Clinical Focus

  • Neonatal-Perinatal Medicine
  • Neonatology

Academic Appointments

Professional Education

  • Internship:Yale University School of Medicine (1996) CT
  • Medical Education:UC Berkeley School of Public Health (1981) CA
  • Board Certification: Pediatrics, American Board of Pediatrics (1973)
  • Fellowship:UCSD School of Medicine (1972) CA
  • Residency:Yale University School of Medicine (1968) CT
  • Board Certification: Neonatal-Perinatal Medicine, American Board of Pediatrics (1975)
  • Medical Education:University of Rochester School of Medicine (1965) NY
  • MD, U.Rochester School of Medicine, Medicine (1965)

Research & Scholarship

Current Research and Scholarly Interests

Gould is director of the Perinatal Epidemiology and Health Outcomes Research Unit in the division of Neonatology at the School of Medicine and Lucile Packard Children’s Hospital. He also directs the California Perinatal Quality Care Collaborative, a network of 104 California hospitals that provide intensive care to newborns that have volunteered to submit and compare uniform care processes and outcome data and conduct quality improvement initiatives for their mothers and newborns.
Gould is a leading public health researcher in population-based studies related to neonatal and perinatal diseases. Much of his research is focused on developing strategies to assess the quality of perinatal care based on risk-adjusted indicators of neonatal morbidity.


2015-16 Courses


All Publications

  • Labor outcome at extremely advanced maternal age. American journal of obstetrics and gynecology Osmundson, S. S., Gould, J. B., Butwick, A. J., Yeaton-Massey, A., El-Sayed, Y. Y. 2016; 214 (3): 362 e1-7


    Women of advanced maternal age (AMA) are at increased risk for cesarean delivery compared to non-AMA women. However, it is unclear whether how this association is altered by parity and the presence or absence of a trial of labor.We sought to examine modes of delivery and maternal outcomes among AMA women stratified by parity and the presence or absence of a trial of labor.This is a retrospective cohort study of all women delivering singletons births at ?20 weeks' gestation in the state of California from 2007 through 2011. Data were extracted from maternal discharge data linked to infant birth certificate records. We compared non-AMA women (age 20-34 years, reference group) to AMA women who were classified as follows: age 35-39, 40-44, 45-49, and ?50 years). The primary outcome was route of delivery (cesarean vs vaginal) stratified by parity and whether a trial of labor occurred (prelabor vs intrapartum cesarean delivery). The association between a trial of labor and perinatal morbidity was also studied.There were 1,346,889 women who met inclusion criteria, which included 181 (0.01%) women who were age ?50 years at the time of delivery. Overall, 34.7% underwent a cesarean delivery and this risk differed significantly by age group (30.5%, 20-34 years; 40.5%, 35-39 years; 47.3%, 40-44 years; 55.6%, 45-49 years; 62.4%, >50 years). Nulliparous women age ?50 years were significantly less likely to undergo a trial of labor compared to the reference group (relative risk [RR], 0.44; 95% confidence interval [CI], 0.32-0.62). Furthermore, nulliparous women age ?50 years were significantly more likely to experience an intrapartum cesarean delivery (RR, 2.61; 95% CI, 1.31-5.20), however the majority (74%) who underwent a trial of labor experienced a vaginal delivery. Compared to the reference group, women age ?50 years were 5 times more likely to experience severe maternal morbidity (1.7% vs 0.3%; RR, 5.08; 95% CI, 1.65-15.61) and their infants 3 times more likely to require neonatal intensive care unit admission (14.9% vs 5.2%; RR, 3.1; 95% CI, 2.2-4.4), however these outcomes were not associated significantly with having undergone a trial of labor, a cesarean delivery following labor, or a prelabor cesarean delivery. Similar trends were observed among multiparous women.Compared to non-AMA women, women age ?50 years with a singleton pregnancy experience significantly higher rates of cesarean delivery. However the majority of those who undergo a trial of labor will have a vaginal delivery. Neither a trial of labor nor a prelabor cesarean delivery is significantly associated with maternal or neonatal morbidity. These data support either approach in women of extremely AMA.

