Exercise During Pregnancy and Cesarean Delivery: North Carolina PRAMS, 2004-2005

Background—The current rate of cesarean delivery in the United States is 31 percent. Previous studies have suggested that exercise during pregnancy may be associated with a lower risk of cesarean delivery, but sample sizes were small and methods often inadequate. This study examined whether or not an association exists between prenatal exercise and delivery mode using data from the 2004 and 2005 North Carolina Pregnancy Risk Assessment Monitoring System (PRAMS) survey. Methods—PRAMS postpartum questionnaire responses about frequency of exercise during the last 3 months of pregnancy for 1,955 women without a prior cesarean delivery were linked to birth certificates. Results—Among 1,342 women delivering at term, exercise was not associated with delivery mode in this data set: compared with women exercising less than once a week, neither women exercising 1 to 4 times per week nor those exercising 5 times or more per week had an altered risk of cesarean [RR (95% CL) 0.89 (0.69, 1.15), 1.04 (0.66, 1.64), respectively, adjusted for parity, gestational age, hypertension]. Among 613 women delivering preterm, the results were also not statistically significant, but a compelling trend toward a protective effect could be seen [RR (95% CL) 0.65 (0.38, 1.13), 0.62 (0.29, 1.33)]. Conclusions—Maternal self-reported frequency of exercise during pregnancy was not associated with a reduced risk of cesarean delivery. Larger studies with better exposure ascertainment may provide a more definitive answer

Maternal Physical Activity and Birth Outcomes

Background: Information on physical activity (PA) during pregnancy and subsequent maternal birth outcomes (such as cesarean rate, labor duration) is plentiful in the literature, but consensus among studies is lacking. Poor exposure analytic methods may be a source of conflicting results. Objective: To estimate associations between PA during pregnancy and maternal birth outcomes using appropriate statistical methods. Methods: Detailed 7-day PA recalls were administered to pregnant women at two time points: 17-22 and 27-30 weeks' completed gestation. Covariables and labor outcomes were obtained by a combination of self-administered questionnaires and medical record abstraction. Physical activity was treated in analyses as a continuous, non-linear variable. We analyzed separately 8 different exposures: total hours/week PA at each time point, hours/week moderate-to-vigorous PA (MVPA) at each time point; total hours/week recreational PA at each time point, and finally hours/week recreational MVPA at each time point. Outcomes included induction, labor duration, augmentation, operative vaginal delivery (OVD), cesarean birth, episiotomy, and laceration severity. Covariables for each model were selected using directed acyclic graphs (DAGs); variables in final models were chosen through backwards stepwise selection using analysis of deviance. Sensitivity analyses explored the effects of excluding women reporting extremely large PA volumes and of excluding women reporting zero hours/week PA. Results: Physical activity during pregnancy was associated with a decreased risk of induction. Recreational PA at the second time point only was associated with a decreased risk of augmentation. PA during pregnancy was associated with longer labor durations, but our measure of labor duration was crude and we do not consider this result definitive. PA was not associated in these data with episiotomy, OVD, or cesarean. PA may be associated with increased laceration severity, but effects were quite small. Conclusions: Lack of consensus in the literature on the associations between PA and maternal birth outcomes may be partially because of categorical treatment of the exposure and lack of attention to gestational age at time of exposure

Risky Behavior: Perceived Risk of Infectious Disease in Youth Entering Alcohol/Drug Treatment

Upon entering a residential drug and alcohol treatment, typically clients are directed to complete a risk assessment form. Risk assessment forms are anonymous, self-reported questionnaires that inquire about demographics, health, sexual behaviors, as well as drug and alcohol use. The YES house is a youth treatment facility in Corvallis Oregon that asked the Public Health department of Oregon State University to analyze their risk assessment forms from the years of 1999-2011. We cleaned and analyzed the data using SPSS Version 21.0., running frequencies on all questions within their document. We compared rates of adolescents coming into the facility by county to the population of each county. We ran an ordinal logistic regression on two questions within the form that were the patient’s perceived risk of HIV and Hepatitis C. We found that 55.1% of these patients had been to jail and 22.3% had been homeless sometime in their life. The median age was 16.4 and 64% were male. We found that for each point in the sex predictor questions they were 1.8 times more likely to perceive themselves at risk for HIV and 1.4 times more likely to perceive themselves at risk for contracting Hepatitis C. We concluded that adolescence entering YES house don’t tend to perceive themselves at risk for diseases while surprising numbers have engaged in risky behaviors at a very early age

