BACKGROUND: Severe maternal morbidity (SMM) is broadly defined as an unexpected and potentially life-threatening event associated with labor and delivery. The Centers for Disease Control and Prevention (CDC) produced 21 different indicators based on International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) hospital diagnostic and procedure codes to identify cases of SMM. OBJECTIVES: To examine existing SMM indicators and determine which indicators identified the most in-hospital mortality at delivery hospitalization. METHODS: Data from the 1993-2015 and 2017-2019 Healthcare Cost and Utilization Project's National Inpatient Sample were used to report SMM indicator-specific prevalences, in-hospital mortality rates, and population attributable fractions (PAF) of mortality. We hierarchically ranked indicators by their overall PAF of in-hospital mortality. Predictive modeling determined if SMM prevalence remained comparable after transition to ICD-10-CM coding. RESULTS: The study population consisted of 18,198,934 hospitalizations representing 87,864,173 US delivery hospitalizations. The 15 top ranked indicators identified 80% of in-hospital mortality; the proportion identified by the remaining indicators was negligible (2%). The top 15 indicators were: restoration of cardiac rhythm; cardiac arrest; mechanical ventilation; tracheostomy; amniotic fluid embolism; aneurysm; acute respiratory distress syndrome; acute myocardial infarction; shock; thromboembolism, pulmonary embolism; cerebrovascular disorders; sepsis; both DIC and blood transfusion; acute renal failure; and hysterectomy. The overall prevalence of the top 15 ranked SMM indicators (~22,000 SMM cases per year) was comparable after transition to ICD-10-CM coding. CONCLUSIONS: We determined the 15 indicators that identified the most in-hospital mortality at delivery hospitalization in the US. Continued testing of SMM indicators can improve measurement and surveillance of the most severe maternal complications at the population level.

BACKGROUND: Studies evaluating the association between prenatal ultrasounds and autism spectrum disorder (ASD) have largely produced negative results. Concern remains due to the rising identification of children with ASD and ultrasound use. OBJECTIVE: To evaluate the association between prenatal ultrasound use and ASD. METHODS: We used data from the Study to Explore Early Development, a multisite case-control study of preschool-aged children with ASD implemented during 2007-2012. We recruited cases from children receiving developmental disability services and randomly selected population controls from birth records. ASD case status was based on in-person standardised assessments. We stratified analyses by pre-existing maternal medical conditions and pregnancy complications associated with increased ultrasound use (ultrasound indications) and used logistic regression to model case status by increasing ultrasound counts. For pregnancies with medical record data on ultrasound timing, we conducted supplementary tests to model associations by trimester of exposure. RESULTS: Among 1524 singleton pregnancies, ultrasound indications were more common for ASD cases than controls; respectively, for each group, no indications were reported for 45.1% and 54.2% of pregnancies, while ≥2 indications were reported for 26.1% and 18.4% of pregnancies. The percentage of pregnancies with multiple ultrasounds varied by case status and the presence of ultrasound indications. However, stratified regression models showed no association between increasing ultrasound counts and case status, either for pregnancies without (aOR 1.01, 95% CI 0.92, 1.11) or with ultrasound indications (aOR 1.01, 95% CI 0.95, 1.08). Trimester-specific analyses using medical record data showed no association in any individual trimester. CONCLUSIONS: We found no evidence that prenatal ultrasound use increases ASD risk. Study strengths included gold-standard assessments for ASD case classification, comparison of cases with controls, and a stratified sample to account for conditions associated both with increased prenatal ultrasound use and ASD.

Global emergence of the COVID-19 pandemic in 2020 curtailed vaccine-preventable disease (VPD) surveillance activities, but little is known about which surveillance components were most affected. In May 2021, we surveyed 214 STOP (originally Stop Transmission of Polio) Program consultants to determine how VPD surveillance activities were affected by the COVID-19 pandemic throughout 2020, primarily in low- and middle-income countries, where program consultants are deployed. Our report highlights the responses from 154 (96%) of the 160 consultants deployed to the World Health Organization African Region, which comprises 75% (160/214) of all STOP Program consultants deployed globally in early 2021. Most survey respondents observed that VPD surveillance activities were somewhat or severely affected by the COVID-19 pandemic in 2020. Reprioritization of surveillance staff and changes in health-seeking behaviors were factors commonly perceived to decrease VPD surveillance activities. Our findings suggest the need for strategies to restore VPD surveillance to prepandemic levels.

OBJECTIVES: Prepregnancy body mass index (BMI) and gestational weight gain (GWG) are known determinants of maternal and child health; calculating both requires an accurate measure of prepregnancy weight. We compared self-reported prepregnancy weight to measured weights to assess reporting bias by maternal and clinical characteristics. METHODS: We conducted a retrospective cohort study among pregnant women using electronic health records (EHR) data from Kaiser Permanente Northwest, a non-profit integrated health care system in Oregon and southwest Washington State. We identified women age ≥ 18 years who were pregnant between 2000 and 2010 with self-reported prepregnancy weight, ≥ 2 measured weights between ≤ 365-days-prior-to and ≤ 42-days-after conception, and measured height in their EHR. We compared absolute and relative difference between self-reported weight and two "gold-standards": (1) weight measured closest to conception, and (2) usual weight (mean of weights measured 6-months-prior-to and ≤ 42-days-after conception). Generalized-estimating equations were used to assess predictors of misreport controlling for covariates, which were obtained from the EHR or linkage to birth certificate. RESULTS: Among the 16,227 included pregnancies, close agreement (± 1 kg or ≤ 2%) between self-reported and closest-measured weight was 44% and 59%, respectively. Overall, self-reported weight averaged 1.3 kg (SD 3.8) less than measured weight. Underreporting was higher among women with elevated BMI category, late prenatal care entry, and pregnancy outcome other than live/stillbirth (p < .05). Using self-reported weight, BMI was correctly classified for 91% of pregnancies, but ranged from 70 to 98% among those with underweight or obesity, respectively. Results were similar using usual weight as gold standard. CONCLUSIONS FOR PRACTICE: Accurate measure of prepregnancy weight is essential for clinical guidance and surveillance efforts that monitor maternal health and evaluate public-health programs. Identification of characteristics associated with misreport of self-reported weight can inform understanding of bias when assessing the influence of prepregnancy BMI or GWG on health outcomes.

