovery rate (FDR) was used to correct for multiple comparisons. Results:Among 201 enrolled neonates, 75 were unexposed (mean [SD] postmenstrual age, 42.76 [2.05] weeks; 45 male [60.0%]) and 126 were antenatally opioid exposed (mean [SD] postmenstrual age, 42.72 [2.06] weeks; 65 male [51.6%]), of which 79 were exposed to buprenorphine, 30 to methadone, and 14 to other opioids. Neonates who were opioid exposed showed a significantly lower mean diffusivity (mean difference [β] = -0.06 × 10-3 mm2/s [95% CI, -0.11 to -0.01 × 10-3 mm2/s]; FDR P = .04) and radial diffusivity (β = -0.07 × 10-3 mm2/s [95% CI, -0.12 to -0.02 × 10-3 mm2/s]; FDR P = .04) in the fornix. Secondary, exploratory analyses revealed buprenorphine-specific associations (eg, higher mean diffusivity in the left parahippocampal gyrus vs no opioid exposure: β = 0.02 × 10⁻3 mm2/s [95% CI, 0.00 to 0.04 × 10⁻3 mm2/s]) and other opioid-specific associations (eg, higher fractional anisotropy in the left thalamus for other opioids vs unexposed: β = 0.01 [95% CI, 0.01 to 0.02]) in GM limbic system structures. Conclusions and Relevance:This study found altered limbic system microstructure, particularly in the fornix, in neonates with antenatal opioid exposure, and exploratory analyses showed different patterns of limbic system microstructure across opioid exposure subgroups. Clinical correlation is needed.

Abstract Objective To determine whether and to what extent hospitals across the United States vary in their use of late-preterm steroids using a novel data set in which the timing of steroid administration relative to delivery can be observed. Methods This was a retrospective cohort study of singleton births with known gestational ages identified in the Premier Healthcare Database from 2015 to 2022. The primary variable of interest was hospital-level adoption of antenatal corticosteroids for late-preterm singleton deliveries, calculated as the proportion of late-preterm singleton births (34-36 completed weeks of gestation) with any betamethasone exposure during the same late-preterm period. Hospital adoption was defined as the weighted average rate of ALPS administration among late-preterm infants across the entire post-period. Hospitals were ranked by their late-preterm steroid adoption rates and categorized by quartile based on the empirical distribution. Temporal trends were assessed using annual hospital-level adoption rates and visualized using time-series plots and distributional plots. A logistic regression model was constructed to determine hospital characteristics associated with being a highest-quartile adopting hospital. Results The analysis cohort included 728 hospitals and 5,452,791 births, of which 361,006 (6.6%) were singleton late preterm births. Hospital steroid exposure rates ranged from 0 to 82% and were categorized into quartiles based on overall exposure rate, with cutoffs at 20.6%, 29.8%, and 40.1%. Median exposure rates increased progressively across quartiles from 14.1% (IQR 9.3-17.4%) in the lowest adopting hospitals (Q1) to 47.6% (IQR 43.7-53.2%) in the highest adopting hospitals (Q4), with substantial within-quartile variation. In the multivariable model, urban location was a strong predictor of high adoption after adjustment (aOR 2.05; 95% CI 1.11-3.83, p=0.02). Compared to Midwest hospitals, Southern hospitals had significantly lower odds of being high adopters (aOR 0.37; 95% CI 0.20-0.69, p<0.01). Among clinical case mix variables, a higher proportion of late preterm births at 34 weeks’ gestation was strongly associated with high adoption (aOR 2.21; 95% CI 1.58-3.14, p<0.001). Conclusion Following publication of the ALPS Trial, there was heterogeneous adoption of late preterm steroids among US hospitals. These findings highlight the need for a more in-depth exploration of local factors that drive the adoption of evidence-based practices outside of observable hospital characteristics.

INTRODUCTION:Wildfire smoke is an increasing source of pollution in the United States and can affect communities far from active fires. The developing fetus is vulnerable to prenatal smoke exposure, yet existing evidence is focused on a few western states. This population-based retrospective cohort study documents national patterns and trends in prenatal wildfire smoke exposure across geographic and sociodemographic groups. METHODS:Satellite-based wildfire smoke plumes were combined with restricted-use vital statistics microdata for 34,440,915 live births in the contiguous United States from 2012-2020. Prenatal exposure was measured as the number of days during gestation with medium or heavy wildfire smoke in the mother's county of residence. Changes in median smoke-days, the share of infants prenatally exposed to ≥7 smoke-days, and wildfire-attributed PM2.5 on smoke-days overall and by maternal and county characteristics were examined. Statistical significance was assessed using t-tests and quantile regression. Analysis was performed from March to November 2024. RESULTS:25.5 million infants (74.2%) had prenatal smoke exposure. 4.3 million (22.7%) births had at least 7 days of exposure in 2016-2020, a significant increase from 2012-2015 (p<0.001). Median exposure significantly increased from 0.6 days in 2012-2015 to 2.0 days in 2016-2020 (p<0.001). Non-Hispanic American Indian/Alaska Native infants, infants living in rural counties, and states in the Upper and Western Midwest and Rocky Mountains faced the highest prenatal exposures. CONCLUSIONS:Prenatal wildfire smoke exposure is widespread, increasing, and not confined to regions near active fires. These findings highlight a growing national public health concern and underscore the need for preparedness, targeted prevention, and risk-appropriate care across communities.

