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An Expanded Obstetric Comorbidity Scoring System for Predicting Severe Maternal Morbidity. Obstetrics and gynecology Leonard, S. A., Kennedy, C. J., Carmichael, S. L., Lyell, D. J., Main, E. K. 2020
Abstract

OBJECTIVE: To develop and validate an expanded obstetric comorbidity score for predicting severe maternal morbidity that can be applied consistently across contemporary U.S. patient discharge data sets.METHODS: Discharge data from birth hospitalizations in California during 2016-2017 were used to develop the score. The outcomes were severe maternal morbidity, defined using the Centers for Disease Control and Prevention index, and nontransfusion severe maternal morbidity (excluding cases where transfusion was the only indicator of severe maternal morbidity). We selected 27 potential patient-level risk factors for severe maternal morbidity, identified using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used a targeted causal inference approach integrated with machine learning to rank the risk factors based on adjusted risk ratios (aRRs). We used these results to assign scores to each comorbidity, which sum to a single numeric score. We validated the score in California and national data sets and compared the performance to that of a previously developed obstetric comorbidity index.RESULTS: Among 919,546 births, the rates of severe maternal morbidity and nontransfusion severe maternal morbidity were 168 and 74 per 10,000 births, respectively. The highest risk comorbidity was placenta accreta spectrum (aRR of 30.5 for severe maternal morbidity and 54.7 for nontransfusion severe maternal morbidity) and the lowest was gestational diabetes mellitus (aRR of 1.06 for severe maternal morbidity and 1.12 for nontransfusion severe maternal morbidity). Normalized scores based on the aRR were developed for each comorbidity, which ranged from 1 to 59 points for severe maternal morbidity and from 1 to 36 points for nontransfusion severe maternal morbidity. The overall performance of the expanded comorbidity scores was good (C-statistics were 0.78 for severe maternal morbidity and 0.84 for nontransfusion severe maternal morbidity in California data and 0.82 and 0.87, respectively, in national data) and improved on prior comorbidity indices developed for obstetric populations. Calibration plots showed good concordance between predicted and actual risks of the outcomes.CONCLUSION: We developed and validated an expanded obstetric comorbidity score to improve comparisons of severe maternal morbidity rates across patient populations with different comorbidity case mixes.

View details for DOI 10.1097/AOG.0000000000004022

View details for PubMedID 32769656
Weight gain during pregnancy and the risk of severe maternal morbidity by prepregnancy BMI. The American journal of clinical nutrition Leonard, S. A., Abrams, B., Main, E. K., Lyell, D. J., Carmichael, S. L. 2020
Abstract

BACKGROUND: High and low prepregnancy BMI are risk factors for severe maternal morbidity (SMM), but the contribution of gestational weight gain (GWG) is not well understood.OBJECTIVES: We evaluated associations between GWG and SMM by prepregnancy BMI group.METHODS: We analyzed administrative records from 2,483,684 Californian births (2007-2012), utilizing z score charts to standardize GWG for gestational duration. We fit the z scores nonlinearly and categorized GWG as above, within, or below the Institute of Medicine (IOM) recommendations after predicting equivalent GWG at term from the z score charts. SMM was defined using a validated index. Associations were estimated using multivariable logistic regression models.RESULTS: We found generally shallow U-shaped relations between GWG z score and SMM in all BMI groups, except class 3 obesity (?40kg/m2), for which risk was lowest with weight loss. The weight gain amount associated with the lowest risk of SMM was within the IOM recommendations for underweight and class 2 obesity, but above the IOM recommendations for normal weight, overweight, and class 1 obesity. The adjusted risk ratios (RRs) and 95% CIs for GWG below the IOM recommendations, compared with GWG within the recommendations, were the following for underweight, normal weight, overweight, class 1 obesity, class 2 obesity, and class 3 obesity: 1.13 (0.99, 1.29), 1.09 (1.04, 1.14), 1.10 (1.01, 1.19), 1.07 (0.95, 1.21), 1.03 (0.88, 1.22), and 0.89 (0.73, 1.08), respectively. For GWG above the recommendations, the corresponding RRs and 95% CIs were 0.99 (0.84, 1.15), 1.04 (0.99, 1.08), 0.98 (0.92, 1.04), 1.03 (0.95, 1.13), 1.07 (0.94, 1.23), and 1.08 (0.91, 1.30), respectively.CONCLUSIONS: High and low GWG may be modestly associated with increased risk of SMM across BMI groups, except in women with class 3 obesity, for whom low weight gain and weight loss may be associated with decreased risk of SMM.

View details for DOI 10.1093/ajcn/nqaa033

View details for PubMedID 32119734
Racial and ethnic disparities in severe maternal morbidity prevalence and trends. Annals of epidemiology Leonard, S. A., Main, E. K., Scott, K. A., Profit, J., Carmichael, S. L. 2019
Abstract

Racial/ethnic disparities in severe maternal morbidity (SMM) are substantial, but little is known about whether these disparities are changing over time or the role of maternal and obstetric factors.We examined disparities in SMM prevalence and trends using linked birth certificate and delivery discharge records from Californian births during 1997-2014 (n�=�8,252,025).The prevalence of SMM was highest in non-Hispanic (NH) Black women (1.63%), lowest in NH White women (0.84%), and increased from 1997 to 2014 by approximately 170% in each racial/ethnic group. The magnitude of SMM disparities remained consistent over time. Compared with NH White women, the adjusted risk of SMM was higher in women who identified as Hispanic (RR 1.14; 95% CI 1.12, 1.16), Asian/Pacific Islander (RR 1.23; 95% CI 1.20, 1.26), NH Black (RR 1.27; 95% CI 1.23, 1.31), and American Indian/Alaska Native (RR 1.29; 95% CI 1.15, 1.44), accounting for comorbidities, anemia, cesarean birth, and other maternal characteristics.The prevalence of SMM varied considerably by race/ethnicity but increased at similarly high rates among all racial/ethnic groups. Comorbidities, cesarean birth, and other factors did not fully explain the disparities in SMM, which remained persistent over time.