In the United States, approximately 180,000 patients receive mental health services each day at approximately 4,000 inpatient and residential psychiatric facilities (1). SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), can spread rapidly within congregate residential settings (2-4), including psychiatric facilities. On April 13, 2020, two patients were transferred to Wyoming's state psychiatric hospital from a private psychiatric hospital that had confirmed COVID-19 cases among its residents and staff members (5). Although both patients were asymptomatic at the time of transfer and one had a negative test result for SARS-CoV-2 at the originating facility, they were both isolated and received testing upon arrival at the state facility. On April 16, 2020, the test results indicated that both patients had SARS-CoV-2 infection. In response, the state hospital implemented expanded COVID-19 infection prevention and control (IPC) procedures (e.g., enhanced screening, testing, and management of new patient admissions) and adapted some standard IPC measures to facilitate implementation within the psychiatric patient population (e.g., use of modified face coverings). To assess the likely effectiveness of these procedures and determine SARS-CoV-2 infection prevalence among patients and health care personnel (HCP) (6) at the state hospital, a point prevalence survey was conducted. On May 1, 2020, 18 days after the patients' arrival, 46 (61%) of 76 patients and 171 (61%) of 282 HCP had nasopharyngeal swabs collected and tested for SARS-CoV-2 RNA by reverse transcription-polymerase chain reaction. All patients and HCP who received testing had negative test results, suggesting that the hospital's expanded IPC strategies might have been effective in preventing the introduction and spread of SARS-CoV-2 infection within the facility. In congregate residential settings, prompt identification of COVID-19 cases and application of strong IPC procedures are critical to ensuring the protection of other patients and staff members. Although standard guidance exists for other congregate facilities (7) and for HCP in general (8), modifications and nonstandard solutions might be needed to account for the specific needs of psychiatric facilities, their patients, and staff members.

Background: Cryptococcal antigen (CrAg) screening for antiretroviral therapy (ART)-naive adults with advanced HIV/AIDS can reduce the incidence of cryptococcal meningitis (CM) and all-cause mortality. We modeled the cost-effectiveness of laboratory-based "reflex" CrAg screening for ART-naive CrAg-positive patients with CD4<100 cells/microL (those currently targeted in guidelines) and ART-experienced CrAg-positive patients with CD4<100 cells/microL (who make up an increasingly large proportion of individuals with advanced HIV/AIDS). Methods: A decision analytic model was developed to evaluate CrAg screening and treatment based on local CD4 count and CrAg prevalence data, and realistic assumptions regarding programmatic implementation of the CrAg screening intervention. We modeled the number of CrAg tests performed, the number of CrAg positives stratified by prior ART experience, the proportion of patients started on pre-emptive antifungal treatment, and the number of incident CM cases and CM-related deaths. Screening and treatment costs were evaluated, and cost per death or disability-adjusted life year (DALY) averted estimated. Results: We estimated that of 650,000 samples undergoing CD4 testing annually in Botswana, 16,364 would have a CD4<100 cells/microL and receive a CrAg test, with 70% of patients ART-experienced at the time of screening. Under base model assumptions, CrAg screening and pre-emptive treatment restricted to ART-naive patients with a CD4<100 cells/microL prevented 20% (39/196) of CM-related deaths in patients undergoing CD4 testing at a cost of US$2 per DALY averted. Expansion of preemptive treatment to include ART-experienced patients with a CD4<100 cells/microL resulted in 55 additional deaths averted (a total of 48% [94/196]) and was cost-saving compared to no screening. Findings were robust across a range of model assumptions. Conclusions: Reflex laboratory-based CrAg screening for patients with CD4<100 cells/microL is a cost-effective strategy in Botswana, even in the context of a relatively low proportion of advanced HIV/AIDS in the overall HIV-infected population, the majority of whom are ART-experienced.

For the period 2007-17 rural death rates were higher than urban rates for the seven major causes of death analyzed, and disparities widened for five of the seven. In 2017 urban areas had met national targets for three of the seven causes, while rural areas had met none of the targets.

