PURPOSE: We examined reimbursement policies for the removal and reinsertion of long-acting reversible contraception (LARC). PATIENTS AND METHODS: We conducted a standardized, web-based review of publicly available state policies for language on reimbursement of LARC removal and reinsertion. We also summarized policy language on barriers to reimbursement for LARC removal and reinsertion. RESULTS: Twenty-six (52%) of the 50 states had publicly available policies that addressed reimbursement for LARC removal. Of these 26 states, 14 (28%) included language on reimbursement for LARC reinsertion. Eleven (42%) of 26 states included language on additional requirements for reimbursement for removal and/or reinsertion: five state policies included language with other requirements for removal only, three policies included language with additional requirements for reinsertion only, and three included language with additional requirements for both. Three state policies specified no restrictions be placed on reimbursement for removal and one specified no restrictions be placed on reimbursement for reinsertion. CONCLUSION: Half of the states in the US do not have publicly available policies on reimbursement for the removal and reinsertion of LARC devices. Inclusion of unrestricted access to these services is important for contraceptive choice and reproductive autonomy. | This review was done to understand how state policies reimburse providers who remove and then may reinsert a woman’s long-acting, reversible contraception (LARC) device. In this policy review, we found that more than half of all states reimburse providers for removing a LARC device. Of those states, half reimburse providers for reinserting a LARC device if a woman chooses it. Some states also identify reasons why state policies may or may not reimburse for LARC device removal or reinsertion. If women do not have the option to remove a LARC, they may not choose it, and this affects how they decide on the options to prevent a pregnancy. | eng

BACKGROUND: Child maltreatment is an important societal and public health problem. However, there are limited data on the epidemiology of maltreatment related hospitalizations. OBJECTIVE: The objective of this study was to describe maltreatment related hospitalizations among children ages 17 and younger in New York State (NYS). METHODS: Using 2011-2013 statewide planning and research cooperative system (SPARCS) inpatient hospital discharge data, maltreatment related hospitalizations among children ages 17 years and younger were identified using international classification of diseases, ninth revision, clinical modification codes for diagnoses and external cause of injury. Distributions of demographic and inpatient care characteristics were compared between hospitalizations for maltreatment and those for other causes, and between different types of maltreatment, using chi-square tests (for categorical variables) and t-tests (for continuous variables). RESULTS: During 2011-2013, a total of 853 maltreatment related hospitalizations among 836 children ages 17 years and younger were documented in NYS SPARCS. Infants (children < 1) had the highest rates of hospitalization. Overall, physical abuse was the most prevalent maltreatment type reported. CONCLUSIONS: This is the first study in NYS to describe the epidemiology of child maltreatment hospitalizations; it establishes a statewide baseline for this public health and societal issue.

Background: Provider challenges to accessing long-acting reversible contraception (LARC) include level of reimbursement for LARC device acquisition and cost to stock. State-level LARC device reimbursement policies that cover a greater proportion of the cost of the LARC device and enable providers to purchase LARC upfront may improve contraceptive access. Materials and Methods: To summarize state-level policies that include language on LARC device reimbursement in the outpatient setting, we conducted a systematic, web-based review among all 50 states of publicly available LARC device reimbursement policies that include coverage of LARC devices as a medical or pharmacy benefit, the use of the 340B Drug Pricing Program to purchase LARC devices, and separate payment for LARC devices outside of the Medicaid Prospective Payment System (PPS) payment rate for Federally Qualified Health Centers or Rural Health Clinics. Results: Forty-two percent (21/50) of states with publicly available state-level policies included language on LARC device reimbursement. Among the states, 24% (5/21) had coverage policies as a medical benefit, 33% (7/21) as a pharmacy benefit, and 19% (4/21) as both a medical benefit and pharmacy benefit; 38% (8/21) used the 340B Program to purchase LARC devices; and 62% (13/21) indicated separate payment for LARC devices outside of the Medicaid PPS payment rate. Conclusion: State-level policies for LARC device reimbursement vary, highlighting differences in reimbursement strategies across the U.S. Future research could explore how the implementation of these payment methods may impact LARC device reimbursement and whether increased reimbursement may improve access to the full range of contraceptive methods.

OBJECTIVE: To assess variations in low-risk cesarean delivery rates in the United States using the Society for Maternal-Fetal Medicine (SMFM) definition of low-risk for cesarean delivery and to identify factors associated with low-risk cesarean deliveries. METHODS: From hospital discharge data in the 2018 National Inpatient Sample and State Inpatient Databases, we identified deliveries that were low-risk for cesarean delivery using the SMFM definition based on the International Classification of Diseases, Tenth Revision, Clinical Modification codes. We estimated national low-risk cesarean delivery rates overall and by patient characteristics, clinically relevant conditions not included in the SMFM definition, and hospital characteristics based on the nationally representative sample of hospital discharges in the National Inpatient Sample. Multivariate logistic regressions were estimated for the national sample to identify factors associated with low-risk cesarean delivery. We reported low-risk cesarean delivery rates for 27 states and the District of Columbia based on the annual state data that represented the universe of hospital discharges from participating states in the State Inpatient Databases. RESULTS: Of an estimated 3,634,724 deliveries in the 2018 National Inpatient Sample, 2,484,874 low-risk deliveries met inclusion criteria. The national low-risk cesarean delivery rate in 2018 was 14.6% (95% CI 14.4-14.8%). The rates varied widely by state (range 8.9-18.6%). Nationally, maternal age older than 40 years, non-Hispanic Black or Asian race, private insurance as primary payer, admission on weekday, obesity, diabetes, or hypertension, large metropolitan residence, and hospitals of the South census region were associated with low-risk cesarean delivery. CONCLUSION: Approximately one in seven low-risk deliveries was by cesarean in 2018 in the United States using the SMFM definition and the low-risk cesarean delivery rates varied widely by state.