View details for PubMedID 30928320
Risk of severe maternal morbidity in relation to prepregnancy body mass index: Roles of maternal co-morbidities and caesarean birth. Paediatric and perinatal epidemiology Leonard, S. A., Carmichael, S. L., Main, E. K., Lyell, D. J., Abrams, B. 2019
Abstract

An association between prepregnancy body mass index (BMI) and severe maternal morbidity (SMM) has been reported, but evidence has been mixed and potential explanations have not been examined.To evaluate the association between prepregnancy BMI and SMM in a large, diverse birth cohort and assess potential mediation by obesity-related co-morbidities and caesarean birth.This cohort study used linked birth certificate and hospitalisation discharge records from Californian births during 2007-2012. We assessed associations between prepregnancy BMI and SMM, and used inverse probability weighting for multiple mediators to estimate relative and absolute natural direct and indirect effects accounting for mediation by co-morbidities (hypertensive conditions, diabetes, asthma) and caesarean birth.Among 2�650�182 births, the prevalence of SMM was 1.42%. Adjusted risk ratios for the total association between prepregnancy BMI category and SMM were 1.12 (95% confidence interval [CI] 1.07, 1.18) for underweight, 1.02 (95% CI 0.99, 1.04) for overweight, 1.04 (95% CI 1.00, 1.07) for obesity class 1, 1.14 (95% CI 1.09, 1.20) for obesity class 2, and 1.28 (95% CI 1.22, 1.36) for obesity class 3 compared to women with normal weight. After accounting for mediation by co-morbidity and caesarean birth, the risk ratios were 1.19 (95% CI 1.14, 1.26) for underweight, 0.91 (95% CI 0.89, 0.94) for overweight, 0.86 (95% CI 0.84, 0.89) for obesity class 1, 0.88 (95% CI 0.84, 0.92) for obesity class 2, and 0.89 (95% CI 0.83, 0.95) for obesity class 3.Co-morbidities and caesarean birth explained an association between high prepregnancy BMI and SMM. These findings suggest that promotion of healthy prepregnancy weight, along with management of co-morbidities and support of vaginal birth in pregnant women with high BMI, could reduce the risk of SMM. However, these mediators did not reduce the elevated risk of SMM observed in women with low BMI.

View details for DOI 10.1111/ppe.12555

View details for PubMedID 31106879
The contribution of maternal characteristics and cesarean delivery to an increasing trend of severe maternal morbidity. BMC pregnancy and childbirth Leonard, S. A., Main, E. K., Carmichael, S. L. 2019; 19 (1): 16
Abstract

Severe maternal morbidity - life-threatening childbirth complications - has more than doubled in the United States over the past 15?years, affecting more than 50,000 women (1.4% of deliveries) annually. During this time period, maternal age, obesity, comorbidities, and cesarean delivery also increased and may be related to the rise in severe maternal morbidity. We sought to evaluate: (1) the association of advanced maternal age, pre-pregnancy obesity, pre-pregnancy comorbidities, and cesarean delivery with severe maternal morbidity, and (2) whether changes in the prevalence of these risk factors affected the trend of severe maternal morbidity.This population-based cohort study used linked birth record and patient discharge data from live births in California during 2007-2014 (n?=?3,556,206). We used multivariable logistic regression models to assess the association of advanced maternal age (?35?years), pre-pregnancy obesity (body mass index ?30?kg/m2), pre-pregnancy comorbidity (index of 12 conditions), and cesarean delivery with severe maternal morbidity prevalence and trends. Severe maternal morbidity was identified by an index of 18 diagnosis and procedure indicators. We estimated odds ratios, predicted prevalence, and population attributable risk percentages.The prevalence of severe maternal morbidity increased by 65% during 2007-2014. Advanced maternal age, pre-pregnancy obesity, and pre-pregnancy comorbidity also increased during this period, but cesarean delivery did not. None of these risk factors affected the increasing trend of severe maternal morbidity. However, the pre-pregnancy risk factors together were estimated to contribute to 13% (95% confidence interval: 12, 14%) of severe maternal morbidity cases in the study population overall, and cesarean delivery was estimated to contribute to 37% (95% confidence interval: 36, 38%) of cases.Pre-pregnancy health and cesarean delivery are important risk factors for severe maternal morbidity but do not explain an increasing trend of severe maternal morbidity in California during 2007-2014. Investigation of other potential contributors is needed in order to identify ways to reverse the trend of severe maternal morbidity.

View details for PubMedID 30626349
Maternal History of Child Abuse and Obesity Risk in Offspring: Mediation by Weight in Pregnancy. Childhood obesity Leonard, S. A., Petito, L. C., Rehkopf, D. H., Ritchie, L. D., Abrams, B. 2017
Abstract

Women's experience of childhood adversity may contribute to their children's risk of obesity. Possible causal pathways include higher maternal weight and gestational weight gain, which have been associated with both maternal childhood adversity and obesity in offspring.This study included 6718 mother-child pairs from the National Longitudinal Survey of Youth 1979 in the United States (1979-2012). We applied multiple log-binomial regression models to estimate associations between three markers of childhood adversity (physical abuse, household alcoholism, and household mental illness) and offspring obesity in childhood. We estimated natural direct effects to evaluate mediation by prepregnancy BMI and gestational weight gain.Among every 100 mothers who reported physical abuse in childhood, there were 3.7 (95% confidence interval: -0.1 to 7.5) excess cases of obesity in 2- to 5-year olds compared with mothers who did not report physical abuse. Differences in prepregnancy BMI, but not gestational weight gain, accounted for 25.7% of these excess cases. There was no evidence of a similar relationship for household alcoholism or mental illness or for obesity in older children.In this national, prospective cohort study, prepregnancy BMI partially explained an association between maternal physical abuse in childhood and obesity in preschool-age children. These findings underscore the importance of life-course exposures in the etiology of child obesity and the potential multi-generational consequences of child abuse. Research is needed to determine whether screening for childhood abuse and treatment of its sequelae could strengthen efforts to prevent obesity in mothers and their children.