BACKGROUND: Maternal mortality rates in the United States appear to be increasing. One potential reason may be increased identification of maternal deaths after the addition of a pregnancy checkbox to the death certificate. In 2016, four state health departments (Georgia, Louisiana, Michigan, Ohio) implemented a pregnancy checkbox quality assurance pilot, with technical assistance provided by the Centers for Disease Control and Prevention. The pilot aimed to improve accuracy of the pregnancy checkbox on death certificates and resultant state maternal mortality estimates. OBJECTIVE(S): To estimate the validity of the pregnancy checkbox on the death certificate and describe characteristics associated with errors using 2016 data from a four state quality assurance pilot. STUDY DESIGN: Potential pregnancy-associated deaths were identified by linking death certificates with birth or fetal death certificates from within a year preceding death or by pregnancy checkbox status. Death certificates which indicated the decedent was pregnant within a year of death via the pregnancy checkbox, but that did not link to a birth or fetal death certificate, were referred for active follow-up to confirm pregnancy status by either death certifier confirmation or medical record review. Descriptive statistics and 95% confidence intervals were used to examine the distributions of demographic characteristics by pregnancy confirmation category (i.e., confirmed pregnant, confirmed not pregnant, and unable to confirm). We compared the proportion confirmed pregnant and confirmed not pregnant within age, race/ethnicity, pregnancy checkbox category, and certifier type categories using a Wald test of proportions. Binomial and Poisson regression models were used to estimate prevalence ratios for having an incorrect pregnancy checkbox (false positive, false negative) by age group, race/ethnicity, pregnancy checkbox category, and certifier type. RESULTS: Among 467 potential pregnancy-associated deaths, 335 (72%) were confirmed pregnant either via linkage to a birth or fetal death certificate, certifier confirmation, or review of medical records. Ninety-seven (21%) women were confirmed not pregnant (false positives) and 35 (7%) were unable to be confirmed. Women confirmed pregnant were significantly younger than women confirmed not pregnant (p<.001). Deaths certified by coroners and medical examiners were more likely to be confirmed pregnant than confirmed not pregnant (p=0.04). The association between decedent age category and false positive status followed a dose-response relationship (p<0.001), with increasing prevalence ratios for each increase in age category. Death certificates of non-Hispanic black women were more likely to be false positives, compared with non-Hispanic white women [prevalence ratio (PR) 1.41, 95% confidence interval (CI) 1.01, 1.96]. The sensitivity of the pregnancy checkbox among these four states in 2016 was 62% and the positive predictive value was 68%. CONCLUSION(S): We provide a multi-state analysis of the validity of the pregnancy checkbox and highlight a need for more accurate reporting of pregnancy status on death certificates. States and other jurisdictions may increase the accuracy of their data used to calculate maternal mortality rates by implementing quality assurance processes.

The risk of maternal death in the U.S. is higher than peer nations and rising, and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees (MMRC) make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death, and when appropriate to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the 'community vital signs' - the social and community context in which women live, work, and seek healthcare - MMRCs may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.

Approximately 700 women die in the United States each year as a result of pregnancy or its complications, and significant racial/ethnic disparities in pregnancy-related mortality exist (1). Data from CDC's Pregnancy Mortality Surveillance System (PMSS) for 2007-2016 were analyzed. Pregnancy-related mortality ratios (PRMRs) (i.e., pregnancy-related deaths per 100,000 live births) were analyzed by demographic characteristics and state PRMR tertiles (i.e., states with lowest, middle, and highest PRMR); cause-specific proportionate mortality by race/ethnicity also was calculated. Over the period analyzed, the U.S. overall PRMR was 16.7 pregnancy-related deaths per 100,000 births. Non-Hispanic black (black) and non-Hispanic American Indian/Alaska Native (AI/AN) women experienced higher PRMRs (40.8 and 29.7, respectively) than did all other racial/ethnic groups. This disparity persisted over time and across age groups. The PRMR for black and AI/AN women aged >/=30 years was approximately four to five times that for their white counterparts. PRMRs for black and AI/AN women with at least some college education were higher than those for all other racial/ethnic groups with less than a high school diploma. Among state PRMR tertiles, the PRMRs for black and AI/AN women were 2.8-3.3 and 1.7-3.3 times as high, respectively, as those for non-Hispanic white (white) women. Significant differences in cause-specific proportionate mortality were observed among racial/ethnic populations. Strategies to address racial/ethnic disparities in pregnancy-related deaths, including improving women's health and access to quality care in the preconception, pregnancy, and postpartum periods, can be implemented through coordination at the community, health facility, patient, provider, and system levels.

OBJECTIVE: The Lesotho Population-based HIV Impact Assessment (LePHIA) survey was conducted nationally and designed to measure HIV prevalence, incidence, and viral load suppression (VLS). DESIGN: A nationally representative sample of 9,403 eligible households was surveyed between November 2016 and May 2017; analyses account for study design. Consenting participants provided blood samples, socio-demographic and behavioral information. METHODS: Blood samples were tested using the national rapid HIV testing algorithm. HIV-seropositive results were confirmed with Geenius supplemental assay. Screening for detectable concentrations of antiretroviral (ARV) analytes was conducted on dried blood specimens from all HIV-positive adults using high-resolution liquid chromatography coupled with tandem mass spectrometry. Self-reported and/or ARV biomarker data were used to classify individuals as HIV-positive and on treatment. Viral load testing was performed on all HIV-positive samples at central labs. VLS was defined as HIV RNA < 1000 copies per mL. RESULTS: Overall, 25.6% of adults ages 15-59 were HIV-positive. Among seropositive adults, 81.0% (male: 76.6%, female: 84.0%) reported knowing their HIV status, 91.8% of people living with HIV (male: 91.6%, female: 92.0%) who reported knowing their status reporting taking ARVs, and 87.7% (male and female: 87.7%) of these had VLS. Younger age was significantly associated with being less likely to be aware of HIV status for both sexes. CONCLUSIONS: Findings from this population-based survey provide encouraging data in terms of HIV testing and treatment uptake and coverage. Specific attention to reaching youth to engage them in HIV-related intervention is critical to achieving epidemic control.