BACKGROUND: Previous assessment of statewide policies on long-acting reversible contraception (LARC) indicate that an increasing number of states are implementing policies specifically for provision immediately postpartum, supported by current clinical guidelines. Less is known about how state policies describe payment methodologies for the insertion procedure and device costs. METHODS: We conducted a systematic, web-based review of publicly available statewide policy language on immediate postpartum LARC among all 50 states. We examined the payor/s identified in the policy and policy type, if the policy included language on the global obstetric fee, whether providers and/or facilities were authorized to bill for procedure or device costs, and if the billing mechanism was identified as inpatient and/or outpatient services. RESULTS: Three-fourths of states (76%; n = 38) had statewide policies on immediate postpartum LARC. All policies identified Medicaid as the payor, although two also included non-Medicaid plans. Language allowing for reimbursement separate from the global obstetric fee for insertion procedures was present in 76% of states; 23 states permit it and 6 do not. Device cost reimbursement separate from the fee was identified in more state policies (92%); 31 states allow it and 4 do not. More policies included inpatient or outpatient billing mechanisms for device costs (82%; n = 31) than insertion procedures (50%; n = 19). CONCLUSIONS: Medicaid reimbursement policies for immediate postpartum LARC services vary by state reimbursement process, type, and mechanism. Observed differences indicate payment methodologies more often include the cost of the device than provider reimbursement (31 states vs. 23 states). Fewer than one-half of states offer reimbursement for provider insertion fees, a significant systems barrier to contraceptive access for women who choose LARC immediately postpartum.

CONTEXT: On October 1, 2015, the United States transitioned from using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. Continuing to monitor the burden of neonatal abstinence syndrome (NAS) after the transition presently requires use of data dependent on ICD-9-CM coding to enable trend analyses. Little has been published on the validation of using ICD-9-CM codes to identify NAS cases. OBJECTIVE: To assess the validity of hospital discharge data (HDD) from selected Florida hospitals for passive NAS surveillance, based on ICD-9-CM codes, which are used to quantify baseline prevalence of NAS. DESIGN: We reviewed infant and maternal data for all births at 3 Florida hospitals from 2010 to 2011. Potential NAS cases included infants with ICD-9-CM discharge codes 779.5 and/or 760.72 in linked administrative data (ie, HDD linked to vital records) or in unlinked HDD and infants identified through review of neonatal intensive care unit admission logs or inpatient pharmacy records. Confirmed infant cases met 3 clinician-proposed criteria. Sensitivity and positive predictive value were calculated to assess validity for the 2 ICD-9-CM codes, individually and combined. RESULTS: Of 157 confirmed cases, 134 with 779.5 and/or 760.72 codes were captured in linked HDD (sensitivity = 85.4%) and 151 in unlinked HDD (sensitivity = 96.2%). Positive predictive value was 74.9% for linked HDD and 75.5% for unlinked HDD. For either HDD types, the single 779.5 code had the highest positive predictive value (86%), lowest number of false positives, and good to excellent sensitivity. CONCLUSIONS: Passive surveillance using ICD-9-CM code 779.5 in either linked or unlinked HDD identified NAS cases with reasonable validity. Our work supports the use of ICD-9-CM code 779.5 to assess the baseline prevalence of NAS through 2015.

Objective Examine agreement with the medical record (MR) when gestational weight loss (GWL) on the Florida birth certificate (BC) is >/= 0 pounds (lbs). Methods In 2012, 3923 Florida-resident women had a live, singleton birth where BC indicated GWL >/= 0 lbs. Of these, we selected a stratified random sample of 2141 and abstracted from the MR prepregnancy and delivery weight data used to compute four estimates of GWL (delivery minus prepregnancy weight) from different sources found within the MR (first prenatal visit record, nursing admission record, labor/delivery records, BC worksheet). We assessed agreement between the BC and MR estimates for GWL categorized as 0, 1-10, 11-19, and >/= 20 lbs. Results Prepregnancy or delivery weight was missing or source not in the MR for 23-81% of records. Overall agreement on GWL between the BC and the four MR estimates ranged from 39.1 to 57.2%. Agreement by GWL category ranged from 10.6 to 38.0% for 0 lbs, 47.6 to 64.3% for 1-10 lbs, 49.5 to 60.0% for 11-19 lbs, and 47.8 to 67.7% for >/= 20 lbs. Conclusions Prepregnancy and delivery weight were frequently missing from the MR or inconsistently documented across the different sources. When the BC indicated GWL >/= 0 lbs, agreement with different sources of the MR was moderate to poor revealing the need to reduce missing data and better understand the quality of weight data in the MR.