    View details for DOI 10.1016/j.ajog.2015.09.103

    View details for PubMedID 26454124

  • The Association of Level of Care With NICU Quality. Pediatrics Profit, J., Gould, J. B., Bennett, M., Goldstein, B. A., Draper, D., Phibbs, C. S., Lee, H. C. 2016; 137 (3): 1-9


    Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.We conducted a cross-sectional analysis of 21?051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.

    View details for DOI 10.1542/peds.2014-4210

    View details for PubMedID 26908663

  • Effects of race/ethnicity and BMI on the association between height and risk for spontaneous preterm birth. American journal of obstetrics and gynecology Shachar, B. Z., Mayo, J. A., Lee, H. C., Carmichael, S. L., Stevenson, D. K., Shaw, G. M., Gould, J. B. 2015; 213 (5): 700 e1-9


    Short height and obesity have each been associated with increased risk for preterm birth (PTB). However, the effect of short height on PTB risk, across different race/ethnicities and body mass index (BMI) categories, has not been studied. Our objective was to determine the influence of maternal height on the risk for PTB within race/ethnic groups, BMI groups, or adjusted for weight.All California singleton live births from 2007 through 2010 were included from birth certificate data (vital statistics) linked to hospital discharge data. Prepregnancy BMI (kg/m(2)) was categorized as underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9), or obese (?30.0). Maternal race/ethnicity was categorized as: non-Hispanic white, non-Hispanic black, Hispanic, and Asian. Maternal height was classified into 5 categories (shortest, short, middle, tall, tallest) based on racial/ethnic-specific height distributions, with the middle category serving as reference. Poisson regression models were used to estimate relative risks for the association between maternal height and risk of spontaneous PTB (<37 weeks and <32 weeks). Models were stratified on race/ethnicity and BMI. Generalized additive regression models were used to detect nonlinearity of the association. Covariates considered were: maternal age, weight, parity, prenatal care, education, medical payment, previous PTB, gestational and pregestational diabetes, pregestational hypertension, preeclampsia/eclampsia, and smoking.Among 1,655,385 California singleton live births, 5.2% were spontaneous PTB <37 weeks. Short stature (first height category) was associated with increased risk for PTB for non-Hispanic whites and Hispanics across all BMI categories. Among obese women, tall stature (fifth category) was associated with reduced risk for spontaneous PTB for non-Hispanic whites, Asians, and Hispanics. The same pattern of association was seen for height and risk for spontaneous PTB <32 weeks. In the generalized additive regression model plots, short stature was associated with increased risk for spontaneous PTB of <32 and <37 weeks of gestation among whites and Asians. However, this association was not observed for blacks and Hispanics.Maternal shorter height is associated with a modest increased risk for spontaneous PTB regardless of BMI. Our results suggest that PTB risk assessment should consider race/ethnicity-specific height with respect to the norm in addition to BMI assessment.

    View details for DOI 10.1016/j.ajog.2015.07.005

    View details for PubMedID 26187451

  • Effects of race/ethnicity and BMI on the association between height and risk for spontaneous preterm birth AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Shachar, B. Z., Mayo, J. A., Lee, H. C., Carmichael, S. L., Stevenson, D. K., Shaw, G. M., Gould, J. B. 2015; 213 (5)
  • Effect of time of birth on maternal morbidity during childbirth hospitalization in California AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Lyndon, A., Lee, H. C., Gay, C., Gilbert, W. M., Gould, J. B., Lee, K. A. 2015; 213 (5)


