Risk of Preterm Birth Reliably Predicted by New Test

https://www.ucsf.edu/news/2018/05/410456/risk-preterm-birth-reliably-predicted-new-test

 

Scientists at UC San Francisco have developed a test to predict a woman’s risk of preterm birth when she is between 15 and 20 weeks pregnant, which may enable doctors to treat them early and thereby prevent severe complications later in the pregnancy.

Preterm birth is the leading cause of death for children under five in the United States, and rates are increasing both in the U.S. and around the world. It is often associated with inflammation and has many potential causes, including an acute infection in the mother, exposure to environmental toxins, or chronic conditions like hypertension and diabetes.

The new test screens for 25 biomarkers of inflammation and immune system activation, as well as for levels of proteins that are important for placenta development. Combined with information on other risk factors, such as the mother’s age and income, the test can predict whether a woman is at risk for preterm birth with more than 80 percent accuracy. In the highest risk pregnancies—preterm births occurring before 32 weeks or in women with preeclampsia, a potentially fatal pregnancy complication marked by high blood pressure in the mother—the test predicted nearly 90 percent of cases.

In the study, published Thursday, May 24, 2018, in the Journal of Perinatology, the researchers built a comprehensive test that would capture both spontaneous preterm births, which occurs when the amniotic sac breaks or contractions begin spontaneously, and “indicated” preterm birth, in which a physician induces labor or performs a cesarean section because the health of the mother or baby is in jeopardy. The researchers also wanted to be able to identify risk for preeclampsia, which is not included in current tests for preterm birth.

“There are multifactorial causes of preterm birth, and that’s why we felt like we needed to build a model that took into account multiple biological pathways,” said first author Laura Jelliffe-Pawlowski, PhD, director of Precision Health and Discovery with the UCSF California Preterm Birth Initiative and associate professor of epidemiology and biostatistics at UCSF. “The model works especially well for early preterm births and preeclampsia, which suggests that we're effectively capturing severe types of preterm birth.”

The researchers developed the screen using blood samples taken from 400 women as part of routine prenatal care during the second trimester, comparing women who went on to give birth before 32 weeks, between 32 and 36 weeks, and after 38 weeks (full-term). The researchers first tested the samples for more than 60 different immune and growth factors, ultimately narrowing the test down to 25 factors that together could help predict risk for preterm birth. When other data, including whether or not the mother was over 34 years old or if she qualified as low income (indicated by Medicaid eligibility), improved the accuracy of the test by an additional 6 percent.

Researchers said the test could help prevent some cases of preterm birth. Based on a woman’s probability of preterm birth derived by the test, she could discuss with her clinician how best to follow-up and try to lower her risk. Some cases of preterm birth, including those caused by preeclampsia, can be prevented or delayed by taking aspirin, but treatment is most helpful if started before 16 weeks. Physicians could also evaluate high-risk women for underlying infections that may have gone undetected but could be treated. For others, close monitoring by their doctor could help flag early signs of labor like cervical shortening that can be staved off with progesterone treatment.

“We hope that this test could lead to more education and counseling of women about their level of risk so that they know about preterm birth and know what preeclampsia or early signs of labor look like,” said Jelliffe-Pawlowski. “If we can get women to the hospital as soon as possible, even if they’ve gone into labor, we can use medications to stave off contractions. This might give her some additional days before she delivers, which can be really important for the baby.”

A test for preterm birth is currently available, but it is expensive and only screens for spontaneous preterm birth, not for signs that could lead to indicated preterm births or for preeclampsia. Jelliffe-Pawlowski said that the new screen would likely be a fraction of the cost, making it more accessible to women who need it the most.

“One of the reasons we’re most excited about this test is that we see some potential for it addressing preterm birth in those most at risk, including low-income women, women of color, and women living in low-income countries,” she said. “We want to make sure that we're developing something that has the potential to help all women, including those most in need.”

Maternal placenta consumption causes no harm to newborns

The largest study of its kind found mothers who consumed their placenta passed on no harm to their newborn babies. 

May 3, 2018

Summary: A study found mothers who consumed their placenta passed on no harm to their newborn babies when compared to infants of mothers who did not consume their placenta.     