BACKGROUND:The postpartum period is a critical window to address maternal health inequities. Black, Hispanic, Indigenous, and rural populations experience disproportionately high rates of postpartum morbidity and postpartum hospital use (PHU), defined as readmissions or emergency department (ED) visits after delivery. Delivery hospitalizations provide an opportunity for early identification of individuals at high risk of PHU, who may benefit from targeted interventions to prevent adverse outcomes. We previously developed a 30-day PHU prediction model using New York City (NYC) birth data (2016-2018), which achieved an area under the receiver operating curve (AUC) of 0.69. However, its performance in obstetric populations outside of a dense urban setting has not been examined. STUDY DESIGN:We aimed to evaluate the accuracy of our PHU prediction model in South Carolina (SC) and Florida (FL), states with diverse populations, including substantial rural representation, and in a different US geographic region than the NYC development sample. We additionally examined model performance in subgroups defined by race/ethnicity, Medicaid insurance, and rural residence. METHODS:We performed a retrospective cohort study of linked birth certificate and hospital discharge data from 2016 to 2019 births in SC (n=183,836) and FL (n=696,963). We ascertained 21 predictors consistent with the NYC model, excluding two variables (prenatal depression, Apgar) unavailable in the new states. PHU was defined as ≥1 inpatient or ED encounter within 30 days postpartum. Model performance was assessed using calibration (intercept, slope) and discrimination (AUC). We first applied the original NYC model coefficients to generate PHU predicted probabilities among SC and FL births. We then tested a series of stepwise model updating strategies: recalibrating intercepts, re-estimating predictor coefficients, and incorporating additional contextual indicators of hospital access-residential rurality and driving distance to the delivery hospital-hypothesized to be relevant in settings with larger rural populations. RESULTS:Cumulative 30-day PHU incidence was 7.4% in SC and 7.2% in FL; rates were higher among Black individuals, Medicaid-insured individuals, and rural residents. Applying the original NYC model coefficients achieved an AUC of 0.68 (95% CI 0.67-0.68) and 0.69 (95% CI 0.68-0.69) among SC and FL births, respectively, but generated overestimated and extreme risk predictions compared with observed risk. Updating model intercepts corrected calibration, and additionally re-estimating coefficients resulted in an AUC of 0.69 (95% CI 0.68-0.69) in SC and 0.70 (95% CI 0.70-0.71) in FL. Inclusion of hospital distance and rurality did not meaningfully change calibration or discrimination. Model discrimination was slightly lower when subset to Black, Medicaid-insured, and rural residents, but AUC increased within each group after re-estimating predictor coefficients. CONCLUSION:A PHU prediction model developed in an urban NYC cohort demonstrated similarly moderate discrimination in SC and FL as in the original NYC sample, but overestimated absolute risk in these new settings. Modest model updating, including recalibration of intercepts and re-estimation of coefficients, yielded well-calibrated models without requiring new predictors. Hospital access measures did not substantially improve prediction. These findings demonstrate that an existing prediction model for postpartum acute care use can be adapted for use in geographically and socio-demographically diverse populations. Geographic validation and model updating are important steps in deploying predictive tools to reduce persistent gaps in maternal health outcomes.

Social and environmental exposures influence health outcomes across the lifespan, including during the perinatal period. Negative exposures such as neighborhood deprivation, air pollution, and violence, as well as positive exposures such as greenspace, neighborhood cohesion, and walkability, interact to affect many complex health outcomes. Understanding the impact of neighborhood environmental exposures on health is required to design effective interventions to improve health impacts of the places shaping people's daily lives. In the era of geographic information systems (GIS), analyses delineating relationships between area-level exposures and health outcomes have become technically feasible for many public health researchers. In this primer, with a focus on maternal and perinatal health as members of the Pregnancy, Postpartum, and Postnatal Health Enhancing Quality and Access to Achieve Equitable Maternal and Infant Health (P3EQUATE) Health Equity Research Network (HERN) Social Determinants of Health Working Core, we put forth a stepwise approach to performing analyses of area-level exposures and health outcomes with considerations to promote scientific rigor.

Individuals with Medicaid insurance are more likely to have pregnancy-related complications than individuals with private insurance, but previous research has not described postpartum hospital use in the population of patients with Medicaid. Using Medicaid claims data, we analyzed time to the first instance of postpartum hospital use during the postpartum year using Kaplan-Meier curves and described causes of postpartum hospital use at different postpartum windows. Among 1,626,056 birthing individuals, 20.7% had postpartum hospital use at 1 year postpartum. We found a higher proportion of postpartum hospital use after the typical 30-day postpartum analysis window than within the initial 30 days postpartum, with causes of postpartum hospital use shifting away from delivery-related causes over time. This highlights the need to better understand postpartum hospital use in the population of patients with Medicaid insurance, because 40% of births in the United States occur in this population.