    This observational study aimed to determine the relationship between time of birth and maternal morbidity during childbirth hospitalization.Composite maternal morbidities were determined using International Classification of Diseases, Ninth Revision, Clinical Modification and vital records codes, using linked hospital discharge and vital records data for 1,475,593 singleton births in California from 2005 through 2007. Time of birth, day of week, and sociodemographic, obstetric, and hospital volume risk factors were estimated using mixed effects logistic regression models.The odds for pelvic morbidity were lowest between 11 PM-7 AM compared to other time periods and the reference value of 7-11 AM. The odds for pelvic morbidity peaked between 11 AM-7 PM (adjusted odds ratio [AOR], 1101-1500 = 1.07; 95% confidence interval [CI], 1.06-1.09; 1501-1900 = 1.08; 95% CI, 1.06-1.10). Odds for severe morbidity were higher between 11 PM-7 AM (AOR, 2301-0300 = 1.31; 95% CI, 1.21-1.41; 0301-0700 = 1.30; 95% CI, 1.20-1.41) compared to other time periods. The adjusted odds were not statistically significant for weekend birth on pelvic morbidity (AOR, Saturday = 1.00; 95% CI, 0.98-1.02]; Sunday = 1.01; 95% CI, 0.99-1.03) or severe morbidity (AOR, Saturday = 1.09; 95% CI, 1.00-1.18; Sunday = 1.03; 95% CI, 0.94-1.13). Cesarean birth, hypertensive disorders, birthweight, and sociodemographic factors that include age, race, ethnicity, and insurance status were also significantly associated with severe morbidity.Even after controlling for sociodemographic factors and known risks such as cesarean birth and pregnancy complications such as hypertensive disorders, birth between 11 PM-7 AM is a significant independent risk factor for severe maternal morbidity.

    View details for DOI 10.1016/j.ajog.2015.07.018

    View details for Web of Science ID 000365763400029

    View details for PubMedID 26196454

  • Maternal Asthma, Preterm Birth, and Risk of Bronchopulmonary Dysplasia. journal of pediatrics Gage, S., Kan, P., Lee, H. C., Gould, J. B., Stevenson, D. K., Shaw, G. M., O'Brodovich, H. M. 2015; 167 (4): 875-880 e1


    To study the relationship between maternal asthma and the development of bronchopulmonary dysplasia (BPD).Using a large population-based California cohort, we investigated associations between maternal asthma and preterm birth subtype, as well as maternal asthma and BPD. We used data from 2007-2010 maternal delivery discharge records of 2?009?511 pregnancies and International Classification of Diseases, Ninth Revision codes. Preterm birth was defined as <37 weeks gestational age (GA), with subgroups of <28 weeks, 28-32 weeks, and 33-37 weeks GA, as well as preterm subtype, defined as spontaneous, medically indicated, or unknown. Linkage between the 2 California-wide datasets yielded 21?944 singleton preterm infants linked to their mother's records, allowing estimation of the risk of BPD in mothers with asthma and those without asthma.Maternal asthma was associated with increased odds (OR, 1.42; 95% CI, 1.38-1.46) of preterm birth at <37 weeks GA, with the greatest risk for 28-32 GA (aOR, 1.60; 95% CI, 1.47-1.74). Among 21?944 preterm infants, we did not observe an elevated risk for BPD in infants born to mothers with asthma (aOR, 1.03; 95% CI, 0.9-1.2). Stratification by maternal treatment with antenatal steroids revealed increased odds of BPD in infants whose mothers had asthma but did not receive antenatal steroids (aOR, 1.54; 95% CI, 1.15-2.06), but not in infants whose mothers had asthma and were treated with antenatal steroids (aOR, 0.85; 95% CI, 0.67-1.07).Asthma in mothers who did not receive antenatal steroid treatment is associated with an increased risk of BPD in their preterm infants.

    View details for DOI 10.1016/j.jpeds.2015.06.048

    View details for PubMedID 26254835

  • Maternal Asthma, Preterm Birth, and Risk of Bronchopulmonary Dysplasia JOURNAL OF PEDIATRICS Gage, S., Kan, P., Lee, H. C., Gould, J. B., Stevenson, D. K., Shaw, G. M., O'Brodovich, H. M. 2015; 167 (4): 875-?
  • Heightened risk of preterm birth and growth restriction after a first-born son ANNALS OF EPIDEMIOLOGY Bruckner, T. A., Mayo, J. A., Gould, J. B., Stevenson, D. K., Lewis, D. B., Shaw, G. M., Carmichael, S. L. 2015; 25 (10): 743-747


