The Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality: An Outcome Evaluation From the US South, 2011 to 2014.

Objectives. To evaluate the impact of the Southern Public Health Regions’ (Regions IV and IV) Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, supported by the US Health Resources and Services Administration. Methods. We examined pre–post change (2011–2014) for CoIIN strategies with available outcome data from vital records (early elective delivery, smoking) and the Pregnancy Risk Assessment Monitoring System (safe sleep) as well as preterm birth and infant mortality for Regions IV and VI relative to all other regions. Results. For most outcomes, CoIIN improvements were greater in Regions IV and VI than in other regions. For example, early elective delivery decreased by 22% versus 14% in other regions, smoking cessation during pregnancy increased by 7% versus 2%, and back sleep position increased by 5% versus 2%. Preterm birth decreased by 4%, twice that observed in other regions, but infant mortality reductions did not differ significantly. Conclusions. The CoIIN approach to public health improvement shows promise in accelerating progress in intermediate outcomes and preterm birth. Impact on infant mortality may require additional strategies and sustained efforts

The Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality: An Outcome Evaluation From the US South, 2011 to 2014

Objectives. To evaluate the impact of the Southern Public Health Regions’ (Regions IV and IV) Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, supported by the US Health Resources and Services Administration. Methods. We examined pre–post change (2011–2014) for CoIIN strategies with available outcome data from vital records (early elective delivery, smoking) and the Pregnancy Risk Assessment Monitoring System (safe sleep) as well as preterm birth and infant mortality for Regions IV and VI relative to all other regions. Results. For most outcomes, CoIIN improvements were greater in Regions IV and VI than in other regions. For example, early elective delivery decreased by 22% versus 14% in other regions, smoking cessation during pregnancy increased by 7% versus 2%, and back sleep position increased by 5% versus 2%. Preterm birth decreased by 4%, twice that observed in other regions, but infant mortality reductions did not differ significantly. Conclusions. The CoIIN approach to public health improvement shows promise in accelerating progress in intermediate outcomes and preterm birth. Impact on infant mortality may require additional strategies and sustained efforts

Race and Ethnicity Misclassification in Hospital Discharge Data and the Impact on Differences in Severe Maternal Morbidity Rates in Florida

Hospital discharge (HD) records contain important information that is used in public health and health care sectors. It is becoming increasingly common to rely mostly or exclusively on HD data to assess and monitor severe maternal morbidity (SMM) overall and by sociodemographic characteristics, including race and ethnicity. Limited studies have validated race and ethnicity in HD or provided estimates on the impact of assessing health differences in maternity populations. This study aims to determine the differences in race and ethnicity reporting between HD and birth certificate (BC) data for maternity hospitals in Florida and to estimate the impact of race and ethnicity misclassification on state- and hospital-specific SMM rates. We conducted a population-based retrospective study of live births using linked BC and HD records from 2016 to 2019 (n = 783,753). BC data were used as the gold standard. Race and ethnicity were categorized as non-Hispanic (NH)-White, NH-Black, Hispanic, NH-Asian Pacific Islander (API), and NH-American Indian or Alaskan Native (AIAN). Overall, race and ethnicity misclassification and its impact on SMM at the state- and hospital levels were estimated. At the state level, NH-AIAN women were the most misclassified (sensitivity: 28.2%; positive predictive value (PPV): 25.2%) and were commonly classified as NH-API (30.3%) in HD records. NH-API women were the next most misclassified (sensitivity: 57.3%; PPV: 85.4%) and were commonly classified as NH-White (5.8%) or NH-other (5.5%). At the hospital level, wide variation in sensitivity and PPV with negative skewing was identified, particularly for NH-White, Hispanic, and NH-API women. Misclassification did not result in large differences in SMM rates at the state level for all race and ethnicity categories except for NH-AIAN women (% difference 78.7). However, at the hospital level, Hispanic women had wide variability of a percent difference in SMM rates and were more likely to have underestimated SMM rates. Reducing race and ethnicity misclassification on HD records is key in assessing and addressing SMM differences and better informing surveillance, research, and quality improvement efforts

Folic Acid Intake, Fetal Brain Growth, and Maternal Smoking in Pregnancy: A Randomized Controlled Trial

