Shannon N. Lenze

Importance: Both sleep difficulties and cannabis use during pregnancy (CUP) are common and associated with adverse birth and offspring outcomes. Sleep problems are a commonly reported motive for cannabis use during pregnancy. Objective: Estimate associations between cannabis use during pregnancy and common sleep difficulties across trimesters. Design, Setting, and Participants: This cohort study recruited pregnant women with lifetime cannabis use who used (n=298) and did not use (n=143) cannabis during pregnancy. Women who reported heavy episodic alcohol consumption or use of other illicit substances were excluded. Some women tested positive for cotinine in urine drug screens. Exposures: Cannabis use was assessed at each trimester using self-report and urine drug screening. Presence of the nicotine metabolite, cotinine, was measured via urine drug screening at each trimester. Cannabis use during pregnancy (CUP) status was defined separately for each trimester as use versus no use and was treated as a time-varying exposure. The nicotine metabolite cotinine was included as a covariate in all models to account for nicotine exposure. Motivation for cannabis use during pregnancy was assessed during the first trimester. Main Outcomes and Measures: Insomnia symptoms (Women’s Health Initiative Insomnia Rating Scale), daytime sleepiness (Epworth Sleepiness Scale), subjective sleep quality (Pittsburgh Sleep Quality Index single item), and restless legs symptoms were assessed at each trimester. Results: A CUP Status x Trimester interaction was observed for insomnia symptoms (F(2,737.81)=4.98, P _FDR =0.03) wherein use during the third trimester was associated with heightened insomnia. Women reporting sleep difficulties as a motive for use reported worse insomnia symptoms (F(1, 223)=13.09, P _FDR =0.001) and worse sleep quality (F(1, 219)=7.86, P _FDR =0.01), relative to those using for other reasons. Conclusion: Elevated third trimester insomnia symptoms among pregnant women using cannabis compared to women who did not use cannabis suggest a potential trimester-sensitive association. Despite perceptions that cannabis improves sleep, women who reported sleep as their motive for CUP during the first trimester experienced greater insomnia symptoms and poorer sleep quality across pregnancy than those using cannabis for other reasons. Additional studies are needed to determine whether sleep-related difficulties precede cannabis use, follow it, are modified by it, or represent an epiphenomenon. KEY POINTS: Question: Is cannabis use during pregnancy associated with maternal sleep problems? Findings: Within this study of 441 pregnant women, cannabis use was associated with higher third trimester insomnia symptoms but not with other sleep outcomes. Women using cannabis to aid with sleep difficulties had worse insomnia symptoms and poorer sleep quality than those using for other reasons. Meaning: Cannabis use in late pregnancy may mark periods of greater insomnia symptom burden, suggesting that sleep problems during pregnancy may be an important clinical context for understanding cannabis use during pregnancy.

Introduction: Elevating Voices, Addressing Depression, Toxic Stress and Equity (EleVATE) is a group prenatal care (GC) model designed to improve pregnancy outcomes and promote health equity for Black birthing people. This article outlines the foundational community-engaged process to develop EleVATE GC and pilot study results. Methods: We used community-based participatory research principles and the Ferguson Commission Report to guide creation of EleVATE GC. The intervention, designed by and for Black birthing people, centers trauma-informed care, antiracism, and integrates behavioral health strategies into group prenatal care to address unmet mental health needs. Using a convenience sample of patients seeking care at one of three safety-net health care sites, we compared preterm birth, small for gestational age, depression scores, and other pregnancy outcomes between patients in individual care (IC), CenteringPregnancy™ (CP), and EleVATE GC. Results: Forty-eight patients enrolled in the study (n=11 IC; n=14 CP; n=23 EleVATE GC) and 86% self-identified as Black. Patients participating in group prenatal care (EleVATE GC or CP) were significantly less likely to experience a preterm birth <34 weeks. Rates of small for gestational age, preterm birth <37 weeks, depression scores, and other pregnancy outcomes were similar across groups. Participants in CP and EleVATE GC were more likely to attend their postpartum visit and breastfeed at hospital discharge than those in IC. Discussion: Our findings model a systematic approach to design a feasible, patient-centered, community-based, trauma-informed, antiracist intervention. Further study is needed to determine whether EleVATE GC improves perinatal outcomes and promotes health equity.