OBJECTIVE: The Lesotho Population-based HIV Impact Assessment (LePHIA) survey was conducted nationally and designed to measure HIV prevalence, incidence, and viral load suppression (VLS). DESIGN: A nationally representative sample of 9,403 eligible households was surveyed between November 2016 and May 2017; analyses account for study design. Consenting participants provided blood samples, socio-demographic and behavioral information. METHODS: Blood samples were tested using the national rapid HIV testing algorithm. HIV-seropositive results were confirmed with Geenius supplemental assay. Screening for detectable concentrations of antiretroviral (ARV) analytes was conducted on dried blood specimens from all HIV-positive adults using high-resolution liquid chromatography coupled with tandem mass spectrometry. Self-reported and/or ARV biomarker data were used to classify individuals as HIV-positive and on treatment. Viral load testing was performed on all HIV-positive samples at central labs. VLS was defined as HIV RNA < 1000 copies per mL. RESULTS: Overall, 25.6% of adults ages 15-59 were HIV-positive. Among seropositive adults, 81.0% (male: 76.6%, female: 84.0%) reported knowing their HIV status, 91.8% of people living with HIV (male: 91.6%, female: 92.0%) who reported knowing their status reporting taking ARVs, and 87.7% (male and female: 87.7%) of these had VLS. Younger age was significantly associated with being less likely to be aware of HIV status for both sexes. CONCLUSIONS: Findings from this population-based survey provide encouraging data in terms of HIV testing and treatment uptake and coverage. Specific attention to reaching youth to engage them in HIV-related intervention is critical to achieving epidemic control.

BACKGROUND: Approximately 700 women die from pregnancy-related complications in the United States every year. METHODS: Data from CDC's national Pregnancy Mortality Surveillance System (PMSS) for 2011-2015 were analyzed. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births; PRMRs) were calculated overall and by sociodemographic characteristics. The distribution of pregnancy-related deaths by timing relative to the end of pregnancy and leading causes of death were calculated. Detailed data on pregnancy-related deaths during 2013-2017 from 13 state maternal mortality review committees (MMRCs) were analyzed for preventability, factors that contributed to pregnancy-related deaths, and MMRC-identified prevention strategies to address contributing factors. RESULTS: For 2011-2015, the national PRMR was 17.2 per 100,000 live births. Non-Hispanic black (black) women and American Indian/Alaska Native women had the highest PRMRs (42.8 and 32.5, respectively), 3.3 and 2.5 times as high, respectively, as the PRMR for non-Hispanic white (white) women (13.0). Timing of death was known for 87.7% (2,990) of pregnancy-related deaths. Among these deaths, 31.3% occurred during pregnancy, 16.9% on the day of delivery, 18.6% 1-6 days postpartum, 21.4% 7-42 days postpartum, and 11.7% 43-365 days postpartum. Leading causes of death included cardiovascular conditions, infection, and hemorrhage, and varied by timing. Approximately sixty percent of pregnancy-related deaths from state MMRCs were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. MMRC data indicated that multiple factors contributed to pregnancy-related deaths. Contributing factors and prevention strategies can be categorized at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care. CONCLUSIONS: Pregnancy-related deaths occurred during pregnancy, around the time of delivery, and up to 1 year postpartum; leading causes varied by timing of death. Approximately three in five pregnancy-related deaths were preventable. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Strategies to address contributing factors to pregnancy-related deaths can be enacted at the community, health facility, patient, provider, and system levels.

AIMS: To determine whether women with abnormal gestational diabetes (GDM) screening test results short of frank GDM have increased health-services utilization compared to women with normal results. METHODS: We conducted a retrospective-cohort study among 29,999 women enrolled in Kaiser Permanente Northwest who completed GDM screening (two-step method:1-hour, 50-gram glucose-challenge test (GCT); 3-hour, 100-gram oral-glucose-tolerance test (OGTT)). Test results were categorized as normal GCT (referent, n=25,535), normal OGTT (n=2,246), abnormal OGTT but not GDM (n=1477), and GDM (n=741). Rate ratios (RRs) were calculated for utilization measures and analyses were age- and BMI-adjusted. RESULTS: Compared to women with normal GCT, rates for obstetrical ultrasound, noninvasive and invasive antenatal testing, and ambulatory visits to the obstetrics department were significantly greater among women with abnormal OGTT (RRs 1.2 [95%CI 1.1, 1.4], 1.3 [1.1, 1.4], 1.7 [1.3, 2.3], and 1.1 [1.1, 1.1], respectively) and GDM (RRs 1.8, 1.8, 2.0, and 1.3, respectively). Women with abnormal OGTT results were more likely to visit a dietician than women with normal GCT; RRs ranged from 4.0 [3.3, 4.9] for women with abnormal GCT but normal OGTT to 72.1 [64, 81] for women with GDM. CONCLUSIONS: Health-services utilization increased with severity of glucose result, even among women without GDM.