FULL STORY

The largest study of its kind found mothers who consumed their placenta passed on no harm to their newborn babies when compared to infants of mothers who did not consume their placenta.

The joint study by UNLV and Oregon State University was published May 2 in the journal Birth.

Reviewing roughly 23,000 birth records, researchers found no increased risk in three areas: Neonatal Intensive Care Unit admissions in the first six weeks of life; neonatal hospitalization in the first six weeks; and neonatal/infant death in the first six weeks.

The study also found that women who reported a history of anxiety or depression were more likely to consume their placentas, and that the most common reason for choosing the practice was to prevent postpartum depression.

"This research, based on a large sample of consumers, gives us a better understanding of why women are consuming placenta after birth and the effects of that consumption on newborns," said study co-author Melissa Cheyney, a licensed midwife, medical anthropologist and associate professor in Oregon State University's College of Liberal Arts. "The findings also give us a foundation from which to further explore the impact of placenta consumption on postpartum mood disorders."

Consuming the placenta following childbirth is an increasingly popular trend in industrial countries, such as the United Kingdom, France, Germany, Australia, and the United States. Although precise estimates are not yet available, most experts agree there are many thousands of women in the U.S. alone who practice maternal placentophagy. And while the practice appears to be more common in home birth settings, it has been spreading to hospital births.

The new study, which examined birth outcomes and newborn risk, as well as how women consume their placentas and their motivations for doing so, contrasts a recent Centers for Disease Control and Prevention report recommending against placentophagy.

The CDC report was based on a single case study of a baby in Oregon who may have become infected with group B Streptococcus agalactiae following maternal consumption of an infected placenta. Based on that case, the CDC recommended that placenta capsule ingestion should be avoided.

"Our findings were surprising given the recent guidelines recommending against placenta consumption, as well as the known risks of consuming uncooked or undercooked meat," said Daniel Benyshek, a professor of anthropology at UNLV and the study's lead author. "These new findings give us little reason to caution against human maternal placentophagy out of fear of health risks to the baby."

A study by Benyshek and colleagues last year found taking placenta capsules had little to no effect on postpartum mood, maternal bonding, or fatigue, when compared to a placebo, although the study did identify a small, dose-specific impact on some maternal among participants taking the placenta capsules, and may warrant additional research.

The new research was based on the Midwives Alliance of North America Statistics Project, a perinatal registry of maternal and infant health data from midwife-led births primarily at home and in birth centers.

The researchers said nearly one-third of the women in the database consumed their placenta following birth, mostly via capsules containing cooked or raw, dehydrated and ground placenta.

They also found that, among this sample of women who planned community births, those who consumed their placenta were more likely to be from a minority racial or ethnic group; hold a bachelor's degree; be having their first baby; and be from the Western or Rocky Mountain states.

While the study found no risk to babies, it did not examine impact on postpartum mood disorders.

Benyshek and Cheyney also found a small, dose-specific impact on maternal hormones after consumption. Additional research is needed, the professors said.

"While there is currently no evidence to support the efficacy of placentophagy as treatment for mood disorders such as postpartum depression, our study suggests that if neonatal infection from maternal consumption of the placenta is possible, that it is exceedingly rare," Cheyney said.

Story Source:

Materials provided by University of Nevada, Las VegasNote: Content may be edited for style and length.

Journal Reference:

  1. Daniel C. Benyshek, Melissa Cheyney, Jennifer Brown, Marit L. Bovbjerg. Placentophagy among women planning community births in the United States: Frequency, rationale, and associated neonatal outcomesBirth, 2018; DOI: 10.1111/birt.12354

Redesigning Maternal Care: OB-GYNs Are Urged to See New Mothers Sooner and More Often

by Nina Martin April 23

https://www.propublica.org/article/maternal-care-ob-gyns-american-college-of-obstetricians-and-gynecologists

Doctors would see new mothers sooner and more frequently, and insurers would cover the increased visits, under sweeping new recommendations from the organization that sets standards of care for obstetrician-gynecologists in the U.S.

The 11-page “committee opinion” on “Optimizing Postpartum Care,” released today by the American College of Obstetricians and Gynecologists, represents a fundamental reimagining of how providers, insurers and patients can work together to improve care for women after giving birth. “To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs,” the committee opinion states.