    In Scandinavia, delivery of a first-born son elevates the risk of preterm delivery and intrauterine growth restriction of the next-born infant. External validity of these results remains unclear. We test this hypothesis for preterm delivery and growth restriction using the linked California birth cohort file. We examined the hypothesis separately by race and/or ethnicity.We retrieved data on 2,852,976 births to 1,426,488 mothers with at least two live births. Our within-mother tests applied Cox proportional hazards (preterm delivery, defined as less than 37 weeks gestation) and linear regression models (birth weight for gestational age percentiles).For non-Hispanic whites, Hispanics, Asians, and American Indian and/or Alaska Natives, analyses indicate heightened risk of preterm delivery and growth restriction after a first-born male. The race-specific hazard ratios for preterm delivery range from 1.07 to 1.18. Regression coefficients for birth weight for gestational age percentile range from -0.73 to -1.49. The 95% confidence intervals for all these estimates do not contain the null. By contrast, we could not reject the null for non-Hispanic black mothers.Whereas California findings generally support those from Scandinavia, the null results among non-Hispanic black mothers suggest that we do not detect adverse outcomes after a first-born male in all racial and/or ethnic groups.

    View details for DOI 10.1016/j.annepidem.2015.07.002

    View details for Web of Science ID 000361419000004

    View details for PubMedID 26265442

  • Maternal characteristics and mid-pregnancy serum biomarkers as risk factors for subtypes of preterm birth BJOG-AN INTERNATIONAL JOURNAL OF OBSTETRICS AND GYNAECOLOGY Jelliffe-Pawlowski, L. L., Baer, R. J., Blumenfeld, Y. J., Ryckman, K. K., O'Brodovich, H. M., Gould, J. B., Druzin, M. L., El-Sayed, Y. Y., Lyell, D. J., Stevenson, D. K., Shaw, G. M., Currier, R. J. 2015; 122 (11): 1484-1493


    To examine the relationship between maternal characteristics, serum biomarkers and preterm birth (PTB) by spontaneous and medically indicated subtypes.Population-based cohort.California, United States of America.From a total population of 1 004 039 live singleton births in 2009 and 2010, 841 665 pregnancies with linked birth certificate and hospital discharge records were included.Characteristics were compared for term and preterm deliveries by PTB subtype using logistic regression and odds ratios adjusted for maternal characteristics and obstetric factors present in final stepwise models and 95% confidence intervals. First-trimester and second-trimester serum marker levels were analysed in a subset of 125 202 pregnancies with available first-trimester and second-trimester serum biomarker results.PTB by subtype.In fully adjusted models, ten characteristics and three serum biomarkers were associated with increased risk in each PTB subtype (Black race/ethnicity, pre-existing hypertension with and without pre-eclampsia, gestational hypertension with pre-eclampsia, pre-existing diabetes, anaemia, previous PTB, one or two or more previous caesarean section(s), interpregnancy interval ? 60 months, low first-trimester pregnancy-associated plasma protein A, high second-trimester ?-fetoprotein, and high second-trimester dimeric inhibin A). These risks occurred in 51.6-86.2% of all pregnancies ending in PTB depending on subtype. The highest risk observed was for medically indicated PTB <32 weeks in women with pre-existing hypertension and pre-eclampsia (adjusted odds ratio 89.7, 95% CI 27.3-111.2).Our findings suggest a shared aetiology across PTB subtypes. These commonalities point to targets for further study and exploration of risk reduction strategies.Findings suggest a shared aetiology across preterm birth subtypes. Patterns may inform risk reduction efforts.

    View details for DOI 10.1111/1471-0528.13495

    View details for Web of Science ID 000362752100012

    View details for PubMedID 26111589

  • Exome Sequencing of Neonatal Blood Spots and the Identification of Genes Implicated in Bronchopulmonary Dysplasia AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE Li, J., Yu, K., Oehlert, J., Jeliffe-Pawlowski, L. L., Gould, J. B., Stevenson, D. K., Snyder, M., Shaw, G. M., O'Brodovich, H. M. 2015; 192 (5): 589-596