Introduction: Postpartum depression has costly consequences for the mother, baby, and society. Numerous pharmacological and non-pharmacological interventions are available for the prevention and treatment of postpartum depression. To date, no attempt has been made to synthesize the evidence from comparisons of interventions both within and across these categories. Methods: We will perform a systematic review of the literature and perform network meta-analysis of interventions to (a) prevent and (b) treat postpartum depression. This review will include studies of primiparous or multiparous women during pregnancy or within 12 months of delivery of their baby that assess either interventions initiated during pregnancy or within 1 year of childbirth. Comparators will be other eligible interventions or control conditions. The outcome of interests will be related to the antidepressant efficacy of the interventions as well as their acceptability. The published literature will be searched in Ovid MEDLINE 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. The search will use a combination of standardized terms and keywords for postpartum depression, a sensitive search filter to limit for randomized controlled trials, and a librarian-created “humans” filter. The search results will be uploaded to the Covidence online systematic review platform (Veritas Health Information Ltd., Victoria, Australia) where two review team members will independently screen articles. We will extract data to include year of publication, language, country, participants (number, demographic data, eligibility criteria, psychiatric symptoms, and co-morbidities), characteristics of the intervention and control conditions, and reported outcomes. Risk of bias for each study will be assessed independently by two review authors using the RoB 2: A revised Cochrane risk of bias tool for randomized trials. Network meta-analysis will be performed using a Bayesian hierarchical model supplemented with a Markov chain Monte Carlo approach. Discussion: Postpartum depression is a devastating disease with long-lasting consequences. Given the numerous available interventions to both prevent and treat postpartum depression and the great number of studies comparing them, it is imperative that clinicians and patients are provided with an assessment of their comparative efficacy and acceptability. Systematic review registration: Prospero registration (CRD42022303247).

Background: Evidence suggests ketamine may prevent postpartum depression (PPD) after cesarean delivery (CD) although intolerability and inconvenience of administration are problematic. We assessed the feasibility of studying ketamine (0.5 mg/kg, via subcutaneous injection or 40-min intravenous infusion) to prevent PPD after CD. Methods: Twenty-three women scheduled for cesarean delivery under neuraxial anesthesia were randomized to one of three groups: subcutaneous ketamine (SC Group, n = 8), intravenous ketamine (IV Group, n = 8) or placebo (n = 7). We measured depression (Edinburgh Postpartum Depression Scale [EPDS]) scores pre-operatively and at 1, 2, 21 and 42 days postoperatively. Anxiety, adverse effects, surgical site pain and analgesic consumption were also assessed. Feasibility was assessed based on acceptability, burden of disease, ability to collect study data and, tolerability of interventions. Results: Baseline characteristics of groups were similar, however, more women in the placebo group had pre-existing anxiety disorder (p = 0.03). 20.7% (25/121) of those approached consented to participate and 34.8% (8/23), of those assessed, screened positive for depression in the postpartum (EPDS > 12). PPD screening data was complete in 78.3% (18/23). No differences were observed for any adverse effect outcomes except for fewer incidences of intraoperative shivering with ketamine (SC: 25%, IV: 0% and Placebo: 85.7%, p = 0.01). No statistically significant difference in positive screening for PPD was observed (SC: 14.3%, IV: 50% and Placebo: 42.9%, p = 0.58). Conclusion: An RCT was judged to be feasible and there was no evidence of intolerability of either route of ketamine administration. Dispensing with the need for intravenous access makes the subcutaneous route a particularly attractive option for use in the postpartum population. Further examination of these interventions to prevent, and possibly treat, postpartum depression is warranted. Trial registration: NCT04227704, January 14^th, 2020.

Objective To characterize the lived experiences of stress associated with having a preterm infant hospitalized in the NICU among Black and Hispanic mothers. Methods We performed a qualitative content analysis of secondary data from two prior studies that included 39 in-depth interviews with Black and Hispanic mothers of preterm infants at 3 U.S. NICUs. We used a constant comparative method to select important concepts and to develop codes and subsequent themes. Results Black and Hispanic mothers described stressors in the following domains and categories: Individual (feeling overwhelmed, postpartum medical complications, previous stressful life events, competing priorities); Hospital (perceived poor quality of care, provider communication issues, logistical issues); Community (lack of social supports, lack of financial resources, work challenges). Conclusions The findings of this study suggest that stressors both inside and outside of the hospital affect the lived experiences of stress by Black and Hispanic mothers during NICU hospitalization.