Anne M. Mullin

Introduction: Individuals with preterm birth (PTB) are less likely to attend postpartum visits compared to those with term birth but are more likely to have conditions such as hypertensive disorders. PTB can be classified as spontaneous PTB (sPTB) (premature rupture of membranes or preterm labor) and medically indicated PTB (mPTB) (clinician‐initiated due to maternal or fetal conditions). We compared postpartum visit attendance after sPTB and mPTB to term birth. We hypothesized that sPTB and mPTB would be associated with increased risk of not attending postpartum visits compared to term, but risk would be higher after sPTB as mPTB is more often preceded by chronic conditions requiring more healthcare engagement. Methods: We performed a retrospective cohort study of births from 2008 to 2019 in GeoBirth , a curated dataset of singleton births in two hospitals in Philadelphia, PA. Two blinded reviewers manually classified each PTB as sPTB or mPTB. We performed bivariate analyses and mixed‐effects, multivariable, modified Poisson regression models to calculate risk ratios (RRs) of no postpartum visit after sPTB and mPTB compared to term birth. Models were adjusted for age, parity, hospital, insurance, education, race and ethnicity, cesarean birth, body mass index, diabetes, and hypertension. A linear combination test compared RRs between PTB subtypes. Results: Of the 69,110 included births, 3464 (5.0%) were sPTB and 2755 (4.0%) were mPTB. There were 693 (1.0%) excluded as unclassifiable PTBs. Overall, 37.2% of births had no postpartum visit within 12 weeks, with higher proportions after sPTB (46.5%) and mPTB (42.8%) than term birth (36.4%) ( p < 0.001). Compared to term birth, the unadjusted risk of no postpartum care was higher after sPTB (RR, 1.28; 95% confidence interval [CI], 1.23–1.33) than mPTB (RR, 1.18; 95% CI, 1.12–1.23) ( p value comparing RRs = 0.004). In a model including all covariates, risk was similarly elevated for both sPTB (aRR, 1.14; 95% CI, 1.11–1.19) and mPTB (aRR, 1.15; 95% CI, 1.10–1.21) ( p value comparing RRs = 0.78). Conclusion: Individuals with both sPTB and mPTB are at higher risk of not attending postpartum visits compared to term births. Innovative, collaborative, multidisciplinary efforts are essential to meet the needs of this vulnerable population to ensure postpartum healthcare.

Preterm birth (PTB) remains a key public health issue that disproportionately affects Black individuals. Since spontaneous PTB (sPTB) and medically indicated PTB (mPTB) may have different causes and interventions, we quantified racial disparities for sPTB and mPTB, and we characterized the geographic patterning of these phenotypes, overall and according to race/ethnicity. We examined a pregnancy cohort of 83,952 singleton births at 2 Philadelphia hospitals from 2008–2020, and classified each PTB as sPTB or mPTB. We used binomial regression to quantify the magnitude of racial disparities between non-Hispanic Black and non-Hispanic White individuals, then generated small area estimates by applying a Bayesian model that accounts for small numbers and smooths estimates of PTB risk by borrowing information from neighboring areas. Racial disparities in both sPTB and mPTB were significant (relative risk of sPTB = 1.83, 95% confidence interval: 1.70, 1.98; relative risk of mPTB = 2.20, 95% confidence interval: 2.00, 2.42). The disparity was 20% greater in mPTB than sPTB. There was substantial geographic variation in PTB, sPTB, and mPTB risks and racial disparity. Our findings underscore the importance of distinguishing PTB phenotypes within the context of public health and preventive medicine. Future work should consider social and environmental exposures that may explain geographic differences in PTB risk and disparities.

Objective: There is mounting evidence that neighborhoods contribute to perinatal health inequity. We aimed (1) to determine whether neighborhood deprivation (a composite marker of area-level poverty, education, and housing) is associated with early pregnancy impaired glucose intolerance (IGT) and pre-pregnancy obesity and (2) to quantify the extent to which neighborhood deprivation may explain racial disparities in IGT and obesity. Study Design: This was a retrospective cohort study of non-diabetic patients with singleton births ≥ 20 weeks’ gestation from 1 January 2017–31 December 2019 in two Philadelphia hospitals. The primary outcome was IGT (HbA1c 5.7–6.4%) at p < 0.0001). Mean (SD) neighborhood deprivation was higher among Black (0.55 (0.10)) compared with White patients (0.36 (0.11)) (p < 0.0001). Neighborhood deprivation was associated with IGT and obesity in models adjusted for age, insurance, parity, and race (aOR 1.15, 95%CI: 1.07, 1.24 and aOR 1.39, 95%CI: 1.28, 1.52, respectively). Mediation analysis revealed that 6.7% (95%CI: 1.6%, 11.7%) of the Black-White disparity in IGT might be explained by neighborhood deprivation and 13.3% (95%CI: 10.7%, 16.7%) by obesity. Mediation analysis also suggested that 17.4% (95%CI: 12.0%, 22.4%) of the Black–White disparity in obesity may be explained by neighborhood deprivation. Conclusion: Neighborhood deprivation may contribute to early pregnancy IGT and obesity–surrogate markers of periconceptional metabolic health in which there are large racial disparities. Investing in neighborhoods where Black patients live may improve perinatal health equity.