PROBLEM/CONDITION: Since the first U.S. infant conceived with assisted reproductive technology (ART) was born in 1981, both the use of ART and the number of fertility clinics providing ART services have increased steadily in the United States. ART includes fertility treatments in which eggs or embryos are handled in the laboratory (i.e., in vitro fertilization [IVF] and related procedures). Although the majority of infants conceived through ART are singletons, women who undergo ART procedures are more likely than women who conceive naturally to deliver multiple-birth infants. Multiple births pose substantial risks for both mothers and infants, including obstetric complications, preterm delivery (<37 weeks), and low birthweight (<2,500 g). This report provides state-specific information for the United States (including the District of Columbia and Puerto Rico) on ART procedures performed in 2016 and compares birth outcomes that occurred in 2016 (resulting from ART procedures performed in 2015 and 2016) with outcomes for all infants born in the United States in 2016. PERIOD COVERED: 2016. DESCRIPTION OF SYSTEM: In 1995, CDC began collecting data on ART procedures performed in fertility clinics in the United States as mandated by the Fertility Clinic Success Rate and Certification Act of 1992 (FCSRCA) (Public Law 102-493 [October 24, 1992]). Data are collected through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC. This report includes data from 52 reporting areas (the 50 states, the District of Columbia, and Puerto Rico). RESULTS: In 2016, a total of 197,706 ART procedures (range: 162 in Wyoming to 24,030 in California) with the intent to transfer at least one embryo were performed in 463 U.S. fertility clinics and reported to CDC. These procedures resulted in 65,964 live-birth deliveries (range: 57 in Puerto Rico to 8,638 in California) and 76,892 infants born (range: 74 in Alaska to 9,885 in California). Nationally, the number of ART procedures performed per 1 million women of reproductive age (15-44 years), a proxy measure of the ART use rate, was 3,075. ART use rates exceeded the national rate in 14 reporting areas (Connecticut, Delaware, the District of Columbia, Hawaii, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Utah, and Virginia). ART use exceeded 1.5 times the national rate in nine states, including three (Illinois, Massachusetts, and New Jersey) that also had comprehensive mandated health insurance coverage for ART procedures (i.e., coverage for at least four oocyte retrievals). Nationally, among ART transfer procedures for patients using fresh embryos from their own eggs, the average number of embryos transferred increased with increasing age (1.5 among women aged <35 years, 1.7 among women aged 35-37 years, and 2.2 among women aged >37 years). Among women aged <35 years, the national elective single-embryo transfer (eSET) rate was 42.7% (range: 8.3% in North Dakota to 83.9% in Delaware). In 2016, ART contributed to 1.8% of all infants born in the United States (range: 0.3% in Puerto Rico to 4.7% in Massachusetts). ART also contributed to 16.4% of all multiple-birth infants, including 16.2% of all twin infants and 19.4% of all triplets and higher-order infants. ART-conceived twins accounted for approximately 96.5% (21,455 of 22,233) of all ART-conceived infants born in multiple deliveries. The percentage of multiple-birth infants was higher among infants conceived with ART (31.5%) than among all infants born in the total birth population (3.4%). Approximately 30.4% of ART-conceived infants were twins and 1.1% were triplets and higher-order infants. Nationally, infants conceived with ART contributed to 5.0% of all low birthweight (<2,500 g) infants. Among ART-conceived infants, 23.6% had low birthweight compared with 8.2% among all infants. ART-conceived infants contributed to 5.3% of all preterm (gestational age <37 weeks) infants. The percentage of preterm births was higher among infants conceived with ART (29.9%) than among all infants born in the total birth population (9.9%). The percentage of ART-conceived infants who had low birthweight was 8.7% among singletons, 54.9% among twins, and 94.9% among triplets and higher-order multiples; the corresponding percentages among all infants born were 6.2% among singletons, 55.4% among twins, and 94.6% among triplets and higher-order multiples. The percentage of ART-conceived infants who were born preterm was 13.7% among singletons, 64.2% among twins, and 97.0% among triplets and higher-order infants; the corresponding percentages among all infants were 7.8% for singletons, 59.9% for twins, and 97.7% for triplets and higher-order infants. INTERPRETATION: Multiple births from ART contributed to a substantial proportion of all twins, triplets, and higher-order infants born in the United States. For women aged <35 years, who typically are considered good candidates for eSET, on average, 1.5 embryos were transferred per ART procedure, resulting in higher multiple birth rates than could be achieved with single-embryo transfers. Of the four states (Illinois, Massachusetts, New Jersey, and Rhode Island) with comprehensive mandated health insurance coverage, three (Illinois, Massachusetts, and New Jersey) had rates of ART use >1.5 times the national average. Although other factors might influence ART use, insurance coverage for infertility treatments accounts for some of the difference in per capita ART use observed among states because most states do not mandate any coverage for ART treatment. PUBLIC HEALTH ACTION: Twins account for almost all of ART-conceived multiple births born in multiple deliveries. Reducing the number of embryos transferred and increasing use of eSET, when clinically appropriate, could help reduce multiple births and related adverse health consequences for both mothers and infants. Because multiple-birth infants are at increased risk for numerous adverse sequelae that cannot be ascertained from the data collected through NASS alone, long-term follow-up of ART infants through integration of existing maternal and infant health surveillance systems and registries with data available from NASS might be useful for monitoring adverse outcomes.

In the U.S., deaths due to pulmonary embolism (PE) account for 9.2% of all pregnancy-related deaths or approximately 1.5 deaths per 100,000 live births. Maternal deaths and maternal morbidity due to PE are more common among women who deliver by cesarean section. In the past decade, the clinical community has increasingly adopted venous thromboembolism (VTE) guidelines and thromboprophylaxis recommendations for pregnant women. Although deep vein thrombosis rates have decreased during this time-period, PE rates have remained relatively unchanged in pregnancy hospitalizations and as a cause of maternal mortality. Changes in the health profile of women who become pregnant, particularly due to maternal age and co-morbidities, needs more attention to better understand the impact of VTE risk during pregnancy and the postpartum period.