While an ACOG task force began rethinking its approach several years ago, the guidelines arrive at a moment of mounting concern about rising rates of pregnancy-related deaths and near-deaths in the U.S. As ProPublica and NPR have reported, more than 700 women die every year in this country from causes related to pregnancy and childbirth and more than 50,000 suffer life-threatening complications, among the worst records for maternal health in the industrialized world. The death rate for black mothers is three to four times that of white women.

The days and weeks after childbirth can be a time of particular vulnerability for new moms, with physical and emotional risks that include pain and infection, hypertension and stroke, heart problems, blood clots, anxiety and depression. More than half of maternal deaths occur after the baby is born, according to a new CDC Foundation report.

Yet for many women in the U.S., the ACOG committee opinion notes, the postpartum period is “devoid of formal or infor­mal maternal support.” This reflects a troubling tendency in the medical system — and throughout American society — to focus on the health and safety of the fetus or baby more than that of the mother. “The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”

The way that providers currently care for pregnant women and infants versus new mothers exemplifies this difference. During the prenatal period, a woman may see her OB-GYN a dozen or more times, including at least two checkups during her ninth month. Her baby’s first pediatric visit usually occurs a few days after birth. But the mother may not have a follow-up appointment with her own doctor until four to six weeks after delivery — and in many cases, insurance only covers one visit. “As soon as that baby comes out, [the mom] is kind of an afterthought,” said Tamika Auguste, associate medical director of the MedStar Health Simulation Training & Education Lab in Washington, D.C., and a co-author of the ACOG opinion.

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For working mothers, having to wait four to six weeks makes it harder to arrange a check-up.

Some 23 percent of mothers employed outside the home are back on the job within 10 days of giving birth, a 2014 report for the U.S. Department of Labor found; another 22 percent return to work within 40 days. Lack of childcare and transportation can also present significant hurdles to accessing care. According to ACOG, as many as 40 percent of women skip their postpartum visit; for low-income women of color, the rates are even higher.

“You may have a woman that has asthma, is having problems lactating, and is obese, and when they come to see you at six weeks, we have missed the boat here,” Auguste said.

Nor is a single visit enough time to address a new mother’s questions and concerns, especially if she had a complicated pregnancy or is suffering from chronic conditions such as hypertension, diabetes or a mood disorder. “We’re trying to address all of the issues that women are dealing with after having a baby in one 20-minute encounter,” Stuebe said. “And that’s really hard to do.”

Under the new ACOG guidelines, women would see their providers much earlier — from within three days postpartum if they have suffered from severe hypertension to no later than three weeks if their pregnancies and deliveries were normal— and would return as often as needed. Depending on a woman’s symptoms and history, the final postpartum visit could take place as late as 12 weeks after delivery and ideally would include “a full assessment of physical, social, and psychological well-being,” from pain to weight loss to sexuality to management of chronic diseases, ACOG says.

See Our Series

 

Lost Mothers

Maternal Care and Preventable Deaths

In another significant change, ACOG is urging providers to emphasize in conversations with patients the long-term health risks associated with pregnancy complications such as preterm delivery, preeclampsia and gestational diabetes. “These risk factors are emerging as an important predictor of future [cardiovascular disease],” the recommendations state. “ … [B]ut because these conditions often resolve postpartum, the increased cardiovascular disease risk is not consistently communicated to women.”

Earlier, more frequent and more individualized care could be a step toward addressing the stark racial disparities in maternal and infant health, said ACOG’s outgoing president, Haywood Brown, who has made reforming postpartum care one of the main initiatives of his term. Black mothers are at higher risk for many childbirth complications, including preeclampsiaheart failure and blood clots, and they’re more likely to suffer long-lasting health consequences. They also have higher rates of postpartum depression but are less likely to receive treatment. Regardless of race, for women whose pregnancies are covered by Medicaid, the postpartum period may be their best opportunity to get help with chronic conditions before they lose insurance coverage.

The new guidelines urge doctors to take a proactive approach, helping patients develop a postpartum care plan while still pregnant, including a team of family and friends to provide social and other support. According to ACOG, one in four new mothers surveyed recently said they didn’t even have a phone number of a health care provider to contact with concerns about themselves or their babies.