OBJECTIVE: To estimate the percentage of infants with large birth size attributable to excess gestational weight gain (GWG), independent of prepregnancy body mass index, among mothers with preexisting diabetes mellitus (PDM). STUDY DESIGN: We analyzed 2004-2008 Florida linked birth certificate and maternal hospital discharge data of live, term (37-41weeks) singleton deliveries (N=641,857). We calculated prevalence of large-for-gestational age (LGA) (birth weight-for-gestational age≥90th percentile) and macrosomia (birth weight>4500g) by GWG categories (inadequate, appropriate, or excess). We used multivariable logistic regression to estimate the relative risk (RR) of large birth size associated with excess compared to appropriate GWG among mothers with PDM. We then estimated the population attributable fraction (PAF) of large birth size due to excess GWG among mothers with PDM (n=4427). RESULTS: Regardless of diabetes status, half of mothers (51.2%) gained weight in excess of recommendations. Large birth size was higher in infants of mothers with PDM than in infants of mothers without diabetes (28.8% versus 9.4% for LGA, 5.8% versus 0.9% for macrosomia). Among women with PDM, the adjusted RR of having an LGA infant was 1.7 (95% CI 1.5, 1.9) for women with excess GWG compared to those with appropriate gain; the PAF was 27.7% (95% CI 22.0, 33.3). For macrosomia, the adjusted RR associated with excess GWG was 2.1 (95% CI 1.5, 2.9) and the PAF was 38.6% (95% CI 24.9, 52.4). CONCLUSION: Preventing excess GWG may avert over one-third of macrosomic term infants of mothers with PDM. Effective strategies to prevent excess GWG are needed.

Purpose In recognition of the importance of performance measurement and MCH epidemiology leadership to quality improvement (QI) efforts, a plenary session dedicated to this topic was presented at the 2014 CityMatCH Leadership and MCH Epidemiology Conference. This paper summarizes the session and provides two applications of performance measurement to QI in MCH. Description Performance measures addressing processes of care are ubiquitous in the current health system landscape and the MCH community is increasingly applying QI processes, such as Plan-Do-Study-Act (PDSA) cycles, to improve the effectiveness and efficiency of systems impacting MCH populations. QI is maximally effective when well-defined performance measures are used to monitor change. Assessment MCH epidemiologists provide leadership to QI initiatives by identifying population-based outcomes that would benefit from QI, defining and implementing performance measures, assessing and improving data quality and timeliness, reporting variability in measures throughout PDSA cycles, evaluating QI initiative impact, and translating findings to stakeholders. MCH epidemiologists can also ensure that QI initiatives are aligned with MCH priorities at the local, state and federal levels. Two examples of this work, one highlighting use of a contraceptive service performance measure and another describing QI for peripartum hemorrhage prevention, demonstrate MCH epidemiologists' contributions throughout. Challenges remain in applying QI to complex community and systems-level interventions, including those aimed at improving access to quality care. Conclusion MCH epidemiologists provide leadership to QI initiatives by ensuring they are data-informed and supportive of a common MCH agenda, thereby optimizing the potential to improve MCH outcomes.

BACKGROUND: Women with chronic diseases are at increased risk of having unintended pregnancies. Little is known whether chronic diseases are associated with increased likelihood of effective/highly effective contraceptive use. METHODS: We analyzed 2008-2010 Florida Behavioral Risk Factor Surveillance System data for women aged 18-44 years who were at risk of unintended pregnancy. Multivariable Poisson regression estimated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) for contraceptive use in relation to diabetes, cardiovascular disease (CVD), and current asthma. We assessed the association of chronic disease status with use of three different contraception outcomes: (1) any method versus none, (2) less effective methods (methods associated with ≥10 unintended pregnancies/100 women/year) versus none, and (3) effective/highly effective methods (<10 unintended pregnancies/100 women/year) versus none. RESULTS: Among 4473 women at risk for unintended pregnancy, 87% were using any method of contraception (22.5% less effective methods and 64.5% effective/highly effective methods). Women with CVD were more likely than those without CVD to use any contraception (aPR = 1.09, 95% CI: 1.04, 1.15), less effective (aPR = 1.39, 95% CI: 1.13, 1.70), and effective/highly effective (aPR = 1.10, 95% CI: 1.03, 1.19) contraception. Women with diabetes were more likely to use less effective methods than women without diabetes (aPR = 1.34, 95% CI: 1.05, 1.72). No significant associations were observed for asthma, regardless of contraceptive effectiveness. CONCLUSIONS: Self-reported use of effective/highly effective contraception was higher than nonuse or use of less effective methods among all women at risk of unintended pregnancy, but could be improved, especially among women with chronic diseases.

BACKGROUND: Research has shown an association between assisted reproductive technology (ART) and adverse birth outcomes. We identified whether birth outcomes of ART-conceived pregnancies vary across states with different maternal characteristics, insurance coverage for ART services, and type of ART services provided. METHODS: CDC's National ART Surveillance System data were linked to Massachusetts, Florida, and Michigan vital records from 2000 through 2006. Maternal characteristics in ART- and non-ART-conceived live births were compared between states using chi-square tests. We performed multivariable logistic regression analyses and calculated adjusted odds ratios (aOR) to assess associations between ART use and singleton preterm delivery (<32 weeks, <37 weeks), singleton small for gestational age (SGA) (<5th and <10th percentiles) and multiple birth. RESULTS: ART use in Massachusetts was associated with significantly lower odds of twins as well as triplets and higher order births compared to Florida and Michigan (aOR 22.6 vs. 30.0 and 26.3, and aOR 37.6 vs. 92.8 and 99.2, respectively; Pinteraction < 0.001). ART use was associated with increased odds of SGA in Michigan only, and with preterm delivery (<32 and <37 weeks) in all states (aOR range: 1.60, 1.87). CONCLUSIONS: ART use was associated with an increased risk of preterm delivery among singletons that showed little variability between states. The number of twins, triplets and higher order gestations per cycle was lower in Massachusetts, which may be due to the availability of insurance coverage for ART in Massachusetts.