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014 with a mortality rate of 18.0 per 100,000, higher than many other developed countries. In 2012 the first "Putting the 'M' back in Maternal Fetal Medicine" session was held at the Society for Maternal Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified urgent needs to: (i) enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) improve the medical care and management of pregnant women across the country; and (iii) address critical research gaps in maternal medicine. Since that first meeting a broad collaborative effort has made a number of major steps forward including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 "M in MFM" meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next five years given that too many mothers still experience preventable harm and adverse outcomes.

OBJECTIVES: To examine Ebola virus disease (EVD) symptom prevalence and EVD status among pregnant women in Ebola isolation units in Sierra Leone. METHODS: In an observational study, data were obtained for pregnant women admitted to Ebola isolation units across four districts in Sierra Leone from June 29, 2014, to December 20, 2014. Women were admitted to isolation units if they had suspected EVD exposures or fever (temperature >38 degrees C) and three or more self-reported symptoms suggestive of EVD. Associations were examined between EVD status and each symptom using chi(2) tests and logistic regression adjusting for age/labor status. RESULTS: Of 176 pregnant women isolated, 55 (32.5%) tested positive for EVD. Using logistic regression models adjusted for age, EVD-positive women were significantly more likely to have fever, self-reported fatigue/weakness, nausea/vomiting, headache, muscle/joint pain, chest pain, vaginal bleeding, unexplained bleeding, or sore throat upon admission. In models adjusted for age/labor, only women with fever or vaginal bleeding upon admission were significantly more likely to be EVD-positive. CONCLUSIONS: Several EVD symptoms and complications increased the odds of testing EVD-positive; some of these were also signs and symptoms of labor/pregnancy complications. The study results highlight the need to refine screening for pregnant women with EVD. This article is protected by copyright. All rights reserved.

Opioid use by pregnant women represents a significant public health concern given the association of opioid exposure and adverse maternal and neonatal outcomes, including preterm labor, stillbirth, neonatal abstinence syndrome, and maternal mortality (1,2). State-level actions are critical to curbing the opioid epidemic through programs and policies to reduce use of prescription opioids and illegal opioids including heroin and illicitly manufactured fentanyl, both of which contribute to the epidemic (3). Hospital discharge data from the 1999-2014 Healthcare Cost and Utilization Project (HCUP) were analyzed to describe U.S. national and state-specific trends in opioid use disorder documented at delivery hospitalization. Nationally, the prevalence of opioid use disorder more than quadrupled during 1999-2014 (from 1.5 per 1,000 delivery hospitalizations to 6.5; p<0.05). Increasing trends over time were observed in all 28 states with available data (p<0.05). In 2014, prevalence ranged from 0.7 in the District of Columbia (DC) to 48.6 in Vermont. Continued national, state, and provider efforts to prevent, monitor, and treat opioid use disorder among reproductive-aged and pregnant women are needed. Efforts might include improved access to data in Prescription Drug Monitoring Programs, increased substance abuse screening, use of medication-assisted therapy, and substance abuse treatment referrals.

The maternal mortality rate has been and continues to be a key indicator of a nation’s health and health care delivery system. During the 20th century the United States had a dramatic decrease in the risk of death associated with pregnancy and childbirth, largely attributed to improved living standards and the modernization of maternity care. However, as we approached the millennium there was evidence of increasing maternal mortality and that trend continued into the 21st century. Although there remains controversy about how to count maternal deaths and what deaths should be counted, some of which is discussed in this symposium, it is clear that US maternal mortality is not headed in the desired direction; our best estimates indicate that about 700 women die each year during or shortly after the end of pregnancy due to causes specific to or aggravated by the physiology of pregnancy. Moreover, deaths are the tip of an iceberg, with estimates of another 75 to 100 women experiencing severe complications for every woman who dies as a result of being pregnant. As someone who has been studying and thinking about these tragic events at the national level, I am honored to edit this symposium on maternal mortality and severe maternal morbidity. Although it is tempting to focus on the numbers and rates, it is my hope that focusing a lens on maternal morbidity and mortality reminds all of us that behind the numbers are our mothers, sisters and daughters, and the events we count are individual human tragedies we are seeking to prevent.

Despite many efforts at the state, city, and national levels over the past 70 years, a nationwide consensus on how best to identify, review, and prevent maternal deaths remains challenging. We present a brief history of maternal death surveillance in the United States and compare the three systems of national surveillance that exist today: the National Vital Statistics System, the Pregnancy Mortality Surveillance System, and maternal mortality review committees. We discuss strategies to address the perennial challenges of shared terminology and accurate, comparable data among maternal mortality review committees. Finally, we propose that with the opportunity presented by a systematized shared data system that can accurately account for all maternal deaths, state and local-level maternal mortality review committees could become the gold standard for understanding the true burden of maternal mortality at the national level.

Previous outbreaks suggest that pregnant women with Ebola virus disease (EVD) are at increased risk for severe disease and death. Healthcare workers who treat pregnant women with EVD are at increased risk of body fluid exposure. Despite the absence of pregnant women with EVD in the United States, CDC activated the Maternal Health Team (MHT), a functional unit dedicated to emergency preparedness and response issues, on October 18, 2014. We describe major activities of the MHT. A high-priority MHT activity was to publish guiding principles early in the response. The MHT also prepared guidance documents, provided guidance and technical support for hospital preparedness, and addressed inquiries. We analyzed maternal health inquiries received through CDC-INFO, MHT, and CDC's Medical Investigations Team from August 2014 to December 2015. Internal call logs used to capture, monitor, and track inquiries for the three data sources were merged. Inquiries not related to maternal health issues and duplicates were removed. Each inquiry was categorized by route (email/phone), inquirer type, and topic. In total, 201 inquiries were received from clinicians, public health professionals, and the public. The predominant topic was related to infection control for high-risk situations such as labor and delivery. During the Ebola response, most inquiries were received via email rather than telephone, a notable shift compared to the H1N1 emergency response. Lessons learned during the H1N1 and Ebola responses are currently informing CDC's Zika Response, an unprecedented emergency response primarily focused on reproductive health issues.