    Bronchopulmonary dysplasia (BPD), a prevalent severe lung disease of premature infants, has a strong genetic component. Large-scale genome-wide association studies for common variants have not revealed its genetic basis.Given the historical high mortality rate of extremely preterm infants who now survive and develop BPD, we hypothesized that risk loci underlying this disease are under severe purifying selection during evolution; thus, rare variants likely explain greater risk of the disease.We performed exome sequencing on 50 BPD-affected and unaffected twin pairs using DNA isolated from neonatal blood spots and identified genes affected by extremely rare nonsynonymous mutations. Functional genomic approaches were then used to systematically compare these affected genes.We identified 258 genes with rare nonsynonymous mutations in patients with BPD. These genes were highly enriched for processes involved in pulmonary structure and function including collagen fibril organization, morphogenesis of embryonic epithelium, and regulation of Wnt signaling pathway; displayed significantly elevated expression in fetal and adult lungs; and were substantially up-regulated in a murine model of BPD. Analyses of mouse mutants revealed their phenotypic enrichment for embryonic development and the cyanosis phenotype, a clinical manifestation of BPD.Our study supports the role of rare variants in BPD, in contrast with the role of common variants targeted by genome-wide association studies. Overall, our study is the first to sequence BPD exomes from newborn blood spot samples and identify with high confidence genes implicated in BPD, thereby providing important insights into its biology and molecular etiology.

    View details for DOI 10.1164/rccm.201501-0168OC

    View details for Web of Science ID 000361344500012

    View details for PubMedID 26030808

  • Determinants of chronic lung disease severity in the first year of life; A population based study PEDIATRIC PULMONOLOGY Gage, S., Kan, P., Oehlert, J., Gould, J. B., Stevenson, D. K., Shaw, G. M., O'Brodovich, H. M. 2015; 50 (9): 878-888

    View details for DOI 10.1002/ppul.23148

    View details for Web of Science ID 000360091000007

  • Spatial and temporal patterns in preterm birth in the United States PEDIATRIC RESEARCH Byrnes, J., Mahoney, R., Quaintance, C., Gould, J. B., Carmichael, S., Shaw, G. M., Showen, A., Phibbs, C., Stevenson, D. K., Wise, P. H. 2015; 77 (6): 836-844


    Despite years of research, the etiologies of preterm birth remain unclear. In order to help generate new research hypotheses, this study explored spatial and temporal patterns of preterm birth in a large, total-population dataset.Data on 145 million US births in 3,000 counties from the Natality Files of the National Center for Health Statistics for 1971-2011 were examined. State trends in early (<34?wk) and late (34-36?wk) preterm birth rates were compared. K-means cluster analyses were conducted to identify gestational age distribution patterns for all US counties over time.A weak association was observed between state trends in <34?wk birth rates and the initial absolute <34?wk birth rate. Significant associations were observed between trends in <34?wk and 34-36?wk birth rates and between white and African American <34?wk births. Periodicity was observed in county-level trends in <34?wk birth rates. Cluster analyses identified periods of significant heterogeneity and homogeneity in gestational age distributional trends for US counties.The observed geographic and temporal patterns suggest periodicity and complex, shared influences among preterm birth rates in the United States. These patterns could provide insight into promising hypotheses for further research.

    View details for DOI 10.1038/pr.2015.55

    View details for Web of Science ID 000354755000017

    View details for PubMedID 25760546

  • Neonatal intensive care unit antibiotic use. Pediatrics Schulman, J., Dimand, R. J., Lee, H. C., Duenas, G. V., Bennett, M. V., Gould, J. B. 2015; 135 (5): 826-833


    Treatment of suspected infection is a mainstay of the daily work in the NICU. We hypothesized that NICU antibiotic prescribing practice variation correlates with rates of proven infection, necrotizing enterocolitis (NEC), mortality, inborn admission, and with NICU surgical volume and average length of stay.In a retrospective cohort study of 52?061 infants in 127 NICUs across California during 2013, we compared sample means and explored linear and nonparametric correlations, stratified by NICU level of care and lowest/highest antibiotic use rate quartiles.Overall antibiotic use varied 40-fold, from 2.4% to 97.1% of patient-days; median = 24.5%. At all levels of care, it was independent of proven infection, NEC, surgical volume, or mortality. Fifty percent of intermediate level NICUs were in the highest antibiotic use quartile, yet most of these units reported infection rates of zero. Regional NICUs in the highest antibiotic quartile reported inborn admission rate 218% higher (0.24 vs 0.11, P = .03), and length of stay 35% longer (90.2 days vs 66.9 days, P = .03) than regional NICUs in the lowest quartile.Forty-fold variation in NICU antibiotic prescribing practice across 127 NICUs with similar burdens of proven infection, NEC, surgical volume, and mortality indicates that a considerable portion of antibiotic use lacks clear warrant; in some NICUs, antibiotics are overused. Additional study is needed to establish appropriate use ranges and elucidate the determinants and directionality of relationships between antibiotic and other resource use.