You’re from … where, again? A critical assessment of institutional diversity in the Society for Epidemiologic Research

The Society for Epidemiologic Research (SER) has recently taken laudable steps toward increasing diversity, equity, and inclusion within the society, including participation in the annual meeting. In this essay, we argue that there is one critical piece of the diversity and inclusion equation that is, however, overlooked: institution. At the 2019 Annual Meeting, a mere 8 institutions accounted for a disproportionate number of both oral concurrent sessions and symposium speakers. This lack of institutional diversity, unless addressed, will hinder SER’s ability to address other aspects of diversity, equity, and inclusion

The Duration of Spontaneous Active and Pushing Phases of Labour among 75,243 US women when intervention is minimal: A prospective, observational cohort study

Background Friedman\u27s curve, despite acknowledged limitations, has greatly influenced labour management. Interventions to hasten birth are now ubiquitous, challenging the contemporary study of normal labour. Our primary purpose was to characterise normal active labour and pushing durations in a large, contemporary sample experiencing minimal intervention, stratified by parity, age, and body mass index (BMI). Methods This is a secondary analysis of the national, validated Midwives Alliance of North America 4·0 (MANA Stats) data registry (n = 75,243), prospectively collected between Jan 1, 2012 and Dec 31, 2018 to describe labour and birth in home and birth center settings where common obstetric interventions [i.e., oxytocin, planned cesarean] are not available. The MANA Stats cohort includes pregnant people who intended birth in these settings and prospectively collects labour and birth processes and outcomes regardless of where birth or postpartum care ultimately occurs. Survival curves were calculated to estimate labour duration percentiles (e.g. 10th, 50th, 90th, and others of interest), by parity and sub-stratified by age and BMI. Findings Compared to multiparous women (n = 32,882), nulliparous women (n = 15,331) had significantly longer active labour [e.g., median 7.5 vs. 3.3 h; 95th percentile 34.8 vs. 12.0 h] and significantly longer pushing phase [e.g., median 1.1 vs. 0.2 h; 95th percentile 5.5 vs. 1.1 h]. Among nulliparous women, maternal age \u3e35 was associated with longer active first stage of labour and longer pushing phase, and BMI \u3e30 kg/m² was associated with a longer active first stage of labour but a shorter pushing phase. Patterns among multiparous women were different, with those \u3e35 years of age experiencing a slightly more rapid active labour and no difference in pushing duration, and those with BMI \u3e30 kg/m² experiencing a slightly longer active labour but, similarly, no difference in pushing duration. Interpretation Nulliparous women had significantly longer active first stage and pushing phase durations than multiparous women, with further variation noted by age and by BMI. Contemporary US women with low-risk pregnancies who intended birth in settings absent common obstetric interventions and in spontaneous labour with a live, vertex, term, singleton, non-anomalous fetus experienced labour durations that were often longer than prior characterizations, particularly among nulliparous women. Results overcome prior and current sampling limitations to refine understanding of normal labour durations and time thresholds signaling ‘labour dystocia’

Community Versus Out-of-Hospital Birth: What's in a Name?

The term out‐of‐hospital has long been used as a kind of shorthand to refer collectively to births that occur in birth centers or at home. However, this term has also been a persistent cause of concern among health care providers who attend births in these settings, and researchers and midwives are increasingly adopting the term community birth instead to refer to planned home and birth center births. Some who resist the term out‐of‐hospital have argued that it reifies hospital birth as normative and community birth as other, marginal, or alternative. Here we propose community birth as a preferable term because it labels the practice for what it is—instead of for what it is not. This argument is similar to those made by communities of color who have critiqued the use of nonwhite as a demographic category that elevates Euro‐Americans as the default race. Medical anthropologists have also compared the use of the term out‐of‐hospital to the tendency to call nonallopathic forms of healing complementary or alternative. Yet, many so‐called complementary and alternative medicine practitioners prefer to identify their forms of healing as holistic, integrative, or functional to indicate that modalities such as acupuncture, Ayurveda, chiropractic, and so on are autonomous approaches that may exist outside of, but are not subservient to or less than, allopathic and biomedical modalities. These health care providers, too, commonly choose to refer to their practice with terms that convey what it is, rather than what it is not, just as persons of color choose to be identified for who they are, not for who they are not

Exposure Analysis Methods Impact Associations between Maternal Physical Activity and Cesarean Delivery