A total of one in ten infants is born preterm in the U.S. with large racial disparities. Recent data suggest that neighborhood exposures may play a role. Walkability—how easily individuals can walk to amenities–may encourage physical activity. We hypothesized that walkability would be associated with a decreased risk of preterm birth (PTB) and that associations would vary by PTB phenotype. PTB can be spontaneous (sPTB) from conditions such as preterm labor and preterm premature rupture of membranes, or medically indicated (mPTB) from conditions such as poor fetal growth and preeclampsia. We analyzed associations of neighborhood walkability (quantified by their Walk Score^® ranking) with sPTB and mPTB in a Philadelphia birth cohort (n = 19,203). Given racial residential segregation, we also examined associations in race-stratified models. Walkability (per 10 points of Walk Score ranking) was associated with decreased odds of mPTB (aOR 0.90, 95% CI: 0.83, 0.98), but not sPTB (aOR 1.04, 95% CI: 0.97, 1.12). Walkability was not protective for mPTB for all patients; there was a non-significant protective effect for White (aOR 0.87, 95% CI: 0.75, 1.01), but not Black patients (aOR 1.05, 95% CI: 0.92, 1.21) (interaction p = 0.03). Measuring health effects of neighborhood characteristics across populations is key for urban planning efforts focused on health equity.

Infants born preterm are at risk of neonatal morbidity and mortality. Preterm birth (PTB) can be categorized as either spontaneous (sPTB) or medically indicated (mPTB), resulting from distinct pathophysiologic processes such as preterm labor or preeclampsia, respectively. A growing body of literature has demonstrated the impacts of nitrogen dioxide (NO₂) and benzene exposure on PTB, though few studies have investigated how these associations may differ by PTB subtype. We investigated the associations of NO₂ and benzene exposure with sPTB and mPTB among 18,616 singleton live births at two Philadelphia hospitals between 2013 and 2017. Residential NO₂ exposure was estimated using a land use regression model and averaged over the patient’s full pregnancy. Benzene exposure was estimated at the census tract level using National Air Toxics Assessment (NATA) exposure data from 2014. We used logistic mixed-effects models to calculate odds ratios for overall PTB, sPTB, and mPTB separately, adjusting for patient- and tract-level confounders. Given the known racial segregation and PTB disparities in Philadelphia, we also examined race-stratified models. Counter to the hypothesis, neither NO₂ nor benzene exposure differed by race, and neither were significantly associated with PTB or PTB subtypes. As such, these pollutants do not appear to explain the racial disparities in PTB in this setting.

Objective We aimed to determine whether coronavirus-disease-2019 (COVID-19) pandemic exposure duration was associated with PTB and if the pandemic modified racial disparities. Study design We analyzed Philadelphia births and replicated in New Haven. Compared to matched months in two prior years, we analyzed overall PTB, specific PTB phenotypes, and stillbirth. Results Overall, PTB was similar between periods with the following exceptions. Compared to pre-pandemic, early pregnancy (p = 0.04). PTB < 32 weeks’ among White patients decreased during the pandemic, resulting in non-significant widening of the Black-White disparity from aRR 2.51 (95%CI: 1.53–4.16) to aRR 4.07 (95%CI: 1.56–12.01) (interaction P = 0.41). No findings replicated in New Haven. Conclusion We detected no overall pandemic effects on PTB, but potential indirect benefits for some patients which could widen disparities remains possible.

Background. Antibody-based strategies for COVID-19 have shown promise in prevention and treatment of early disease. COVID-19 convalescent plasma (CCP) has been widely used but results from randomized trials supporting its benefit in hospitalized patients with pneumonia are limited. Here, we assess the efficacy of CCP in severely ill, hospitalized adults with COVID-19 pneumonia. Methods. We performed a randomized control trial (PennCCP2), with 80 adults hospitalized with COVID-19 pneumonia, comparing up to 2 units of locally sourced CCP plus standard care versus standard care alone. The primary efficacy endpoint was comparison of a clinical severity score. Key secondary outcomes include 14- and 28-day mortality, 14- and 28-day maximum 8-point WHO ordinal score (WHO8) score, duration of supplemental oxygenation or mechanical ventilation, respiratory SARS-CoV-2 RNA, and anti–SARS-CoV-2 antibodies. Results. Eighty hospitalized adults with confirmed COVID-19 pneumonia were enrolled at median day 6 of symptoms and day 1 of hospitalization; 60% were anti–SARS-CoV-2 antibody seronegative. Participants had a median of 3 comorbidities, including risk factors for severe COVID-19 and immunosuppression. CCP treatment was safe and conferred significant benefit by clinical severity score (median [MED] and interquartile range [IQR] 10 [5.5–30] vs. 7 [2.75–12.25], P = 0.037) and 28-day mortality (n = 10, 26% vs. n = 2, 5%; P = 0.013). All other prespecified outcome measures showed weak evidence toward benefit of CCP. Conclusion. Two units of locally sourced CCP administered early in hospitalization to majority seronegative participants conferred a significant benefit in clinical severity score and 28-day mortality. Results suggest CCP may benefit select populations, especially those with comorbidities who are treated early. Trial Registration. ClinicalTrials.gov NCT04397757. Funding. University of Pennsylvania.