    View details for DOI 10.1542/peds.2014-3409

    View details for PubMedID 25896845

  • A randomized clinical trial of therapeutic hypothermia mode during transport for neonatal encephalopathy. journal of pediatrics Akula, V. P., Joe, P., Thusu, K., Davis, A. S., Tamaresis, J. S., Kim, S., Shimotake, T. K., Butler, S., Honold, J., Kuzniewicz, M., Desandre, G., Bennett, M., Gould, J., Wallenstein, M. B., Van Meurs, K. 2015; 166 (4): 856-61 e1 2


    To determine if temperature regulation is improved during neonatal transport using a servo-regulated cooling device when compared with standard practice.We performed a multicenter, randomized, nonmasked clinical trial in newborns with neonatal encephalopathy cooled during transport to 9 neonatal intensive care units in California. Newborns who met institutional criteria for therapeutic hypothermia were randomly assigned to receive cooling according to usual center practices vs device servo-regulated cooling. The primary outcome was the percentage of temperatures in target range (33°-34°C) during transport. Secondary outcomes included percentage of newborns reaching target temperature any time during transport, time to target temperature, and percentage of newborns in target range 1 hour after cooling initiation.One hundred newborns were enrolled: 49 to control arm and 51 to device arm. Baseline demographics did not differ with the exception of cord pH. For each subject, the percentage of temperatures in the target range was calculated. Infants cooled using the device had a higher percentage of temperatures in target range compared with control infants (median 73% [IQR 17-88] vs 0% [IQR 0-52], P < .001). More subjects reached target temperature during transport using the servo-regulated device (80% vs 49%, P <.001), and in a shorter time period (44 ± 31 minutes vs 63 ± 37 minutes, P = .04). Device-cooled infants reached target temperature by 1 hour with greater frequency than control infants (71% vs 20%, P < .001).Cooling using a servo-regulated device provides more predictable temperature management during neonatal transport than does usual care for outborn newborns with neonatal encephalopathy.

    View details for DOI 10.1016/j.jpeds.2014.12.061

    View details for PubMedID 25684087

  • A Randomized Clinical Trial of Therapeutic Hypothermia Mode during Transport for Neonatal Encephalopathy JOURNAL OF PEDIATRICS Akula, V. P., Joe, P., Thusu, K., Davis, A. S., Tamaresis, J. S., Kim, S., Shimotake, T. K., Butler, S., Honold, J., Kuzniewicz, M., Desandre, G., Bennett, M., Gould, J., Wallenstein, M. B., Van Meurs, K. 2015; 166 (4): 856-U138
  • Referral of Very Low Birth Weight Infants to High-Risk Follow-Up at Neonatal Intensive Care Unit Discharge Varies Widely across California JOURNAL OF PEDIATRICS Hintz, S. R., Gould, J. B., Bennett, M. V., Gray, E. E., Kagawa, K. J., Schulman, J., Murphy, B., Villarin-Duenas, G., Lee, H. C. 2015; 166 (2): 289-295