View details for DOI 10.1089/chi.2017.0019

View details for PubMedID 28440693
Trajectories of maternal weight from before pregnancy through postpartum and associations with childhood obesity. The American journal of clinical nutrition Leonard, S. A., Rasmussen, K. M., King, J. C., Abrams, B. 2017
Abstract

Background: Prepregnancy body mass index [BMI (in kg/m(2))], gestational weight gain, and postpartum weight retention may have distinct effects on the development of child obesity, but their combined effect is currently unknown.Objective: We described longitudinal trajectories of maternal weight from before pregnancy through the postpartum period and assessed the relations between maternal weight trajectories and offspring obesity in childhood.Design: We analyzed data from 4436 pairs of mothers and their children in the National Longitudinal Survey of Youth 1979 (1981-2014). We used latent-class growth modeling in addition to national recommendations for prepregnancy BMI, gestational weight gain, and postpartum weight retention to create maternal weight trajectory groups. We used modified Poisson regression models to assess the associations between maternal weight trajectory group and offspring obesity at 3 age periods (2-5, 6-11, and 12-19 y).Results: Our analysis using maternal weight trajectories based on either latent-class results or recommendations showed that the risk of child obesity was lowest in the lowest maternal weight trajectory group. The differences in obesity risk were largest after 5 y of age and persisted into adolescence. In the latent-class analysis, the highest-order maternal weight trajectory group consisted almost entirely of women who were obese before pregnancy and was associated with a >2-fold increase in the risk of offspring obesity at ages 6-11 y (adjusted RR: 2.39; 95% CI: 1.97, 2.89) and 12-19 y (adjusted RR: 2.74; 95% CI: 2.13, 3.52). In the analysis with maternal weight trajectory groups based on recommendations, the risk of child obesity was consistently highest for women who were overweight or obese at the beginning of pregnancy.Conclusion: These findings suggest that high maternal weight across the childbearing period increases the risk of obesity in offspring during childhood, but high prepregnancy BMI has a stronger influence than either gestational weight gain or postpartum weight retention.

View details for DOI 10.3945/ajcn.117.158683

View details for PubMedID 28877895
Gestational Weight Gain-for-Gestational Age Z-Score Charts Applied across U.S. Populations. Paediatric and perinatal epidemiology Leonard, S. A., Hutcheon, J. A., Bodnar, L. M., Petito, L. C., Abrams, B. 2017
Abstract

Gestational weight gain may be a modifiable contributor to infant health outcomes, but the effect of gestational duration on gestational weight gain has limited the identification of optimal weight gain ranges. Recently developed z-score and percentile charts can be used to classify gestational weight gain independent of gestational duration. However, racial/ethnic variation in gestational weight gain and the possibility that optimal weight gain differs among racial/ethnic groups could affect generalizability of the z-score charts. The objectives of this study were (1) to apply the weight gain z-score charts in two different U.S. populations as an assessment of generalisability and (2) to determine whether race/ethnicity modifies the weight gain range associated with minimal risk of preterm birth.The study sample included over 4 million live, singleton births in California (2007-2012) and Pennsylvania (2003-2013). We implemented a noninferiority margin approach in stratified subgroups to determine weight gain ranges for which the adjusted predicted marginal risk of preterm birth (gestation <37�weeks) was within 1 or 2 percentage points of the lowest observed risk.There were minimal differences in the optimal ranges of gestational weight gain between California and Pennsylvania births, and among several racial/ethnic groups in California. The optimal ranges decreased as severity of prepregnancy obesity increased in all groups.The findings support the use of weight gain z-score charts for studying gestational age-dependent outcomes in diverse U.S. populations and do not support weight gain recommendations tailored to race/ethnicity.

View details for DOI 10.1111/ppe.12435

View details for PubMedID 29281119
Weight gain during pregnancy and the black-white disparity in preterm birth. Annals of epidemiology Leonard, S. A., Petito, L. C., Stephansson, O., Hutcheon, J. A., Bodnar, L. M., Mujahid, M. S., Cheng, Y., Abrams, B. 2017; 27 (5): 323?28.e1
Abstract

To quantify the relationship between pregnancy weight gain with early and late preterm birth and evaluate whether associations differed between non-Hispanic (NH) black and NH white women.We analyzed a retrospective cohort of all live births to NH black and NH white women in the United States 2011-2015 (n�=�10,714,983). We used weight gain z-scores in multiple logistic regression models stratified by prepregnancy body mass index (BMI) and race to calculate population attributable risk (PAR) percentages for the contribution of high and low pregnancy weight gain to early and late preterm birth.Pregnancy weight gain was related to early and late preterm birth, but associations varied by BMI and race. For early preterm birth, the PAR percentage for high pregnancy weight gain ranged from 8 to 10% in NH black women and from 6 to 8% in NH white women. There was little evidence of racial differences in late preterm birth: PAR percentages ranged from 2 to 7% in NH black women and from 3 to 7% in NH white women.Moderate gestational weight gain is associated with lower rate of preterm birth, with greatest reductions for early preterm birth in NH black women.

View details for DOI 10.1016/j.annepidem.2017.05.001

View details for PubMedID 28595737
Weight gain in pregnancy and child weight status from birth to adulthood in the United States. Pediatric obesity Leonard, S. A., Petito, L. C., Rehkopf, D. H., Ritchie, L. D., Abrams, B. 2016
Abstract

High weight gain in pregnancy has been associated with child adiposity, but few studies have assessed the relationship across childhood or in racially/ethnically diverse populations.The objectives of the study are to test if weight gain in pregnancy is associated with high birthweight and overweight/obesity in early, middle and late childhood and whether these associations differ by maternal race/ethnicity.Mother-child dyads (n = 7539) were included from the National Longitudinal Survey of Youth 1979, a nationally representative cohort study in the USA (1979-2012). Log-binomial regression models were used to analyse associations between weight gain and the outcomes: high birthweight (>4000?g) and overweight/obesity at ages 2-5, 6-11 and 12-19?years.Excessive weight gain was positively associated, and inadequate weight gain was negatively associated with high birthweight after confounder adjustment (P?
View details for DOI 10.1111/ijpo.12163

View details for PubMedID 27350375

View details for PubMedCentralID PMC5404997
Prepregnancy Risk Factors for Preterm Birth and the Role of Maternal Nativity in a Low-Income, Hispanic Population MATERNAL AND CHILD HEALTH JOURNAL Leonard, S. A., Crespi, C. M., Gee, D. C., Zhu, Y., Whaley, S. E. 2015; 19 (10): 2295-2302
Abstract

The aim of this study was to assess potential prepregnancy risk factors for preterm birth in a low-income, Hispanic population in Southern California. Additionally, the study assessed whether the prevalence of preterm birth and any associations between risk factors and preterm birth differed between U.S.- and foreign-born mothers.The study sample included 1174 mothers participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) within 1 year postpartum, including an augment sample of mothers who delivered preterm. Maternal sociodemographic traits, prepregnancy health-related characteristics and behaviors, and birth outcomes were collected by telephone survey. Odds ratios for associations between risk factors and preterm birth were estimated by logistic regression with sampling weights. Effect measure modification of any association by maternal nativity was also assessed using interaction terms.After adjustment for confounding, significant prepregnancy risk factors for preterm birth included maternal age ?35 years (OR 2.00; 95 % CI 1.04, 3.84) compared to age 18-24 years, and experience of a financially stressful life event among U.S.-born, but not foreign-born, women (OR 2.61; 95 % CI 1.43, 4.77). The weighted prevalence of preterm birth was 15.1 % and did not significantly differ by maternal nativity (P = 0.19).Further investigation with large, prospective studies is needed to better understand the risk factors for and disparities in preterm birth among the growing Hispanic population in the U.S. so that women who are at risk prepregnancy can be identified and provided risk-specific services.