ACOG isn’t the only organization calling for a reinvention of postpartum care; patient-safety groups, researchers, nurses and midwives have also tackled the issue, recasting the three months after birth as akin to a “fourth trimester.”

“The postpartum period has become a priority,” said Debra Bingham, a professor of nursing at the University of Maryland and executive director of the Institute for Perinatal Quality Improvement who has participated in many of these initiatives.

Some providers, including Brown, who is affiliated with Duke University, are already incorporating some of ACOG’s ideas. Still, putting the reforms into common practice may take years. One of the biggest impediments is insurance reimbursement. Currently, payment for prenatal care, delivery and a single post-birth visit is bundled together into one global fee, creating a disincentive for doctors to see patients more than once, Auguste said.

The disincentives are greater for women on Medicaid, which pays for about half of U.S. births. What’s more, in many states Medicaid coverage ends at two months postpartum. The ACOG opinion didn’t estimate the cost of implementing its recommendations.

Brown agreed that revamping how postpartum care is reimbursed is critical, and insurance representatives — along with members of other medical specialties — were on the ACOG task force that drafted the new guidelines. “I want to make sure that I get some employee health plans and some health systems to adopt this nationally,” Brown said.

Indeed, although the guidelines are aimed at OB-GYNs, they would require changes throughout the maternal care system. That’s what ACOG is hoping for. “It’s really a societal call to action,” Stuebe said.

New Study reports benefits for delayed cord clamping with no adverse clinical issues

Read the full study here.

"Prompt administration of oxytocin after delivery helps reduce the risk of maternal postpartum hemorrhage, while the bolus of placental blood delivered by delayed umbilical cord clamping provides benefit to the infant by increasing hemoglobin and hematocrit and reducing the incidence of iron deficiency during the newborn period.There were no such adverse events that reached the level of clinical relevance among any of the mothers or infants in the study population, she said."

Evidence on Doulas

Of all the ways birth outcomes could be improved, continuous labor support seems like one of the most important and basic needs for birthing people. Providing labor support to birthing people is both risk-free and highly effective. Evidence shows that continuous support can significantly decrease the risk of Cesareans, NICU admissions, Pitocin, and medications for pain relief. Labor support also increases satisfaction and the chance of a spontaneous vaginal birth. Although continuous support can also be offered by birth partners, midwives, nurses, or even some physicians, research has shown that with some outcomes, doulas have a stronger effect than other types of support persons. As such, doulas should be viewed by both parents and providers as a valuable, evidence-based member of the birth care team.

For most of these outcomes (designated with asterisks*), the best results occurred when a birthing person had continuous labor support from a doula– someone who was NOT a staff member at the hospital and who was NOT part of their social network. When continuous labor support was provided by a doula, women experienced a:

  • 31% decrease in the use of Pitocin*
  • 28% decrease in the risk of Cesarean*
  • 12% increase in the likelihood of a spontaneous vaginal birth*
  • 9% decrease in the use of any medications for pain relief
  • 14% decrease in the risk of newborns being admitted to a special care nursery
  • 34% decrease in the risk of being dissatisfied with the birth experience*

See the full article here.

the odds of a woman's having a cesarean are two times higher in for-profit hospitals than in not-for-profit hospitals

Results

Controlling for patient-level characteristics, we found that the odds of a woman's having a cesarean were two times higher in for-profit hospitals than in not-for-profit hospitals. We also found for-profit hospitals were significantly more likely to be members of multihospital systems and to have fewer full-time registered nurses and staff members per hospital bed.

Conclusion

This research suggests that women who give birth in for-profit hospitals are more likely to have cesareans than women who give birth in not-for-profit hospitals. This information is important to women when deciding where to give birth. Knowing which hospital characteristics are associated with a greater likelihood of cesarean is helpful since hospital cesarean rates may be difficult to find. These findings are also informative for obstetric professionals, who can implement improvement initiatives to decrease cesarean rates and improve the overall quality of care for childbearing women in the United States.

http://onlinelibrary.wiley.com/doi/10.1111/birt.12299/full