We examined the acceptability and feasibility of a multi-component digital health outreach intervention to promote uptake of guideline-recommended postpartum screening for type 2 diabetes among patients with gestational diabetes (GDM). We conducted a 24 randomized factorial experiment as part of the Multiphase Optimization Strategy (MOST) preparation phase for developing behavioral interventions. Participants with current or recent GDM in an integrated healthcare system were randomized to receive an outreach message with up to four intervention components, designed to be self-administered in about 10 min and efficiently delivered online via REDCap: a streamlined values affirmation, personalized information on diabetes risk, an interactive motivational interviewing-based component, and an interactive action planning component. Patient-reported acceptability and feasibility outcomes were assessed via survey. Among 162 participants, 72% self-identified with a racial/ethnic minority group. Across components, acceptability scores averaged 3.9/5; ≥91% of participants read most or all of the outreach message; ≥89% perceived the amount of information as “about right”; and ≥ 87% completed ≥1 interactive prompt. Each intervention component was acceptable to diverse patients and feasible to deliver in a brief, self-directed, online format. These novel components target unaddressed barriers to patient engagement in guideline-recommended postpartum diabetes screening and adapt theory-based behavior change techniques for large-scale use.
We examined the effectiveness of maternal vaccination against SARS-CoV-2 infection in 30,288 infants born at Kaiser Permanente Northern California from December 15, 2020, to May 31, 2022. Using Cox regression, the effectiveness of maternal vaccination was 85% (95% confidence interval [CI]: 67, 93), 64% (CI: 43, 78) and 57% (CI: 36,71) during the first 2, 4 and 6 months of life, respectively, in the Delta variant period. In the Omicron variant period, the effectiveness of maternal vaccination in these three age intervals was 22% (CI: -18,48), 14% (CI: -10,32) and 12% (CI: -4,26), respectively. Over the entire study period, the incidence of hospitalization for COVID-19 was lower during the first 6 months of life among infants of vaccinated mothers compared with infants of unvaccinated mothers (21/100,000 person-years vs. 100/100,000 person-years). Maternal vaccination was protective, but protection was lower during Omicron than during Delta. Protection during both periods decreased as infants aged.
ABSTRACT Approximately 8% of pregnancies in the United States are affected by gestational diabetes mellitus (GDM) per year. The condition is associated with higher risk of adverse perinatal outcomes, including hypertensive disorders of pregnancy, cesarean delivery (CD), macrosomia, shoulder dystocia, neonatal hypoglycemia, and adverse long-term outcomes, including diabetes and cardiovascular disease. Randomized clinical trials have suggested that glycemic control of GDM with medical nutritional and insulin therapies may improve perinatal outcomes. The American Diabetes Association recommends using self-monitoring of blood glucose (BG) to manage glycemic control during pregnancy. However, large-scale, population-based studies evaluating self-monitoring of BG are limited. In addition, the conventional model for glycemic control status using optimal versus suboptimal is insufficient to capture progressive changes during pregnancy. The aim of this study was to review whether glycemic control trajectories (GCTs) from GDM diagnosis to delivery are associated with the risk of perinatal complications. This was a population-based, cohort study of individuals with GDM who received prenatal care in an integrated health care delivery system between 2007 and 2017. Included were those diagnosed with GDM at 24 to 28 weeks of gestation. Excluded were those who had diabetes before pregnancy. Individuals were asked to self-monitor BG measurements to assess glycemic control 4 times per day at mealtimes. The measurements were collected by nurses or dietitians during weekly counseling calls. Optimal glycemic control was defined as <95 mg/dL for fasting and <140 mg/dL for 1 hour after lunch or dinner. Perinatal complications were the outcomes measured, including CD, preterm birth, shoulder dystocia, neonatal intensive care unit (NICU) admission, NICU stays ≥7 days, stillbirth, large-for-gestational age (LGA), and small-for-gestational age (SGA). To estimate associations between GCTs with the perinatal complications, multivariate Poisson regression models were used. A total of 26,774 individuals were included in the analysis. Four distinct GCTs were identified: trajectory 1 (T1) for stably optimal GCTs (39.3% of individuals), trajectory 2 (T2) for rapidly improving GCTs (34.9%), trajectory 3 (T3) for slowly improving to near-optimal GCTs (15.4%), and trajectory 4 (T4) for slowly improving to suboptimal GCTs (11%). For the T1 group, there were lower risks of CD (adjusted relative risk [aRR], 0.93; 95% confidence internal [CI], 0.89–0.96), shoulder dystocia (aRR, 0.75; 95% CI, 0.61–0.92), and NICU admission (aRR, 0.90; 95% CI, 0.83–0.97) compared with the T2 or reference group ( P for trend <0.001), whereas for the T4 group there were higher risks of CD (aRR, 1.18; 95% CI, 1.12–1.24; P for trend <0.001), shoulder dystocia (aRR, 1.41; 95% CI, 1.12–1.78; P for trend <0.001), and NICU admission (aRR, 1.33; 95% CI, 1.20–1.47; P for trend <0.001). There was an increased risk of LGA across GCTs (from T1 [aRR, 0.74; 95% CI, 0.69–0.80] to T4 [aRR, 1.42; 95% CI, 1.31–1.53]; P for trend <0.001; vs T2), but there was a decreased trend of SGA (from T1 [aRR, 1.10; 95% CI, 1.02–1.20] to T4 [aRR, 0.63; 95% CI, 0.53–0.75]; P for trend <0.001). There was not a significant trend across GCTs for the risk of preterm birth and NICU stays ≥7 days. Overall, there was increasing risk of perinatal complications from T1 to T4 GCT, except for SGA. This study highlights the need for early GDM management to prevent perinatal complications.