Background: Previous studies report conflicting results regarding a possible association between maternal physical activity (PA) and cesarean delivery. Methods: 7-day PA recalls were collected by telephone from n=1205 pregnant women from North Carolina, without prior cesarean, during two time windows: 17-22 weeks and 27-30 weeks completed gestation. PA was treated as a continuous, non-linear variable in binomial regressions (log-link function); models controlled for primiparity, maternal contraindications to exercise, pre-eclampsia, pre-gravid BMI, and percent poverty. We examined both total PA and moderate-to-vigorous PA (MVPA) at each time. Outcomes data came from medical records. Results: The dose-response curves between PA or MVPA and cesarean risk at 17-22 weeks followed an inverse J-shape, but at 27-30 weeks the curves reversed and were J-shaped. However, only (total) PA at 27-30 weeks was strongly associated with cesarean risk; this association was attenuated when women reporting large volumes of PA (>97.5th percentile) were excluded. Conclusion: We did not find evidence of an association between physical activity and cesarean birth. We did, however, find evidence that associations between PA and risk of cesarean may be non-linear and dependent on gestational age at time of exposure, limiting the accuracy of analyses that collapse maternal PA into categories

Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009

INTRODUCTION: Between 2004 and 2010, the number of home births in the United States rose by 41%, increasing the need for accurate assessment of the safety of planned home birth. This study examines outcomes of planned home births in the United States between 2004 and 2009. METHODS: We calculated descriptive statistics for maternal demographics, antenatal risk profiles, procedures, and outcomes of planned home births in the Midwives Alliance of North American Statistics Project (MANA Stats) 2.0 data registry. Data were analyzed according to intended and actual place of birth. RESULTS: Among 16,924 women who planned home births at the onset of labor, 89.1% gave birth at home. The majority of intrapartum transfers were for failure to progress, and only 4.5% of the total sample required oxytocin augmentation and/or epidural analgesia. The rates of spontaneous vaginal birth, assisted vaginal birth, and cesarean were 93.6%, 1.2%, and 5.2%, respectively. Of the 1054 women who attempted a vaginal birth after cesarean, 87% were successful. Low Apgar scores (< 7) occurred in 1.5% of newborns. Postpartum maternal (1.5%) and neonatal (0.9%) transfers were infrequent. The majority (86%) of newborns were exclusively breastfeeding at 6 weeks of age. Excluding lethal anomalies, the intrapartum, early neonatal, and late neonatal mortality rates were 1.30, 0.41, and 0.35 per 1000, respectively. DISCUSSION: For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the best available data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.This is the publisher’s final pdf. The article is copyrighted by the American College of Nurse-Midwives and published by John Wiley & Sons, Inc. It can be found at: http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%291542-2011.Keywords: pregnancy outcomes, home childbirth, midwifery, midwife, birth place, perinatal outcom

Exposure Analysis Methods Impact Associations Between Maternal Physical Activity and Cesarean Delivery

BACKGROUND: Previous studies report conflicting results regarding a possible association between maternal physical activity (PA) and cesarean delivery. METHODS: 7-day PA recalls were collected by telephone from n=1205 pregnant women from North Carolina, without prior cesarean, during two time windows: 17-22 weeks and 27-30 weeks completed gestation. PA was treated as a continuous, non-linear variable in binomial regressions (log-link function); models controlled for primiparity, maternal contraindications to exercise, pre-eclampsia, pregravid BMI, and percent poverty. We examined both total PA and moderate-to-vigorous PA (MVPA) at each time. Outcomes data came from medical records. RESULTS: The dose-response curves between PA or MVPA and cesarean risk at 17-22 weeks followed an inverse J-shape, but at 27-30 weeks the curves reversed and were J-shaped. However, only (total) PA at 27-30 weeks was strongly associated with cesarean risk; this association was attenuated when women reporting large volumes of PA (>97.5th percentile) were excluded. CONCLUSION: We did not find evidence of an association between physical activity and cesarean birth. We did, however, find evidence that associations between PA and risk of cesarean may be non-linear and dependent on gestational age at time of exposure, limiting the accuracy of analyses that collapse maternal PA into categories.This is an author's peer-reviewed final manuscript, as accepted for publication. The published article is copyrighted by Human Kinetics, Inc., and can be found at: http://journals.humankinetics.com/jpah-back-issues/jpah-volume-12-issue-1-january/exposure-analysis-methods-impact-associations-between-maternal-physical-activity-and-cesarean-deliveryKeywords: childbirth, exposure coding, exercise, prospective, cohort stud