View details for DOI 10.1007/s10995-015-1748-4

View details for Web of Science ID 000361625100023

View details for PubMedID 25994418

View details for PubMedCentralID PMC4575879
Associations Between Preterm Birth, Low Birth Weight, and Postpartum Health in a Predominantly Hispanic WIC Population JOURNAL OF NUTRITION EDUCATION AND BEHAVIOR Leonard, S. A., Gee, D., Zhu, Y., Crespi, C. M., Whaley, S. E. 2014; 46 (6): 499-505
Abstract

To describe the postpartum health of predominantly Hispanic participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and identify how health characteristics differ between mothers who delivered preterm or low birth weight infants and those who did not.Cross-sectional survey among postpartum WIC mothers.Los Angeles and Orange Counties, CA.WIC participants within 1�year of delivery (n�=�1,420).Postpartum health behaviors, health characteristics, and birth spacing intentions and behaviors.Frequencies of health characteristics were estimated using analyses with sample weights. Differences were assessed with chi-square and Fisher exact tests with Bonferroni correction for pairs of tests.Many women exhibited postpartum risk factors for future adverse health events, including overweight or obesity (62.3%), depressive symptoms (27.5%), and no folic acid supplementation (65.5%). Most characteristics did not differ significantly (P�>�.025) between mothers of preterm infants and full-term infants or between mothers of low birth weight and normal birth weight infants.Despite few differences between postpartum characteristics of mothers who delivered preterm or low birth weight infants and those who did not, a high percentage of mothers had risk factors that need to be addressed. Current postpartum educational activities of WIC programs should be evaluated and shared.

View details for DOI 10.1016/j.jneb.2014.06.008

View details for Web of Science ID 000345000500010

View details for PubMedID 25092236

View details for PubMedCentralID PMC4252510
Larger Infant Size at Birth Reduces the Negative Association between Maternal Prepregnancy Body Mass Index and Breastfeeding Duration JOURNAL OF NUTRITION Leonard, S. A., Rasmussen, K. M. 2011; 141 (4): 645-653
Abstract

Women who are overweight or obese prepregnancy have shorter durations of producing milk (PM) and feeding breast milk exclusively (FBM-ex) than normal-weight women. We proposed that infant size at birth may reduce the negative associations between prepregnancy BMI and the durations of PM and FBM-ex. We used data from 2798 participants in the Infant Feeding Practices Study II and characterized infant size at birth as weight-for-gestational age (WGA). To assess possible mediation of the associations between maternal BMI and the durations of PM and FBM-ex by infant size at birth, Baron and Kenny's methods, the Sobel test, and bootstrapping were used. As expected, prepregnancy BMI was negatively associated (P < 0.0001) with the durations of PM and FBM-ex; it also was positively associated (P < 0.0001) with infant size at birth. However, infant WGA was positively associated (P < 0.0003) with the durations of PM and FBM-ex after adjustment for BMI. Thus, the negative associations between BMI and the durations of PM and FBM-ex were reduced by infant WGA; i.e. the statistical removal of infant size at birth increased the magnitude of the negative associations between BMI and the durations of PM and FBM-ex. Thus, the tendency of heavier mothers to deliver heavier infants reduces the true magnitude of the association between maternal prepregnancy BMI and shortened breastfeeding duration.

View details for DOI 10.3945/jn.110.129874

View details for Web of Science ID 000288876800016

View details for PubMedID 21346096
Associations between high prepregnancy body mass index, breast-milk expression, and breast-milk production and feeding AMERICAN JOURNAL OF CLINICAL NUTRITION Leonard, S. A., Labiner-Wolfe, J., Geraghty, S. R., Rasmussen, K. M. 2011; 93 (3): 556-563
Abstract

Breast-milk expression is widely practiced by American mothers, but little is known about who expresses milk, how expression affects breastfeeding, or whether overweight or obese women, who have less breastfeeding success than do normal-weight women, express milk differently.We investigated 1) whether breast-milk expression behavior differed by body mass index (BMI; in kg/m(2)) category and 2) whether the different breastfeeding behaviors of overweight (BMI: ?25 and <30) and obese (BMI: ?30) women resulted in different breastfeeding outcomes.The subjects (n = 2288) provided information on BMI and breast-milk production, feeding, and expression in mail-in questionnaires as part of the Infant Feeding Practices Study II. Longitudinal and cross-sectional data were analyzed by using regression procedures adjusted for confounding.Women of different BMI categories overall did not differ in whether, when, or why they expressed breast milk. Before 2 mo postpartum, however, obese women were more likely (P = 0.04, unadjusted) to try milk expression and were less likely (P = 0.01, unadjusted) to express milk successfully. In addition, overweight or obesity was associated (P < 0.03, unadjusted) with a shorter duration of breast-milk production only in women who never expressed milk. In overweight or obese women, those who ever expressed milk had longer durations of breastfeeding (P < 0.003, unadjusted) than did those who never expressed milk.Breast-milk expression behaviors may differ by maternal BMI category only in the early postpartum period. In addition, breast-milk expression may reduce differences between BMI categories in the duration of breastfeeding and support longer durations of breastfeeding.