Importance Food insecurity is a growing public health concern, but its association with perinatal complications remains unclear. Objective To examine whether food insecurity in pregnancy was associated with the risk of perinatal complications and determine whether these potential associations differed by receipt of food assistance. Design, Setting, and Participants This cohort study used data from a pregnancy survey conducted between June 22, 2020, and September 9, 2022, at Kaiser Permanente Northern California, an integrated health care system serving a diverse population of 4.6 million. Participants included individuals who delivered singletons. Data were analyzed from December 2023 to June 2024. Exposure Food insecurity in pregnancy assessed using the validated 2-item Hunger Vital Sign screener. Main Outcomes and Measures Maternal (gestational diabetes, gestational hypertension, preeclampsia, cesarean delivery) and neonatal (preterm birth, neonatal intensive care unit [NICU] admission, small-for-gestational age [SGA], and large-for-gestational age [LGA]) complications extracted from the electronic health records, and a composite adverse perinatal outcome (APO) of maternal and neonatal complications. Modified Poisson regression models were adjusted for covariates and stratified by receipt of food assistance in pregnancy. Results Among 19 338 individuals, 2707 (14.0%) reported food insecurity in pregnancy. Individuals with food insecurity in pregnancy had a higher risk of gestational diabetes (adjusted relative risk [aRR], 1.13 [95% CI, 1.01-1.29]), preeclampsia (aRR, 1.28 [95% CI, 1.11-1.49]), preterm birth (aRR, 1.19 [95% CI, 1.02-1.38]), NICU admission (aRR, 1.23 [95% CI, 1.07-1.42]), and APO (aRR, 1.07 [95% CI, 1.02-1.13]) compared with individuals without food insecurity. Among 1471 individuals (7.6%) who received food assistance in pregnancy, associations of food insecurity in pregnancy with perinatal complications were attenuated to the null, except for preeclampsia (aRR, 1.64 [95% CI, 1.06-2.53]). On the contrary, the associations persisted among individuals who did not receive food assistance: gestational diabetes (aRR, 1.20 [95% CI, 1.04-1.37]), preeclampsia (aRR, 1.24 [95% CI, 1.06-1.46]), preterm birth (aRR, 1.23 [95% CI, 1.05-1.46]), NICU admission (aRR, 1.31 [95% CI, 1.12-1.52]), and APO (aRR, 1.12 [95% CI, 1.06-1.18]). Conclusions and Relevance In this cohort study, food insecurity in pregnancy was associated with a higher risk of perinatal complications, and these associations were overall attenuated to the null among individuals who received food assistance in pregnancy. These findings support clinical guidelines of screening for food insecurity in pregnancy and provide evidence to expand food assistance programs that may help improve maternal and neonatal outcomes.
Objective This study aims to quantitate the incidence of preterm labor (PTL) admissions and determine the frequency and predictors of preterm delivery (PTD) during these admissions. Study Design Retrospective cohort of singleton pregnancies within Kaiser Permanente Northern California, 2001 to 2011. PTL admissions were defined as inpatient encounters > 24 hours with an International Classification of Diseases, 9th Revision code for PTL. Results Total study population was 365,897 with PTL admission rate 11%. PTD occurred in 85% of pregnancies with PTL admission. Delivery occurred within 48 hours of admission in 96% ≥34 weeks, 67% 31 to 33 weeks, and 51.9% <31 weeks. Predictors of delivery during PTL admission included gestational age 34 to 36 weeks (adjusted odds ratio [aOR], 6.90), chorioamnionitis (aOR, 105.58), and preterm rupture of membranes (aOR 19.29). Conclusion We demonstrate a high rate of PTD per PTL admission in a highly integrated health care system. More work is needed to determine optimal practices for hospitalization and treatment of women diagnosed with PTL.
In the US, an unacceptably high percentage of pregnant women do not undergo prenatal HIV testing. Previous studies have found increased uptake of prenatal HIV testing with abbreviated pre-test counseling, however little is known about patient decision making, testing satisfaction and knowledge in this setting.A randomized-controlled, non-inferiority trial was conducted from October 2006 through February 2008 at San Francisco General Hospital (SFGH), the public teaching hospital of the City and County of San Francisco. A total of 278 English- and Spanish-speaking pregnant women were randomized to receive either abbreviated or standard nurse-performed HIV test counseling at the initial prenatal visit. Patient decision making experience was compared between abbreviated versus standard HIV counseling strategies among a sample of low-income, urban, ethnically diverse prenatal patients. The primary outcome was the decisional conflict score (DCS) using O'Connor low-literacy scale and secondary outcomes included satisfaction with test decision, basic HIV knowledge and HIV testing uptake. We conducted an intention-to-treat analysis of 278 women--134 (48.2%) in the abbreviated arm (AA) and 144 (51.8%) in the standard arm (SA). There was no significant difference in the proportion of women with low decisional conflict (71.6% in AA vs. 76.4% in SA, p = .37), and the observed mean difference between the groups of 3.88 (95% CI: -0.65, 8.41) did not exceed the non-inferiority margin. HIV testing uptake was very high (97. 8%) and did not differ significantly between the 2 groups (99.3% in AA vs. 96.5% in SA, p = .12). Likewise, there was no difference in satisfaction with testing decision (97.8% in AA vs. 99.3% in SA, p = .36). However, women in AA had significantly lower mean HIV knowledge scores (78.4%) compared to women in SA (83.7%, p<0.01).This study suggests that streamlining the pre-test counseling process, while associated with slightly lower knowledge, does not compromise patient decision making or satisfaction regarding HIV testing.ClinicalTrials.gov NCT00503308.