In 1988, the by the World Health Assembly established the Global Polio Eradication Initiative, which consisted of a partnership among the World Health Organization (WHO), Rotary International, the Centers for Disease Control and Prevention (CDC), and the United Nations Children's Fund. By 2016, the annual incidence of polio had decreased by >99.9%, compared with 1988, and at the time of writing, only 3 countries in which wild poliovirus circulation has never been interrupted remain: Afghanistan, Nigeria, and Pakistan. A key strategy for polio eradication has been the development of a skilled and deployable workforce to implement eradication activities across the globe. In 1999, the Stop Transmission of Polio (STOP) program was developed and initiated by the CDC, in collaboration with the WHO, to train and mobilize additional human resources to provide technical assistance to polio-endemic countries. STOP has also informed the development of other public health workforce capacity to support polio eradication efforts, including national STOP programs. In addition, the program has diversified to address measles and rubella elimination, data management and quality, and strengthening routine immunization programs. This article describes the STOP program and how it has contributed to polio eradication by building global public health workforce capacity.

Preeclampsia is a common and severe pregnancy complication and a leading cause of maternal and infant illness and death.1–3 The incidence of preeclampsia increased in the United States during the past 3 decades,4,5 and substantial evidence suggests that a history of preeclampsia is a significant risk factor for heart disease in the future years following pregnancy.6 In addition to adverse health consequences, preeclampsia is costly because of the medical services needed to treat pregnant and postpartum women and their infants, who are often born preterm.1,7 | In this issue, Stevens et al8 documented the short-term medical costs associated with preeclampsia. The authors combined state hospital discharge data with birth certificate data, commercial insurance claims data, and nationally representative Healthcare Cost and Utilization Project (HCUP) data to derive nationally representative estimates of the additional cost of medical treatment for women with preeclampsia and their newborns vs women without preeclampsia. This aggregated incremental cost was found to be $2.18 billion to the US health care system, including $1.03 billion in maternal health care costs and $1.15 billion for infants born to mothers with preeclampsia (in 2012 US dollars), which is about one third of the total $6.4 billion short-term estimated health care costs for preeclampsia pregnancies. This study is the first to quantify the medical costs associated with preeclampsia in the United States up to 1-year postdelivery. Previous studies estimated only the cost of hypertension during pregnancy in a Medicaid population in a single state,9 the per-person cost associated with pregnancies complicated by hypertension,10 or the cost of prematurity, regardless of the cause.7

OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011-2013. METHODS: We conducted an observational study using population-based data from the Pregnancy Mortality Surveillance System to calculate pregnancy-related mortality ratios by year, age group, and race-ethnicity groups. We explored 10 cause-of-death categories by pregnancy outcome during 2011-2013 and compared their distribution with those in our earlier reports since 1987. RESULTS: The 2011-2013 pregnancy-related mortality ratio was 17.0 deaths per 100,000 live births. Pregnancy-related mortality ratios increased with maternal age, and racial-ethnic disparities persisted with non-Hispanic black women having a 3.4 times higher mortality ratio than non-Hispanic white women. Among causes of pregnancy-related deaths, the following groups contributed more than 10%: cardiovascular conditions ranked first (15.5%) followed by other medical conditions often reflecting pre-existing illnesses (14.5%), infection (12.7%), hemorrhage (11.4%), and cardiomyopathy (11.0%). Relative to the most recent report of Pregnancy Mortality Surveillance System data for 2006-2010, the distribution of cause-of-death categories did not change considerably. However, compared with serial reports before 2006-2010, the contribution of hemorrhage, hypertensive disorders of pregnancy, and anesthesia complications declined, whereas that of cardiovascular and other medical conditions increased (population-level percentage comparison). CONCLUSION: The pregnancy-related mortality ratio and the distribution of the main causes of pregnancy-related mortality have been relatively stable in recent years.

