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

Patient Experiences with an mHealth App for Complex Chronic Disease Care: Connections Despite Lack of Traditional Clinical Interactions

Chronic diseases are costly to treat and burdensome for patients. Mobile health (mHealth) technologies might reduce costs of care and increase patient self-efficacy in chronic disease management, but the patient experience of mHealth is poorly understood. Our objective, therefore, was to evaluate patient experiences with using an mHealth app for complex chronic disease management, within a U.S. population of low-income patients. We used nurse/patient text messages from an mHealth complex chronic disease management tool, and exit interviews from patients, to assess qualitatively Medicaid patients\u27 experiences with a remote monitoring mHealth app. Salient themes about the patient experience included: (1) Visibility and Invisibility in the Medical System (patients felt both seen and heard when using the app), (2) Deconstructing the Clinical Encounter (patients were reassured by being able to access care from any place at any time), (3) Familiarity in the Nurse/Patient Relationship (patients felt connected to the nurses running the app), and (4) Technology as a Conduit of Caring (the technology enhanced nursing care, rather than detracting from it). M-Health apps might be a way to improve provision of care for high-utilizing patients, particularly those from historically marginalized groups

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

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

Improving Smoking Cessation Counseling Using a Point-of-Care Health Intervention Tool (IT): From the Virginia Practice Support and Research Network (VaPSRN)

Purpose: Primary care practices are an ideal setting for reducing national smoking rates because >70% of smokers visit their physician annually, yet smoking cessation counseling is inconsistently delivered to patients. We designed and created a novel software program for handheld computers and hypothesized that it would improve clinicians' ability to provide patient-tailored smoking cessation counseling at the point of care. Methods: A handheld computer software program was created based on smoking cessation guidelines and an adaptation of widely accepted behavioral change theories. The tool was evaluated using a validated before/after survey to measure physician smoking cessation counseling behaviors, knowledge, and comfort/self-efficacy. Results: Participants included 17 physicians (mean age, 41 years; 71% male; 5 resident physicians) from a practice-based research network. After 4 months of use in direct patient care, physicians were more likely to advise patients to stop smoking (P = .049) and reported an increase in use of the “5 As” (P = .03). Improved self-efficacy in counseling patients regarding smoking cessation (P = .006) was seen, as was increased comfort in providing follow-up to patients (P = .04). Conclusions: Use of a handheld computer software tool improved smoking cessation counseling among physicians and shows promise for translating evidence about smoking cessation counseling into practice and educational settings.This is the publisher’s final pdf. The published article can be found at: http://www.jabfm.org/Keywords: Practice-based Research, Health Information Technology, Smoking Cessation, Behavioral Counselin

Comparison of placenta consumers’ and non-consumers’ postpartum depression screening results using EPDS in US community birth settings (n=6038): a propensity score analysis

Abstract Background Preventing postpartum depression (PPD) is the most common self-reported motivation for human maternal placentophagy, yet very little systematic research has assessed mental health following placenta consumption. Our aim was to compare PPD screening scores of placenta consumers and non-consumers in a community birth setting, using propensity score matching to address anticipated extensive confounding. Methods We used a medical records-based data set (n = 6038) containing pregnancy, birth, and postpartum information for US women who planned and completed community births. We first compared PPD screening scores as measured by the Edinburgh Postpartum Depression Scale (EPDS) of individuals who consumed their placenta to those who did not, with regard to demographics, pregnancy characteristics, and history of mental health challenges. Matching placentophagic (n = 1876) and non-placentophagic (n = 1876) groups were then created using propensity scores. The propensity score model included more than 90 variables describing medical and obstetric history, demographics, pregnancy characteristics, and intrapartum and postpartum complications, thus addressing confounding by all of these variables. We then used logistic regression to compare placentophagic to non-placentophagic groups based on commonly-cited EPDS cutoff values (≥ 11; ≥ 13) for likely PPD. Results In the unmatched and unadjusted analysis, placentophagy was associated with an increased risk of PPD. In the matched sample, 9.9% of women who ate their placentas reported EPDS ≥ 11, compared to 8.4% of women who did not (5.5% and 4.8%, respectively, EPDS ≥ 13 or greater). After controlling for over 90 variables (including prior mental health challenges) in the matched and adjusted analysis, placentophagy was associated with an increased risk of PPD between 15 and 20%, depending on the published EPDS cutoff point used. Numerous sensitivity analyses did not alter this general finding. Conclusions Placentophagic individuals in our study scored higher on an EPDS screening than carefully matched non-placentophagic controls. Why placentophagic women score higher on the EPDS remains unclear, but we suspect reverse causality plays an important role. Future research could assess psychosocial factors that may motivate some individuals to engage in placentophagy, and that may also indicate greater risk of PPD