PURPOSE: In May 2012, the Association of Maternal and Child Health (MCH) Programs initiated a project to develop indicators for use at a state or community level to assess, monitor, and evaluate the application of life course principles to public health. DESCRIPTION: Using a developmental framework established by a national expert panel, teams of program leaders, epidemiologists, and academicians from seven states proposed indicators for initial consideration. More than 400 indicators were initially proposed, 102 were selected for full assessment and review, and 59 were selected for final recommendation as Maternal and Child Health (MCH) life course indicators. ASSESSMENT: Each indicator was assessed on five core features of a life course approach: equity, resource realignment, impact, intergenerational wellness, and life course evidence. Indicators were also assessed on three data criteria: quality, availability, and simplicity. CONCLUSION: These indicators represent a major step toward the translation of the life course perspective from theory to application. MCH programs implementing program and policy changes guided by the life course framework can use these initial measures to assess and influence their approaches.

Neonatal abstinence syndrome (NAS) is a constellation of physiologic and neurobehavioral signs exhibited by newborns exposed to addictive prescription or illicit drugs taken by a mother during pregnancy. The number of hospital discharges of newborns diagnosed with NAS has increased more than 10-fold (from 0.4 to 4.4 discharges per 1,000 live births) in Florida since 1995, far exceeding the three-fold increase observed nationally. In February 2014, the Florida Department of Health requested the assistance of CDC to 1) assess the accuracy and validity of using Florida's hospital inpatient discharge data, linked to birth and infant death certificates, as a means of NAS surveillance and 2) describe the characteristics of infants with NAS and their mothers. This report focuses only on objective two, describing maternal and infant characteristics in the 242 confirmed NAS cases identified in three Florida hospitals during a 2-year period (2010-2011). Infants with NAS experienced serious medical complications, with 97.1% being admitted to an intensive care unit, and had prolonged hospital stays, with a mean duration of 26.1 days. The findings of this investigation underscore the important public health problem of NAS and add to current knowledge on the characteristics of these mothers and infants. Effective June 2014, NAS is now a mandatory reportable condition in Florida. Interventions are also needed to 1) increase the number and use of community resources available to drug-abusing and drug-dependent women of reproductive age, 2) improve drug addiction counseling and rehabilitation referral and documentation policies, and 3) link women to these resources before or earlier in pregnancy.

OBJECTIVE: To investigate the risk of preterm birth among liveborn singletons to primiparas who conceived with assisted reproductive technology (ART) using four mutually exclusive categories of infertility (female infertility only, male infertility only, female and male infertility, and unexplained infertility) and to examine preterm birth risk along the gestational age continuum. DESIGN: Retrospective cohort study. SETTING: Michigan (2000-2009), Massachusetts and Florida (2000-2010). PATIENT(S): Singletons born to primiparas who conceived with or without ART. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Preterm (<37 weeks' gestation) and preterm/early term birth <39 weeks' gestation). RESULT(S): For the male infertility only, female infertility only, combined male and female infertility, and unexplained infertility groups, ART-conceived singletons were significantly more likely than non-ART singletons to be born preterm: adjusted odds ratio (aOR) 1.24 (95% CI, 1.13, 1.37), aOR 1.60 (95% CI, 1.50, 1.70), aOR 1.49 (95% CI, 1.35, 1.64), and aOR 1.26 (1.12, 1.43) respectively. Among infants whose mothers were diagnosed with infertility, the odds of preterm birth were highest between 28-30 weeks [female infertility only, aOR 1.95 (95% CI, 1.59, 2.39); male and female infertility: 2.21 (95% CI, 1.62, 3.00)] compared with infants in the general population. Within the ART population, singletons of couples with female infertility only were more likely to be born preterm than singletons born to couples with other infertility diagnoses. CONCLUSION(S): Among singleton births to primiparas, those conceived with ART had an increased risk for preterm birth, even when only the male partner had been diagnosed with infertility. The risk of preterm birth for ART-conceived infants whose mothers were diagnosed with infertility included the earliest deliveries.

The Iowa Department of Public Health annually links Medicaid claims data to the birth certificate. Because the latest version of the birth certificate provides more timely and less costly information on delivery payment source, we were interested in assessing the validity and reliability of the birth certificate payment source compared to Medicaid paid claims. We linked Medicaid paid claims to birth certificates for calendar years 2007-2009 (n = 120,626). We measured reliability by Kappa statistic and validity by sensitivity, specificity, predictive value positive and negative. We examined reliability and validity overall and by maternal characteristics (e.g. age, race, ethnicity, education). The Kappa statistic for the birth certificate payment source indicated substantial agreement (0.78; 95 % CL 0.78-0.79). Sensitivity and specificity were also high, 86.3 % (95 % CL 86.0-86 6 %) and 91.9 % (95 % CL 91.7-92.1 %), respectively. The predictive value positive was 87.0 %. The predictive value negative was 91.4 %. Kappa and specificity were lower among women of racial and ethnic minorities, women younger than age 24, and women with less education. The overall Kappa, sensitivity and specificity generally suggest the birth certificate payment source is as valid and reliable as the linked data source. The birth certificate payment source is less valid and reliable for women of racial and ethnic minorities, women younger than age 24, and those with less education. Consequently caution should be exercised when using the birth certificate payment source for monitoring service use by the Medicaid population within specific population subgroups.