BACKGROUND: Maternal mortality ratios (MMR) appear to have increased in the United States over the last decade. Three potential contributing factors are: 1) a shifting maternal age distribution, 2) changes in age-specific MMR, and 3) the addition of a checkbox indicating recent pregnancy on the death certificate. OBJECTIVE: Determine the contribution of rising maternal age on changes in MMR from 1978-2012, and estimate the contribution of the pregnancy checkbox on increases in MMR over the last decade. STUDY DESIGN: Kitagawa decomposition analyses were conducted to partition the maternal age contribution to the MMR increase into two components: changes due to a shifting maternal age distribution, and changes due to higher age-specific mortality ratios. We used National Vital Statistics System (NVSS) natality and mortality data. The following five-year groupings were used: 1978-1982, 1988-1992, 1998-2002, and 2008-2012. Changes in age-specific MMRs among states that adopted the standard pregnancy checkbox onto their death certificate before 2008 (n=23) were compared with states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (n=11) to estimate the percentage increase in the MMR due to the pregnancy checkbox. RESULTS: Overall U.S. MMRs for 1978-1982, 1988-1992, and 1998-2002 were 9.0, 8.1, and 9.1 deaths per 100,000 live births, respectively. There was a modest increase in the MMR between 1998-2002 and 2008-2012 in the 11 states that had not adopted the standard pregnancy checkbox on their death certificate by the end of 2012 (8.6 and 9.9 deaths per 100,000 respectively). However, the MMR more than doubled between 1998-2002 and 2008-2012 in the 23 states that adopted the standard pregnancy checkbox (9.0 to 22.4); this dramatic rise was almost entirely attributable to increases in age-specific MMRs (94.9%) as opposed to increases in maternal age (5.1%), with an estimated 90% of the observed change reflecting the change in maternal death identification rather than a real change in age-specific rates alone. Of all age categories, women ages 40 and older in states that adopted the standard pregnancy checkbox had the largest increase in MMR-from 31.9 to 200.5-a relative increase of 528%, which accounted for nearly one-third of the overall increase. An estimated 28.8% of the observed change was potentially due to maternal death misclassification among women ≥40. CONCLUSION: Increasing age-specific maternal mortality seems to be contributing more heavily than a changing maternal age distribution to recent increases in MMR. In states with the standard pregnancy checkbox, the vast majority of the observed change in MMR over the last decade was estimated to be due to the pregnancy checkbox, with the greatest change in MMR occurring in women ages ≥40 years. The addition of a pregnancy checkbox on state death certificates appears to be increasing case identification, but may also be leading to maternal death misclassification, particularly for women ages ≥40 years.

MacDorman et al1 aim to quantify the contribution of a pregnancy checkbox added to the 2003 U.S. standard death certificate to the estimated increase in U.S. maternal mortality during 2000–2014. Given its variable adoption by states, both in terms of format and timing, the authors skillfully employ innovative methods to estimate maternal mortality and are to be congratulated. | As the authors recognize, the analysis relies on the cause-of-death information recorded on death certificates and a statistical definition of maternal deaths—all records of women who died during or within 42 days of pregnancy who receive an International Classification of Diseases (version 10) O chapter code (except O96 and O97) are considered maternal deaths. Of note, using the Centers for Disease Control and Prevention's WONDER mortality data,2 the proportion of females aged 15–54 years with the nonspecific O chapter-coded underlying cause of death O26.8 (other specified pregnancy-related conditions) or O99.8 (other specified diseases and conditions complicating pregnancy, childbirth and the puerperium) increased from less than 10% to more than 40% during 2000–2014 as more states used the pregnancy checkbox (Fig. 1). At first glance, this suggests an increase in maternal deaths that parallels documented increases in chronic medical conditions in pregnant women in the United States.3 However, the incorrect marking of the pregnancy checkbox vis-à-vis pregnant status or timing of death can influence the assignment of cause-of-death International Classification of Diseases codes, especially regarding these nonspecific O codes.

OBJECTIVE: To characterize the presence of Clostridium sordellii and Clostridium perfringens in the vagina and rectum, identify correlates of presence, and describe strain diversity and presence of key toxins. METHODS: We conducted an observational cohort study in which we screened a diverse cohort of reproductive-aged women in the United States up to three times using vaginal and rectal swabs analyzed by molecular and culture methods. We used multivariate regression models to explore predictors of presence. Strains were characterized by pulsed-field gel electrophoresis and tested for known virulence factors by polymerase chain reaction assays. RESULTS: Of 4,152 participants enrolled between 2010 and 2013, 3.4% (95% confidence interval [CI] 2.9-4.0) were positive for C sordellii and 10.4% (95% CI 9.5-11.3) were positive for C perfringens at baseline. Among the 66% with follow-up data, 94.7% (95% CI 88.0-98.3) of those positive for C sordellii and 74.4% (95% CI 69.0-79.3) of those positive for C perfringens at baseline were negative at follow-up. At baseline, recent gynecologic surgery was associated with C sordellii presence, whereas a high body mass index was associated with C perfringens presence in adjusted models. Two of 238 C sordellii isolates contained the lethal toxin gene, and none contained the hemorrhagic toxin gene. Substantial strain diversity was observed in both species with few clusters and no dominant clones identified. CONCLUSION: The relatively rare and transient nature of C sordellii and C perfringens presence in the vagina and rectum makes it inadvisable to use any screening or prophylactic approach to try to prevent clostridial infection. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01283828.

Amniotic fluid embolism is a leading cause of maternal mortality in developed countries. Our understanding of risk factors, diagnosis, treatment, and prognosis is hampered by a lack of uniform clinical case definition; neither histologic nor laboratory findings have been identified unique to this condition. Amniotic fluid embolism is often overdiagnosed in critically ill peripartum women, particularly when an element of coagulopathy is involved. Previously proposed case definitions for amniotic fluid embolism are nonspecific, and when viewed through the eyes of individuals with experience in critical care obstetrics, would include women with a number of medical conditions much more common than amniotic fluid embolism. We convened a working group under the auspices of a committee of the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation whose task was to develop uniform diagnostic criteria for the research reporting of amniotic fluid embolism. These criteria rely on the presence of the classic triad of hemodynamic and respiratory compromise accompanied by strictly defined disseminated intravascular coagulopathy. It is anticipated that limiting research reports involving amniotic fluid embolism to women who meet these criteria will enhance the validity of published data and assist in the identification of risk factors, effective treatments, and possibly useful biomarkers for this condition. A registry has been established in conjunction with the Perinatal Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to collect both clinical information and laboratory specimens of women with suspected amniotic fluid embolism in the hopes of identifying unique biomarkers of this condition.