View details for DOI 10.3945/ajcn.110.002352

View details for Web of Science ID 000287475000014

View details for PubMedID 21209224
Birth Hospital and Racial/Ethnic Differences in Severe Maternal Morbidity in the State of California. American journal of obstetrics and gynecology Mujahid, M. S., Kan, P., Leonard, S. A., Hailu, E. M., Wall-Wieler, E., Abrams, B., Main, E., Profit, J., Carmichael, S. L. 2020
Abstract

BACKGROUND: Birth hospital has recently emerged as a potentially key contributor to disparities in severe maternal morbidity, but investigations remain limited.OBJECTIVES: We leveraged state-wide data from California to examine whether birth hospital explained racial/ethnic differences in severe maternal morbidity.METHODS: This cohort study used data on all births ?20 weeks in California (2007-2012). Severe maternal morbidity during birth hospitalization was measured using the Centers for Disease Control and Prevention index of having at least one of 21 diagnoses and procedures (e.g. eclampsia, blood transfusion, hysterectomy). Mixed effects logistic regression models (i.e. women nested within hospitals) were used to compare racial/ethnic differences in severe maternal morbidity before and after adjustment for maternal sociodemographic and pregnancy-related factors, co-morbidities, and hospital characteristics. We also estimated risk-standardized severe maternal morbidity rates for each hospital (N=245) and the percent reduction in severe maternal morbidity if each group of racially/ethnically minoritized women gave birth at the same distribution of hospitals as non-Hispanic White women.RESULTS: Of the 3,020,525 women who gave birth, 39,192 (1.3%) had severe maternal morbidity (2.1% Black; 1.3% US-born Hispanic; 1.3% foreign-born Hispanic; 1.3% Asian/Pacific Islander; 1.1% White; 1.6% American Indian/Alaska Native and Mixed Race referred to as "Other"). Risk-standardized rates of severe maternal morbidity ranged from 0.3 to 4.0 per 100 births across hospitals. After adjusting for covariates, odds of severe maternal morbidity was greater among non-White women compared to Whites in a given hospital (Odds Ratios and 95% Confidence Intervals; Black =1.25 (1.19-1.31), US-born Hispanic=1.25 (1.20-1.29), Foreign-born Hispanic=1.17 (1.11-1.24), Asian/Pacific Islander=1.26 (1.21-1.32), "Other"=1.31 (1.15-1.50). Among the studied hospital factors, only teaching status was associated with severe maternal morbidity in fully adjusted models. Although 33% of White women delivered in hospitals with the highest tertile of severe maternal morbidity rates compared to 53% of Black women, birth hospital only accounted for 7.8% of the differences in severe maternal morbidity comparing Black and White women and accounted for 16.1-24.2% of the differences for all other racial/ethnic groups.CONCLUSION: In California, excess odds of severe maternal morbidity among racially/ethnically minoritized women was not fully explained by birth hospital. Structural causes of racial/ethnic disparities in severe maternal morbidity may vary by region, which warrants further examination to inform effective policies.

View details for DOI 10.1016/j.ajog.2020.08.017

View details for PubMedID 32798461
Cellular Aging in Pregnancy: Telomere Dynamics Across Gestation. Panelli, D. M., Leonard, S. A., Wong, R. J., Girsen, A. I., Baskovic, M., Stevenson, D. K., Bianco, K. SPRINGER HEIDELBERG. 2020: 127A?128A
View details for Web of Science ID 000525432600181
Postpartum Depression Among Women with Cardiac Disease: Considerations During the Delivery Admission Panelli, D., Sherwin, E. B., Lee, C. J., Suharwardy, S., Miller, H. E., Tolani, A. T., Girsen, A. I., Leonard, S. A., Warshawsky, S., Judy, A., Khandel-Wal, A., Bianco, Y. K. SPRINGER HEIDELBERG. 2020: 246A
View details for Web of Science ID 000525432601113
Vaginal progesterone treatment is associated with intrahepatic cholestasis of pregnancy Tsur, A., Kan, P., Datoc, I., Leonard, S. A., Girsen, A., Shaw, G. M., Stevenson, D. K., El-Sayed, Y. Y., Druzin, M. L., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2020: S58?S59
View details for DOI 10.1016/j.ajog.2019.11.084

View details for Web of Science ID 000504997300069
Pre-pregnancy Obesity and the Risk of Peripartum Cardiomyopathy. American journal of perinatology Cho, S. H., Leonard, S. A., Lyndon, A., Main, E. K., Abrams, B., Hameed, A. B., Carmichael, S. L. 2020
Abstract

?The aim of this study is to evaluate the contribution of pre-pregnancy obesity and overweight to peripartum cardiomyopathy.?This population-based study used linked birth record and maternal hospital discharge data from live births in California during 2007 to 2012 (n?=?2,548,380). All women who had a diagnosis of peripartum cardiomyopathy during the childbirth hospitalization or who were diagnosed with peripartum cardiomyopathy during a postpartum hospital readmission within 5 months of birth were identified as cases. Pre-pregnancy body mass index (BMI, kg/m2) was classified as normal weight (18.5-24.9), overweight (25.0-29.9), obesity class 1 (30.0-34.9), obesity class 2 (35.0-39.9), and obesity class 3 (?40). Because of small numbers, we excluded women with underweight BMI, and in some analyses, we combined obesity classes into one group. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) expressing associations between BMI and peripartum cardiomyopathy, adjusted for maternal age, race/ethnicity, education, health care payer, parity, plurality, and comorbidities.?The overall prevalence of peripartum cardiomyopathy during hospital admissions was 1.3 per 10,000 live births (n?=?320). Unadjusted ORs were 1.32 (95% CI: 1.01-1.74) for women with overweight BMI and 2.03 (95% CI: 1.57-2.62) for women with obesity, compared with women with normal pre-pregnancy BMI. Adjusted ORs were 1.26 (95% CI: 0.95-1.66) for overweight women and 1.38 (95% CI: 1.04-1.84) for women with obesity. The ORs suggested a dose-response relationship with increasing levels of obesity, but the 95% CIs for the specific classes of obesity included 1.00.?Pre-pregnancy obesity was associated with an increased risk of peripartum cardiomyopathy. These findings underscore the importance of BMI during pregnancy. There is a need to recognize the increased risk of peripartum cardiomyopathy in women with high BMI, especially in the late postpartum period.� Pre-pregnancy obesity affects maternal health.. � Effects may extend to peripartum cardiomyopathy.. � The risk includes peripartum cardiomyopathy that emerges postpartum..