    To determine rates and factors associated with referral to the California Children's Services high-risk infant follow-up (HRIF) program among very low birth weight (BW) infants in the California Perinatal Quality of Care Collaborative.Using multivariable logistic regression, we examined independent associations of demographic and clinical variables, neonatal intensive care unit (NICU) volume and level, and California region with HRIF referral.In 2010-2011, 8071 very low BW infants were discharged home; 6424 (80%) were referred to HRIF. Higher odds for HRIF referral were associated with lower BW (OR 1.9, 95% CI 1.5-2.4; ? 750 g vs 1251-1499 g), higher NICU volume (OR 1.6, 1.2-2.1; highest vs lowest quartile), and California Children's Services Regional level (OR 3.1, 2.3-4.3, vs intermediate); and lower odds with small for gestational age (OR 0.79, 0.68-0.92), and maternal race African American (OR 0.58, 0.47-0.71) and Hispanic (OR 0.65, 0.55-0.76) vs white. There was wide variability in referral among regions (8%-98%) and NICUs (<5%-100%), which remained after risk adjustment.There are considerable disparities in HRIF referral, some of which may indicate regional and individual NICU resource challenges and barriers. Understanding demographic and clinical factors associated with failure to refer present opportunities for targeted quality improvement initiatives.

    View details for DOI 10.1016/j.jpeds.2014.10.038

    View details for Web of Science ID 000348496200021

    View details for PubMedID 25454311

  • Hospital Variation and Risk Factors for Bronchopulmonary Dysplasia in a Population-Based Cohort JAMA PEDIATRICS Lapcharoensap, W., Gage, S. C., Kan, P., Profit, J., Shaw, G., Gould, J. B., Stevenson, D. K., O'Brodovich, H., Lee, H. C. 2015; 169 (2)
  • Hospital variation and risk factors for bronchopulmonary dysplasia in a population-based cohort. JAMA pediatrics Lapcharoensap, W., Gage, S. C., Kan, P., Profit, J., Shaw, G. M., Gould, J. B., Stevenson, D. K., O'Brodovich, H., Lee, H. C. 2015; 169 (2)


    Bronchopulmonary dysplasia (BPD) remains a serious morbidity in very low-birth-weight (VLBW) infants (<1500 g). Deregionalization of neonatal care has resulted in an increasing number of VLBW infants treated in community hospitals with unknown impact on the development of BPD.To identify individual risk factors for BPD development and hospital variation of BPD rates across all levels of neonatal intensive care units (NICUs) within the California Perinatal Quality Care Collaborative.Retrospective cohort study (January 2007 to December 2011) from the California Perinatal Quality Care Collaborative including more than 90% of California's NICUs. Eligible VLBW infants born between 22 to 29 weeks' gestational age.Varying levels of intensive care.Bronchopulmonary dysplasia was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age. A combined outcome of BPD or mortality prior to 36 weeks was used. Multivariable logistic regression accounting for hospital as a random effect and gestational age as a risk factor was used to assess individual risk factors for BPD. This model was applied to determine risk-adjusted rates of BPD across hospitals and assess associations between levels of care and BPD rates.The study cohort included 15?779 infants, of which 1534 infants died prior to 36 weeks' postmenstrual age. A total of 7081 infants, or 44.8%, met the primary outcome of BPD or death prior to 36 weeks. Combined BPD or death rates across 116 NICUs varied from 17.7% to 73.4% (interquartile range, 38.7%-54.1%). Compared with level IV NICUs, the risk for developing BPD was higher for level II NICUs (odds ratio, 1.23; 95% CI, 1.02-1.49) and similar for level III NICUs (odds ratio, 1.04; 95% CI, 0.95-1.14).Bronchopulmonary dysplasia or death prior to 36 weeks' postmenstrual age affects approximately 45% of VLBW infants across California. The wide variability in BPD occurrence across hospitals could offer insights into potential risk or preventive factors. Additionally, our findings suggest that increased regionalization of NICU care may reduce BPD among VLBW infants.

    View details for DOI 10.1001/jamapediatrics.2014.3676

    View details for PubMedID 25642906

  • Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis. JAMA pediatrics Kastenberg, Z. J., Lee, H. C., Profit, J., Gould, J. B., Sylvester, K. G. 2015; 169 (1): 26-32