To describe 2008 Florida sleep-related sudden unexpected infant deaths (SUIDs) by describing (a) percentage distribution of medical examiner (ME) cause-of-death determinations; (b) mortality rates by maternal and infant characteristics; (c) prevalence of selected suffocation or sudden infant death syndrome (SIDS) risk and protective factors; (d) frequency of selected scene investigation and autopsy components (including extent of missing data); and (e) percentage with public health program contact. In this population-based study, we identified sleep-related SUIDs occurring among Florida residents from the 2008-linked Florida infant death and birth certificates. Information about the circumstances of death was abstracted from ME, law enforcement, and hospital records. We used frequencies and percentages to describe characteristics of sleep-related SUID cases. Of 215 sleep-related SUID cases, MEs identified 47.9 % as accidental suffocation and strangulation in bed, 35.4 % as unknown or undetermined cause, and 16.7 % as SIDS. Sleep-related SUID most frequently occurred in an adult bed (n = 108; 50.2 %). At death, 82.4 % of sleep-related SUIDs had ≥1 suffocation or SIDS risk factor with 54.4 % infants sharing a sleep surface, 38.1 % placed nonsupine, 24.2 % placed on a pillow, and 10.2 % having head covering. Missing data frequently resulted from incomplete scene investigation and autopsy components. SUID contributed to ≥1 in seven Florida infant deaths in 2008. Approximately 80 % of sleep-related SUIDs were reported among infants placed in unsafe sleeping environments. Effective interventions are needed to promote safe sleep among caregivers of Florida infants. These interventions must reach infant caregivers at highest risk and change unsafe sleep practices. The substantial percentage of missing investigation data reinforces the need for standardized reporting.

BACKGROUND: Assisted Reproductive Technology (ART) includes fertility procedures where both egg and sperm are handled in the lab. ART use has increased considerably in recent years, accounting for 47 090 livebirths in the US in 2010. ART increases the probability of multiple gestation births, which are at higher risks than singletons for adverse outcomes. Additionally, ART is associated with a greater risk of complications during pregnancy, labour, and delivery, and increased risk of adverse perinatal outcomes in singleton births. METHODS: We merged Florida and Massachusetts birth records from 2004-06 with the National ART Surveillance System (NASS) and using NASS as the gold standard, calculated sensitivity, specificity, and positive predictive value (PPV) of ART reporting on the birth certificates by maternal, infant, and hospital characteristics. We fit random-effects logistic regression models to evaluate simultaneously the association of ART reporting with these predictors while accounting for correlation among births occurring in the same hospital. RESULTS: Sensitivity of ART reporting on the birth certificate was 28.9% in Florida and 41.4% in Massachusetts. Specificity was >99% in both states. PPV was 45.5% in Florida and 54.6% in Massachusetts. The odds of ART reporting varied by state and by several maternal and delivery characteristics including age, parity, history of fetal loss, plurality, race/Hispanic ethnicity, delivery payment source, pre-existing conditions, and complications during pregnancy or labour and delivery. CONCLUSIONS: There was significant under-reporting of ART procedures on the birth certificates. Using data on ART births identified only from birth certificates yields a biased sample of the population of ART births.

OBJECTIVE: To estimate the percentage of large-for-gestational age (LGA) neonates associated with maternal overweight and obesity, excessive gestational weight gain, and gestational diabetes mellitus (GDM)-both individually and in combination-by race or ethnicity. METHODS: We analyzed 2004-2008 linked birth certificate and maternal hospital discharge data of live, singleton deliveries in Florida. We used multivariable logistic regression to assess the independent contributions of mother's prepregnancy body mass index (BMI), gestational weight gain, and GDM status on LGA (birth weight-for-gestational age 90th percentile or greater) risk by race and ethnicity while controlling for maternal age, nativity, and parity. We then calculated the adjusted population-attributable fraction of LGA neonates to each of these exposures. RESULTS: Large-for-gestational age prevalence was 5.7% among normal-weight women with adequate gestational weight gain and no GDM and 12.6%, 13.5% and 17.3% among women with BMIs of 25 or higher, excess gestational weight gain, and GDM, respectively. A reduction ranging between 46.8% in Asian and Pacific Islanders and 61.0% in non-Hispanic black women in LGA prevalence might result if women had none of the three exposures. For all race or ethnic groups, GDM contributed the least (2.0-8.0%), whereas excessive gestational weight gain contributed the most (33.3-37.7%) to LGA. CONCLUSION: Overweight and obesity, excessive gestational weight gain, and GDM all are associated with LGA; however, preventing excessive gestational weight gain has the greatest potential to reduce LGA risk.