View details for DOI 10.1055/s-0040-1712451

View details for PubMedID 32512606
Cervical insufficiency, cerclage, and early preterm birth: differences among racial/ethnic subgroups Miller, H. E., Suharwardy, S., Leonard, S. A., Girsen, A., Lyell, D. J. MOSBY-ELSEVIER. 2020: S540
View details for DOI 10.1016/j.ajog.2019.11.879

View details for Web of Science ID 000504997301190
Early postpartum readmissions or emergency department visits: Identifying risk factors Girsen, A., Leonard, S. A., Carmichael, S. L., Gibbs, R. S. MOSBY-ELSEVIER. 2020: S351?S352
View details for DOI 10.1016/j.ajog.2019.11.562

View details for Web of Science ID 000504997300545
Maternal genitourinary and wound infections: Early postpartum readmissions and emergency department visits Leonard, S. A., Girsen, A., Carmichael, S. L., Gibbs, R. S. MOSBY-ELSEVIER. 2020: S169
View details for DOI 10.1016/j.ajog.2019.11.261

View details for Web of Science ID 000504997300245
Effect of an automated conversational agent on postpartum mental health: A randomized, controlled trial Suharwardy, S., Ramachandran, M., Leonard, S. A., Gunaseelan, A., Robinson, A., Darcy, A., Lyell, D. J., Judy, A. MOSBY-ELSEVIER. 2020: S91
View details for DOI 10.1016/j.ajog.2019.11.132

View details for Web of Science ID 000504997300116
Acceptability of postnatal mood management through a smartphone-based automated conversational agent Ramachandran, M., Suharwardy, S., Leonard, S. A., Gunaseelan, A., Robinson, A., Darcy, A., Lyell, D. J., Judy, A. MOSBY-ELSEVIER. 2020: S62
View details for DOI 10.1016/j.ajog.2019.11.090

View details for Web of Science ID 000504997300075
Antepartum iron-deficiency anemia: An opportunity to reduce severe maternal morbidity Leonard, S. A., Main, E. K., Lyell, D. J., Butwick, A. J., Carmichael, S. L. MOSBY-ELSEVIER. 2020: S168?S169
View details for DOI 10.1016/j.ajog.2019.11.260

View details for Web of Science ID 000504997300244
Antepartum anemia and racial/ethnic disparities in blood transfusion in california Igbinosa, I., Leonard, S. A., Butwick, A. J., Lyell, D. J. MOSBY-ELSEVIER. 2020: S304
View details for DOI 10.1016/j.ajog.2019.11.480

View details for Web of Science ID 000504997300463
Comparing insulin, metformin, and glyburide in treating diabetes in pregnancy and analyzing obstetric outcomes Sperling, M., Bentley, J., Girsen, A., Leonard, S. A., Sherwin, E. B., Panelli, D. M., Suharwardy, S., El Sayed, Y., Herrero, T. MOSBY-ELSEVIER. 2020: S481
View details for DOI 10.1016/j.ajog.2019.11.773

View details for Web of Science ID 000504997301086
Sustaining the practice of operative vaginal delivery: Maternal and neonatal outcomes among a contemporary cohort Panelli, D. M., Leonard, S. A., Judy, A., El-Sayed, Y. Y., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2020: S568
View details for DOI 10.1016/j.ajog.2019.11.929

View details for Web of Science ID 000504997301240
Pregnancy outcomes of american indian and alaskan native women residing in rural versus urban areas Estes, J., Girsen, A., Sie, L., Leonard, S. A., Carmichael, S. L., El-Sayed, Y. Y. MOSBY-ELSEVIER. 2020: S97
View details for DOI 10.1016/j.ajog.2019.11.143

View details for Web of Science ID 000504997300127
Relationships of uterine fibroids to racial/ethnic disparities in severe maternal morbidity Igbinosa, I., Leonard, S. A., El-Sayed, Y. Y., Lyell, D. J. MOSBY-ELSEVIER. 2020: S170?S171
View details for DOI 10.1016/j.ajog.2019.11.263

View details for Web of Science ID 000504997300247
Operative vaginal delivery in the modern obstetric era: How does it compare to the alternative? Panelli, D. M., Leonard, S. A., Judy, A., El-Sayed, Y. Y., Gilbert, W., Lyell, D. J. MOSBY-ELSEVIER. 2020: S327?S328
View details for DOI 10.1016/j.ajog.2019.11.519

View details for Web of Science ID 000504997300502
Prenatal and postnatal inflammation-related risk factors for retinopathy of prematurity JOURNAL OF PERINATOLOGY Goldstein, G. P., Leonard, S. A., Kan, P., Koo, E. B., Lee, H. C., Carmichael, S. L. 2019; 39 (7): 964?73
View details for DOI 10.1038/s41372-019-0357-2

View details for Web of Science ID 000472630200010
Racial and ethnic disparities in severe maternal morbidity prevalence and trends ANNALS OF EPIDEMIOLOGY Leonard, S. A., Main, E. K., Scott, K. A., Profit, J., Carmichael, S. L. 2019; 33: 30?36
View details for DOI 10.1016/j.annepidem.2019.02.007

View details for Web of Science ID 000469160800004
Morbidly Adherent Placenta Among Women With Twin Gestation Miller, H., Fox, K., Carusi, D. A., Leonard, S., Lyell, D. LIPPINCOTT WILLIAMS & WILKINS. 2019: 68S
View details for Web of Science ID 000473810000232
Invited Commentary: The Causal Association Between Obesity and Stillbirth-Strengths and Limitations of the Consecutive-Pregnancies Approach. American journal of epidemiology Snowden, J. M., Leonard, S. A. 2019
Abstract

There has been a resurgence in analyses of consecutive pregnancies (or similarly, sibling designs) in perinatal and pediatric epidemiology. These approaches have attractive qualities for estimating associations with complex multifactorial exposures like obesity. In an article appearing in this issue of the Journal, Yu et al. (Am J Epidemiol. 2019;000(00):000-000) apply a consecutive-pregnancies approach to characterize the risk of stillbirth among women who develop obesity between pregnancies ("incident obesity"). Working within a causal framework and using parametric and nonparametric estimation techniques, the authors find an increase in stillbirth risk associated with incident obesity. Risk differences varied between 0.4 per 1,000 births (95% confidence interval (CI): 0.1, 0.7) and 6.9 per 1,000 births (95% CI: 3.7, 10.0), and risk ratios ranged from 1.12 (95% CI: 1.02, 1.23) to 2.99 (95% CI: 2.19, 4.08). The strengths of this approach include starting from a clearly defined causal estimand and exploring the sensitivity of parameter estimates to model selection. In this commentary, we put these findings in the broader context of research on obesity and birth outcomes and highlight concerns regarding the generalizability of results derived from within-family designs. We conclude that while causal inference is an important goal, in some instances focusing on formulation of a causal question drives results away from broad applicability.