Background: Folic acid supplementation during pregnancy plays an important role in fetal growth and development. To our knowledge, no experimental study has examined the effect of folic acid on fetal brain growth in women who smoke cigarettes during pregnancy. Objectives: The aim of this study was to investigate the efficacy of higher-dose compared with standard-dose folic acid supplementation on prenatal fetal brain growth, measured by head circumference, brain weight, and brain-body weight ratio (BBR). Design: In this randomly assigned, double-blind, controlled clinical trial, we recruited 345 smoking pregnant women attending a community health center in Tampa, FL between 2010 and 2014. Participants were randomly assigned in a 1:1 ratio to receive either 0.8 mg folic acid/d (standard of care at the study center) or 4 mg folic acid/d (higher strength). Participants were also enrolled in a smoking cessation program. A 2-level linear growth model was used to assess treatment effect and factors that predict intrauterine growth in head circumference over time. Multiple linear regression analyses were conducted to estimate the effect of higher-strength folic acid on head circumference at birth, fetal brain weight, and fetal BBRs. Results: Mothers who received the higher dose of folic acid had infants with a 1.18 mm larger mean head circumference compared with infants born to mothers who received the standard dose, but this difference was not statistically significant (P = 0.2762). Higher-dose folic acid also had no significant effect on brain weight. The BBR of infants of mothers who received higher-dose folic acid was, however, 0.33 percentage points lower than that for infants of mothers who received the standard dose of folic acid (P = 0.044). Conclusions: Infants of smokers in pregnancy may benefit from higher-strength maternal folic acid supplementation. We noted a decrease in the proportion of infants with impaired BBR among those on higher-dose folic acid. This trial was registered at clinicaltrials.gov as NCT01248260

Folic Acid Intake, Fetal Brain Growth, and Maternal Smoking in Pregnancy: A Randomized Controlled Trial

Background: Folic acid supplementation during pregnancy plays an important role in fetal growth and development. To our knowledge, no experimental study has examined the effect of folic acid on fetal brain growth in women who smoke cigarettes during pregnancy. Objectives: The aim of this study was to investigate the efficacy of higher-dose compared with standard-dose folic acid supplementation on prenatal fetal brain growth, measured by head circumference, brain weight, and brain-body weight ratio (BBR). Design: In this randomly assigned, double-blind, controlled clinical trial, we recruited 345 smoking pregnant women attending a community health center in Tampa, FL between 2010 and 2014. Participants were randomly assigned in a 1:1 ratio to receive either 0.8 mg folic acid/d (standard of care at the study center) or 4 mg folic acid/d (higher strength). Participants were also enrolled in a smoking cessation program. A 2-level linear growth model was used to assess treatment effect and factors that predict intrauterine growth in head circumference over time. Multiple linear regression analyses were conducted to estimate the effect of higher-strength folic acid on head circumference at birth, fetal brain weight, and fetal BBRs. Results: Mothers who received the higher dose of folic acid had infants with a 1.18 mm larger mean head circumference compared with infants born to mothers who received the standard dose, but this difference was not statistically significant (P = 0.2762). Higher-dose folic acid also had no significant effect on brain weight. The BBR of infants of mothers who received higher-dose folic acid was, however, 0.33 percentage points lower than that for infants of mothers who received the standard dose of folic acid (P = 0.044). Conclusions: Infants of smokers in pregnancy may benefit from higher-strength maternal folic acid supplementation. We noted a decrease in the proportion of infants with impaired BBR among those on higher-dose folic acid. This trial was registered at clinicaltrials.gov as NCT01248260

Multilevel Factors Associated with Length of Stay for Neonatal Abstinence Syndrome in Florida’s NICUs: 2010–2015

To investigate potential factors influencing initial length of hospital stay (LOS) for infants with neonatal abstinence syndrome (NAS) in Florida. The study population included 2984 term, singleton live births in 33 Florida hospitals. We used hierarchical linear modeling to evaluate the association of community, hospital, and individual factors with LOS. The average LOS of infants diagnosed with NAS varied significantly across hospitals. Individual-level factors associated with increased LOS for NAS included event year (P \u3c 0.001), gestational age at birth (P \u3c 0.001), maternal age (P = 0.002), maternal race and ethnicity (P \u3c 0.001), maternal education (P = 0.032), and prenatal care adequacy (P \u3c 0.001). Average annual hospital NAS volume (P = 0.022) was a significant hospital factor. NAS varies widely across hospitals in Florida. In addition to focusing on treatment regimens, to reduce LOS, public health and quality improvement initiatives should identify and adopt strategies that can minimize the prevalence and impact of these contributing factors