Based on their higher risk of type 2 diabetes, non-Hispanic blacks (NHBs) would be expected to have higher gestational diabetes mellitus (GDM) risk compared to non-Hispanic whites (NHWs). However, previous studies have reported lower GDM risk in NHBs versus NHWs. We examined whether GDM risk was lower in NHBs and NHWs, and whether this disparity differed by age group. The cohort consisted of 462,296 live singleton births linked by birth certificate and hospital discharge data from 2004 to 2007 in Florida. Using multivariable regression models, we examined GDM risk stratified by age and adjusted for body mass index (BMI) and other covariates. Overall, NHBs had a lower prevalence of GDM (2.5 vs. 3.1 %, p < 0.01) and a higher proportion of preconception DM births (0.5 vs. 0.3 %, p ≤ 0.01) than NHWs. Among women in their teens (risk ratio 0.56, p < 0.01) and 20-29 years of age (risk ratio 0.85, p < 0.01), GDM risk was lower in NHBs than NHWs. These patterns did not change with adjustment for BMI and other covariates. Among women 30-39 years (risk ratio 1.18, p < 0.01) and ≥40 years (risk ratio 1.22, p < 0.01), GDM risk was higher in NHBs than NHWs, but risk was higher in NHWs after adjustment for BMI. Associations between BMI and GDM risk did not vary by race/ethnicity or age group. NHBs have lower risk of GDM than NHWs at younger ages, regardless of BMI. NHBs had higher risk than NHWs at older ages, largely due to racial/ethnic disparities in overweight/obesity at older ages.

BACKGROUND: Infant mortality rates (IMRs) are disproportionally high in the U.S. South; however, the proximate contributors that could inform regional action remain unclear. PURPOSE: To quantify the components of excess infant mortality in the U.S. South by maternal race/ethnicity, underlying cause of death, and gestational age. METHODS: U.S. Period Linked Birth/Infant Death Data Files 2007-2009 (analyzed in 2013) were used to compare IMRs between the South (U.S. Public Health Regions IV and VI) and all other regions combined. RESULTS: Compared to other regions, there were 1.18 excess infant deaths per 1000 live births in the South, representing about 1600 excess infant deaths annually. New Mexico and Texas did not have elevated IMRs relative to other regions; excess death rates among other states ranged from 0.62 per 1000 in Kentucky to 3.82 per 1000 in Mississippi. Racial/ethnic compositional differences, generally the greater proportion of non-Hispanic black births in the South, explained 59% of the overall regional difference; the remainder was mostly explained by higher IMRs among non-Hispanic whites. The leading causes of excess Southern infant mortality were sudden unexpected infant death (SUID; 36%, range=12% in Florida to 90% in Kentucky) and preterm-related death (22%, range= -71% in Kentucky to 51% in North Carolina). Higher rates of preterm birth, predominantly <34 weeks, accounted for most of the preterm contribution. CONCLUSIONS: To reduce excess Southern infant mortality, comprehensive strategies addressing SUID and preterm birth prevention for both non-Hispanic black and white births are needed, with state-level findings used to tailor state-specific efforts.

PURPOSE: Having an emergency plan may reduce negative effects of disaster on the health of postpartum women and their infants. However, little is known about the prevalence of emergency plans among postpartum women. In 2009, Arkansas added a question to the Pregnancy Risk Assessment Monitoring System surveillance system about whether women who gave birth that year had an emergency plan. In this study, we first describe the sociodemographic characteristics, disaster experience, and region of residence of postpartum women in Arkansas who indicated that they had an emergency plan for their families in 2009, and second, examine associations between sociodemographic characteristics and disaster experience and the presence of an emergency plan. METHODS: Multivariable logistic regression (n = 1,173) was conducted to examine associations between maternal race/ethnicity, sociodemographic characteristics, region of residence, disaster experience, and having a disaster plan. We adjusted for maternal education, federal poverty level, and family size in our final model. FINDINGS: Forty-eight percent (n = 559) of women reported having an emergency plan. Hispanic women were less likely to report having a plan compared with non-Hispanic White women (n = 102 [10%]; adjusted prevalence ratio [aPR], 0.6; 95% confidence interval [CI], 0.4-0.9). Families with five or more members were more likely to have a plan compared with smaller families (n = 123 [11%]; aPR, 1.3; 95% CI, 1.1-1.6). CONCLUSIONS: Policymakers and public health practitioners can use these results to promote emergency planning among postpartum women in Arkansas, with special outreach to postpartum women who are Hispanic or have smaller families.

Assisted reproductive technology (ART) refers to fertility treatments in which both eggs and sperm are handled outside the body. The Centers for Disease Control and Prevention (CDC) oversees the National ART Surveillance System (NASS), which collects data on all ART procedures performed in the United States. The NASS, while a comprehensive source of data on ART patient demographics and clinical procedures, includes limited information on outcomes related to women's and children's health. To examine ART-related health outcomes, CDC and three states (Massachusetts, Florida, and Michigan) established the States Monitoring ART (SMART) Collaborative to evaluate maternal and perinatal outcomes of ART and improve state-based ART surveillance. To date, NASS data have been linked with states' vital records, disease registries, and hospital discharge data with a linkage rate of 90.2%. The probabilistic linkage methodology used in the SMART Collaborative has been validated and found to be both accurate and efficient. A wide breadth of applied research within the Collaborative is planned or ongoing, including examinations of the impact of insurance mandates on ART use as well as the relationships between ART and birth defects and cancer, among others. The SMART Collaborative is working to improve state-based ART surveillance by developing state surveillance plans, establishing partnerships, and conducting data analyses. The SMART Collaborative has been instrumental in creating linked datasets and strengthening epidemiologic and research capacity for improving maternal and infant health programs and evaluating the public health impact of ART.