View details for DOI 10.1093/aje/kwz079

View details for PubMedID 31111943
Prenatal and postnatal inflammation-related risk factors for retinopathy of prematurity. Journal of perinatology : official journal of the California Perinatal Association Goldstein, G. P., Leonard, S. A., Kan, P., Koo, E. B., Lee, H. C., Carmichael, S. L. 2019
Abstract

To evaluate the relationship between prenatal and postnatal inflammation-related risk factors and severe retinopathy of prematurity (ROP).The study included infants born <30 weeks in California from 2007 to 2011. Multivariable log-binomial regression was used to assess the association between prenatal and postnatal inflammation-related exposures and severe ROP, defined as stage 3-5 or surgery for ROP.Of 14,816 infants, 10.8% developed severe ROP. Though prenatal inflammation-related risk factors were initially associated with severe ROP, after accounting for the effect of these risk factors on gestational age at birth through mediation analysis, the association was non-significant (P?=?0.6). Postnatal factors associated with severe ROP included prolonged oxygen exposure, sepsis, intraventricular hemorrhage, and necrotizing enterocolitis.Postnatal inflammation-related factors were associated with severe ROP more strongly than prenatal factors. The association between prenatal inflammation-related factors and ROP was explained by earlier gestational age in infants exposed to prenatal inflammation.

View details for PubMedID 30932029
Gestational Weight Gain and Severe Maternal Morbidity at Delivery Hospitalization. Obstetrics and gynecology Leonard, S. A., Carmichael, S. L., Abrams, B. 2019; 134 (2): 420
View details for DOI 10.1097/AOG.0000000000003389

View details for PubMedID 31348212
Prepregnancy maternal body mass index and venous thromboembolism: A population based cohort study. BJOG : an international journal of obstetrics and gynaecology Butwick, A. J., Bentley, J., Leonard, S. A., Carmichael, S. L., El-Sayed, Y. Y., Stephansson, O., Guo, N. 2018
Abstract

OBJECTIVE: To assess the relationship between maternal body mass index (BMI) and pregnancy-related venous thromboembolism (VTE).DESIGN: Cross-sectional study.SETTING & POPULATION: 2,449,133 women with singleton pregnancies who underwent delivery hospitalization in California between 2008 and 2012.METHODS: Association of prepregnancy BMI and the risk of an antepartum and postpartum VTE was examined using logistic regression, with normal BMI as reference.MAIN OUTCOME MEASURES: Antepartum and postpartum VTE related hospitalization.RESULTS: The prevalences of antepartum and postpartum VTE increased with increasing BMI (antepartum: 2.3, 3.0, 3.8, 4.2, 4.7, and 10.6 per 10 000 women for underweight, normal BMI, overweight, obesity class I, II, and III, P<0.001. postpartum: 2.0, 3.1, 3.9, 5.6, 9.0, and 13.2 per 10 000 women, P<0.01). The adjusted odds of antepartum and postpartum VTE increased progressively with increasing BMI, and obese class III women being at highest risk of pregnancy-related VTE compared with normal BMI women: adjusted odds ratio (OR) for antepartum VTE: 2.9; 95% CI 2.2-3.8 and adjusted OR for postpartum VTE: 3.6; 95% CI 2.9-4.6.CONCLUSIONS: Our findings clearly demonstrate an increasing risk of pregnancy-related VTE with increasing BMI. This article is protected by copyright. All rights reserved.

View details for PubMedID 30500109
Maternal body mass index and risk of intraventricular hemorrhage in preterm infants. Pediatric research Pai, V. V., Carmichael, S. L., Kan, P., Leonard, S. A., Lee, H. C. 2018
Abstract

BACKGROUND: Intraventricular hemorrhage (IVH) and pre-pregnancy obesity and underweight have been linked to inflammatory states. We hypothesize that IVH in preterm infants is associated with pre-pregnancy obesity and underweight due to an inflammatory intrauterine environment.METHODS: Population-based study of infants born between 22 and 32 weeks' gestation from 2007 to 2011. Data were extracted from vital statistics and the California Perinatal Quality Care Collaborative. Results were examined for all cases (any IVH) and for severe IVH.RESULTS: Among 20,927 infants, 4,818 (23%) had IVH and 1,514 (7%) had severe IVH. After adjustment for confounders, there was an increased risk of IVH associated with pre-pregnancy obesity, relative risk 1.14 (95% CI 1.06, 1.32) for any IVH, and 1.25 (85% CI 1.10, 1.42) for severe IVH. The direct effect of pre-pregnancy obesity on any IVH was significant (P<0.001) after controlling for antenatal inflammation-related conditions, but was not significant after controlling for gestational age (P=0.56).CONCLUSION: Pre-pregnancy obesity was found to be a risk factor for IVH in preterm infants; however, this relationship appeared to be largely mediated through the effect of BMI on gestational age at delivery. The etiology of IVH is complex and it is important to understand contributing maternal factors.Pediatric Research accepted article preview online, 06 April 2018. doi:10.1038/pr.2018.47.

View details for PubMedID 29624572
Healthier vending machines in a university setting: Effective and financially sustainable. Appetite Viana, J., Leonard, S. A., Kitay, B., Ansel, D., Angelis, P., Slusser, W. 2018; 121: 263?67
View details for DOI 10.1016/j.appet.2017.11.094

View details for PubMedID 29137969
Do the health benefits of education vary by sociodemographic subgroup? Differential returns to education and implications for health inequities. Annals of epidemiology Vable, A. M., Cohen, A. K., Leonard, S. A., Glymour, M. M., Duarte, C. D., Yen, I. H. 2018; 28 (11): 759?66.e5
Abstract

Evidence suggests education is an important life course determinant of health, but few studies examine differential returns to education by sociodemographic subgroup.Using National Longitudinal Survey of Youth 1979 (n�= 6158) cohort data, we evaluate education attained by age 25 years and physical health (PCS) and mental health component summary scores (MCS) at age 50 years. Race / ethnicity, sex, geography, immigration status, and childhood socioeconomic status (cSES) were evaluated as effect modifiers in birth year�adjusted linear regression models.The association between education and PCS was large among high cSES respondents (?�= 0.81 per year of education, 95% CI: 0.67, 0.94), and larger among low cSES respondents (interaction ?�= 0.39, 95% CI: 0.06, 0.72). The association between education and MCS was imprecisely estimated among White men (?�= 0.44; 95% CI:�-0.03, 0.90), while, Black women benefited more from each year of education (interaction ?�= 0.91; 95% CI: 0.19, 1.64). Similarly, compared to socially advantaged groups, low cSES Blacks, and low and high cSES women benefited more from each year of education, while immigrants benefited less from each year of education.If causal, increases in educational attainment may reduce some social inequities in health.