The objectives of this study is to identify factors associated with lack of preventive dental care among U.S. children and state-level factors that explain variation in preventive dental care access across states. We performed bivariate analyses and multilevel regression analyses among 68,350 children aged 5-17 years using the 2007 National Survey of Children's Health data and relevant state-level data. Odds ratios (ORs) for child- and state-level variables were calculated to estimate associations with preventive dental care. We calculated interval odds ratios (IOR), median odds ratios (MOR), and intraclass correlation coefficients (ICC) to quantify variation in preventive dental care across states. Lack of preventive dental care was associated with various child-level factors. For state-level factors, a higher odds of lack of preventive dental care was associated with a higher percentage of Medicaid-enrolled children not receiving dental services (OR = 1.30, 95 % confidence interval (CI): 1.15-1.47); higher percentage of children uninsured (OR = 1.48, 95 % CI: 1.29-1.69); lower dentist-to-population ratio (OR = 1.36, 95 % CI: 1.03-1.80); and lower percentage of dentists submitting Medicaid/State Children's Health Insurance Program claims (OR = 1.04, 95 % CI: 1.01-1.06). IORs for the first three state-level factors did not contain one, indicating that these state-level characteristics were important in understanding variation across states. Lack of preventive dental care varied by state (MOR = 1.40). The state-level variation (ICC = 3.66 %) accounted for a small percentage of child- and state-level variation combined. Child- and state-level characteristics were associated with preventive dental care access among U.S. children aged 5-17 years. State-level factors contribute to variation in dental care access across states and need to be considered in state-level planning.

Assess whether the 55% increase in Florida's Hispanic infant mortality rate (HIMR) during 2004-2007 was real or artifactual. Using linked data from Florida resident live births and infant deaths for 2004-2007, we calculated traditional (infant Hispanic ethnicity from death certificates and maternal Hispanic ethnicity from birth certificates) and nontraditional (infant and maternal Hispanic ethnicity from birth certificate maternal ethnicity) HIMRs. We assessed trends in HIMRs (per 1,000 live births) using Chi-square statistics. We tested agreement in Hispanic ethnicity after implementation of a revised 2005 death certificate by using kappa statistics and used logistic regression to test the associations of infant mortality risk factors. Hispanic was defined as being of Mexican, Puerto Rican, Cuban, Central/South American, or other/unknown Hispanic origin. During 2004-2007 traditional HIMR increased 55%, from 4.0 to 6.2 (Chi-square, P < 0.001) and nontraditional HIMR increased 20%, from 4.5 to 5.4 (Chi-square, P = 0.03). During 2004-2005, agreement in Hispanic ethnicity did not change with use of the revised certificate (kappa = 0.70 in 2004; kappa = 0.76 in 2005). Birth weight was the most significant risk factor for trends in Hispanic infant mortality (OR = 1.33, 95% CI = 1.10-1.61). Differences in Hispanic reporting on revised death certificates likely accounted for the majority of traditional HIMR increase, indicating a primarily artifactual increase. Reasons for the 20% increase in nontraditional HIMR during 2004-2007 should be further explored through other individual and community factors. Use of nontraditional HIMRs, which use a consistent source of Hispanic classification, should be considered.

INTRODUCTION: Gestational diabetes mellitus (GDM) affects 3% to 7% of pregnant women in the United States, and Asian, black, American Indian, and Hispanic women are at increased risk. Florida, the fourth most populous US state, has a high level of racial/ethnic diversity, providing the opportunity to examine variations in the contribution of maternal body mass index (BMI) status to GDM risk. The objective of this study was to estimate the race/ethnicity-specific percentage of GDM attributable to overweight and obesity in Florida. METHODS: We analyzed linked birth certificate and maternal hospital discharge data for live, singleton deliveries in Florida from 2004 through 2007. We used logistic regression to assess the independent contributions of women's prepregnancy BMI status to their GDM risk, by race/ethnicity, while controlling for maternal age and parity. We then calculated the adjusted population-attributable fraction of GDM cases attributable to overweight and obesity. RESULTS: The estimated GDM prevalence was 4.7% overall and ranged from 4.0% among non-Hispanic black women to 9.9% among Asian/Pacific Islander women. The probability of GDM increased with increasing BMI for all racial/ethnic groups. The fraction of GDM cases attributable to overweight and obesity was 41.1% overall, 15.1% among Asians/Pacific Islanders, 39.1% among Hispanics, 41.2% among non-Hispanic whites, 50.4% among non-Hispanic blacks, and 52.8% among American Indians. CONCLUSION: Although non-Hispanic black and American Indian women may benefit the most from prepregnancy reduction in obesity, interventions other than obesity prevention may be needed for women from other racial/ethnic groups.

This paper provides an overview of the origins, purpose, and methods of the Perinatal Periods of Risk (PPOR) approach to community-based planning for action to improve maternal and infant health outcomes. PPOR includes a new analytic framework that enables urban communities to better understand and address fetal and infant mortality. This article serves as the core reference for accompanying specific PPOR methods and practice articles. PPOR is based on core principles of full community engagement and equity and follows a six stage community-based planning process. In Stage 1, communities are mobilized and engaged, related planning efforts aligned, and community and analytic readiness assessed. In Stage 2, feto-infant mortality is mapped, excess mortality is estimated, likely causes of feto-infant mortality are determined, and appropriate actions are suggested. Stage 3 produces action plans for targeted prevention strategies. Stages 4 and 5 include implementation, monitoring, and evaluation. Stage 6 fosters political will to sustain efforts. PPOR can be used in local maternal child health (MCH) practice for improving perinatal outcomes. MCH programs can use PPOR to integrate health assessments, initiate planning, identify significant gaps, target more in-depth inquiry, and suggest clear interventions for lowering feto-infant mortality. PPOR enables greater cooperation in improving MCH through more effective data use, strengthened data capacity, and greater shared understanding of complex infant mortality issues. PPOR offers local health departments and their community partners a comprehensive approach to address the health of women and infants in their jurisdictions.

Childhood obesity is a major public health concern and is associated with substantial morbidities. Access to less-healthy foods might facilitate dietary behaviors that contribute to obesity. However, less-healthy foods are usually available in school vending machines. This cross-sectional study examined the prevalence of students buying snacks or beverages from school vending machines instead of buying school lunch and predictors of this behavior. Analyses were based on the 2003 Florida Youth Physical Activity and Nutrition Survey using a representative sample of 4,322 students in grades six through eight in 73 Florida public middle schools. Analyses included chi2 tests and logistic regression. The outcome measure was buying a snack or beverage from vending machines 2 or more days during the previous 5 days instead of buying lunch. The survey response rate was 72%. Eighteen percent of respondents reported purchasing a snack or beverage from a vending machine 2 or more days during the previous 5 school days instead of buying school lunch. Although healthier options were available, the most commonly purchased vending machine items were chips, pretzels/crackers, candy bars, soda, and sport drinks. More students chose snacks or beverages instead of lunch in schools where beverage vending machines were also available than did students in schools where beverage vending machines were unavailable: 19% and 7%, respectively (P≤0.05). The strongest risk factor for buying snacks or beverages from vending machines instead of buying school lunch was availability of beverage vending machines in schools (adjusted odds ratio=3.5; 95% confidence interval, 2.2 to 5.7). Other statistically significant risk factors were smoking, non-Hispanic black race/ethnicity, Hispanic ethnicity, and older age. Although healthier choices were available, the most common choices were the less-healthy foods. Schools should consider developing policies to reduce the availability of less-healthy choices in vending machines and to reduce access to beverage vending machines.

Since 2000, the Coalition for Excellence in Maternal and Child Health (MCH) Epidemiology has recognized the significant contributions of individuals and organizations to improve the health of women, children, infants, and families by giving the National MCH Epidemiology Awards. The awards are presented annually at the MCH Epidemiology Conference. These awards are supported each year by sixteen national health organizations, and all should be commended for recognizing and promoting continuing excellence in the field of MCH epidemiology (Table 1) The Coalition for Excellence in MCH Epidemiology defines MCH Epidemiology in the following way: | Table 1 Coalition for excellence in maternal and child health (MCH) epidemiology member organizations | Full size table | The systematic collection, analysis, and interpretation of population-based and program-specific health and related data in order to assess the distribution and determinants of the health status and needs of the maternal child population for the purpose of planning, implementing, and assessing effective, science-based strategies and promoting policy development [1].

The Perinatal Periods of Risk (PPOR) methods provide the necessary framework and tools for large urban communities to investigate feto-infant mortality problems. Adapted from the Periods of Risk model developed by Dr. Brian McCarthy, the six-stage PPOR approach includes epidemiologic methods to be used in conjunction with community planning processes. Stage 2 of the PPOR approach has three major analytic parts: Analytic Preparation, which involves acquiring, preparing, and assessing vital records files; Phase 1 Analysis, which identifies local opportunity gaps; and Phase 2 Analyses, which investigate the opportunity gaps to determine likely causes of feto-infant mortality and to suggest appropriate actions. This article describes the first two analytic parts of PPOR, including methods, innovative aspects, rationale, limitations, and a community example. In Analytic Preparation, study files are acquired and prepared and data quality is assessed. In Phase 1 Analysis, feto-infant mortality is estimated for four distinct perinatal risk periods defined by both birthweight and age at death. These mutually exclusive risk periods are labeled Maternal Health and Prematurity, Maternal Care, Newborn Care, and Infant Health to suggest primary areas of prevention. Disparities within the study community are identified by comparing geographic areas, subpopulations, and time periods. Excess mortality numbers and rates are estimated by comparing the study population to an optimal reference population. This excess mortality is described as the opportunity gap because it indicates where communities have the potential to make improvement.

The perinatal periods of risk (PPOR) methods provide a framework and tools to guide large urban communities in investigating their feto-infant mortality problem. The PPOR methods have 11 defined steps divided into three analytic parts: (1) Analytic Preparation; (2) Phase 1 Analysis-identifying the opportunity gaps or populations and risk periods with largest excess mortality; and (3) Phase 2 Analyses-investigating these opportunity gaps. This article focuses on the Phase 2 analytic methods, which systematically investigate the opportunity gaps to discover which risk and preventive factors are likely to have the largest effect on improving a community's feto-infant mortality rate and to provide additional information to better direct community prevention planning. This article describes the last three PPOR epidemiologic steps for investigating identified opportunity gaps: identifying the mechanism for excess mortality; estimating the prevalence of risk and preventive factors; and estimating the impact of these factors. While the three steps provide a common strategy, the specific analytic details are tailored for each of the four perinatal risk periods. This article describes the importance, prerequisites, alternative approaches, and challenges of the Phase 2 methods. Community examples of the methods also are provided.