View details for PubMedID 30309690

View details for PubMedCentralID PMC6215723
Breastfeeding Is Associated With Reduced Obesity in Hispanic 2- to 5-Year-Olds Served by WIC. Journal of nutrition education and behavior Whaley, S. E., Koleilat, M., Leonard, S., Whaley, M. ; 49 (7S2): S144?S150.e1
Abstract

To examine the relationship between breastfeeding (BF) and odds of childhood obesity in a�large, primarily Hispanic Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) population.A large urban WIC program in California.Infants enrolled in WIC born between 2004 and 2007 and observed to age 5�years (N�=�39,801; 88.6% Hispanic).Level of BF: fully BF, fully formula feeding, or combination feeding.Obesity at age 2-5�years, measured by body mass index (BMI)�?�95th percentile.Logistic regression analyses to evaluate the association between initiation, duration, and exclusivity of BF and odds of obesity at age 2-5�years, controlling for ethnicity, preferred language, family size, poverty level, and maternal BMI.Infants exclusively formula fed at birth were significantly more likely than fully breastfed infants to be obese at age 2-5�years (?(2) [2, N�=�39,801]�=�123.31; P�<�.001). For every additional month of any BF, obesity risk at age 2-5�years decreased by 1%. Every additional month of full BF conferred a 3% decrease in obesity risk. Ethnicity, preferred language, family size, poverty level, and maternal BMI were also significantly related to obesity risk.Breastfeeding may have a role in the attenuation of obesity in early childhood among Hispanic children. The BF promotion and support offered at WIC may have a significant role in reducing rates of early childhood obesity.

View details for DOI 10.1016/j.jneb.2017.03.007

View details for PubMedID 28689551
Living in Violent Neighbourhoods is Associated with Gestational Weight Gain Outside the Recommended Range PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Galin, J., Abrams, B., Leonard, S. A., Matthay, E. C., Goin, D. E., Ahern, J. 2017; 31 (1): 37-46
Abstract

During pregnancy, most women do not meet gestational weight gain (GWG) guidelines, potentially resulting in adverse maternal and infant health consequences. Social environment determinants of GWG have been identified, but evidence on the relationship between neighbourhood violence and GWG is scant. Our study aims to examine the relationship between neighbourhood violence and GWG outside the recommended range.We used statewide vital statistics and health care utilization data from California for 2006-12 (n = 2 364 793) to examine the relationship of neighbourhood violence (quarters of zip-code rates of homicide and assault) in the first 37 weeks of pregnancy with GWG (categorized using the Institute of Medicine's pregnancy weight gain guidelines). We estimated risk ratios (RR) and marginal risk differences, and analyses were stratified by maternal race/ethnicity and prepregnancy body mass index.Residence in neighbourhoods with the highest quartile of violence was associated with more excessive GWG (adjusted RR 1.04, 95% confidence interval CI 1.03, 1.05), compared to the lowest quartile of violence; violence was not associated with inadequate GWG. On the difference scale, this association translates to 2.3% more women gaining weight excessively rather than adequately if all women were exposed to high violence compared to if all women were exposed to low violence. Additionally, associations between neighbourhood violence and excessive GWG were larger in non-white women than in white women.These findings support the hypothesis that violence can affect weight gain during pregnancy, emphasizing the importance of neighbourhood violence as a public health issue.

View details for DOI 10.1111/ppe.12331

View details for Web of Science ID 000392509800007

View details for PubMedID 27921300

View details for PubMedCentralID PMC5195875
Associations of maternal obesity and psychosocial factors with breastfeeding intention, initiation, and duration(1-4) AMERICAN JOURNAL OF CLINICAL NUTRITION Hauff, L. E., Leonard, S. A., Rasmussen, K. M. 2014; 99 (3): 524-534
Abstract

Psychosocial factors influence breastfeeding outcomes, but little is known about these characteristics and how they influence breastfeeding behavior of obese women, who are a group that experiences poor breastfeeding outcomes.Our objectives were to determine whether 1) maternal prepregnancy body mass index (BMI) is associated with social knowledge of, social influence toward, maternal confidence in, and behavioral beliefs about breastfeeding; 2) BMI and these psychosocial factors predict outcomes of intention to breastfeed, ever breastfed, and the duration of breastfeeding; and 3) BMI and psychosocial factors are associated with these breastfeeding outcomes independent of each other.Participants (n = 2824) in the Infant Feeding Practices Study II provided data on psychosocial characteristics and breastfeeding outcomes. In this prospective cohort study, data were analyzed by using logistic and proportional hazards regression models.Prepregnancy BMI was associated with confidence in (P < 0.0001), social influence toward (P = 0.02), and social knowledge of (P < 0.0001) breastfeeding but not with behavioral beliefs about breastfeeding (P = 0.45). Obese women did not differ from under- and normal-weight women in the intention to breastfeed (P = 0.07) but had lower odds of ever breastfeeding (P = 0.04) and were at greater risk of an earlier cessation of exclusive (P = 0.0009) and any (P = 0.03) breastfeeding. Only the association with exclusive breastfeeding remained significant after controlling for psychosocial factors (P = 0.01). All psychosocial factors were positively associated with each breastfeeding outcome.Despite their intentions to breastfeed, women with high prepregnancy BMI had psychosocial characteristics associated with poor breastfeeding outcomes. However, these characteristics did not fully explain the association between maternal obesity and breastfeeding outcomes.

View details for DOI 10.3945/ajcn.113.071191

View details for Web of Science ID 000332143900015

View details for PubMedID 24401717

View details for PubMedCentralID PMC3927688

Stephanie A. Leonard

Instructor, Obstetrics & Gynecology - Maternal Fetal Medicine

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