    There has been a significant expansion in the number of low-level and midlevel neonatal intensive care units (NICUs) in recent decades. Infants with necrotizing enterocolitis represent a high-risk subgroup of the very low-birth-weight (VLBW) (<1500 g) population that would benefit from focused regionalization.To describe the current trend toward deregionalization and to test the hypothesis that infants with necrotizing enterocolitis represent a particularly high-risk subgroup of the VLBW population that would benefit from early identification, increased intensity of early management, and possible targeted triage to tertiary hospitals.A retrospective cohort study was conducted of NICUs in California. We used data collected by the California Perinatal Quality Care Collaborative from 2005 to 2011 to assess mortality rates among a population-based sample of 30?566 VLBW infants, 1879 with necrotizing enterocolitis, according to the level of care and VLBW case volume at the hospital of birth.Level and volume of neonatal intensive care at the hospital of birth.In-hospital mortality.There was a persistent trend toward deregionalization during the study period and mortality rates varied according to the level of care. High-level, high-volume (level IIIB with >100 VLBW cases per year and level IIIC) hospitals achieved the lowest risk-adjusted mortality. Infants with necrotizing enterocolitis born into midlevel hospitals (low-volume level IIIB and level IIIA NICUs) had odds of death ranging from 1.42 (95% CI, 1.08-1.87) to 1.51 (95% CI, 1.05-2.15, respectively). In the final year of the study, just 28.6% of the infants with necrotizing enterocolitis were born into high-level, high-volume hospitals. For infants born into lower level centers, transfer to a higher level of care frequently occurred well into the third week of life.These findings represent an immediate opportunity for local quality improvement initiatives and potential impetus for the regionalization of important NICU resources.

    View details for DOI 10.1001/jamapediatrics.2014.2085

    View details for PubMedID 25383940

  • Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout BMJ QUALITY & SAFETY Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C., Amspoker, A. B., Kowalkowski, M. A., Schwendimann, R., Profit, J. 2014; 23 (10): 814-822
  • Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout. BMJ quality & safety Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C., Amspoker, A. B., Kowalkowski, M. A., Schwendimann, R., Profit, J. 2014; 23 (10): 814-822


    Leadership WalkRounds (WR) are widely used in healthcare organisations to improve patient safety. The relationship between WR and caregiver assessments of patient safety culture, and healthcare worker burnout is unknown.This cross-sectional survey study evaluated the association between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture and burnout across 44 neonatal intensive care units (NICUs) actively participating in a structured delivery room management quality improvement initiative.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. More WR feedback was associated with better safety culture results and lower burnout rates in the NICUs. Participation in WR and receiving feedback about WR were less common in NICUs than in a benchmarking comparison of adult clinical areas.WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care.

    View details for DOI 10.1136/bmjqs-2013-002042

    View details for PubMedID 24825895

  • Combined elevated midpregnancy tumor necrosis factor alpha and hyperlipidemia in pregnancies resulting in early preterm birth. American journal of obstetrics and gynecology Jelliffe-Pawlowski, L. L., Ryckman, K. K., Bedell, B., O'Brodovich, H. M., Gould, J. B., Lyell, D. J., Borowski, K. S., Shaw, G. M., Murray, J. C., Stevenson, D. K. 2014; 211 (2): 141 e1-9


    The objective of the study was to determine whether pregnancies resulting in early preterm birth (PTB) (<30 weeks) were more likely than term pregnancies to have elevated midtrimester serum tumor necrosis factor alpha (TNF-?) levels combined with lipid patterns suggestive of hyperlipidemia.In 2 nested case-control samples drawn from California and Iowa cohorts, we examined the frequency of elevated midpregnancy serum TNF-? levels (in the fourth quartile [4Q]) and lipid patterns suggestive of hyperlipidemia (eg, total cholesterol, low-density-lipoproteins, or triglycerides in the 4Q, high-density lipoproteins in the first quartile) (considered independently and by co-occurrence) in pregnancies resulting in early PTB compared with those resulting in term birth (n = 108 in California and n = 734 in Iowa). Odds ratios (ORs) and 95% confidence intervals (CIs) estimated in logistic regression models were used for comparisons.Early preterm pregnancies were 2-4 times more likely than term pregnancies to have a TNF-? level in the 4Q co-occurring with indicators of hyperlipidemia (37.5% vs 13.9% in the California sample (adjusted OR, 4.0; 95% CI, 1.1-16.3) and 26.3% vs 14.9% in the Iowa sample (adjusted OR, 2.7; 95% CI, 1.1-6.3). No differences between early preterm and term pregnancies were observed when TNF-? or target lipid abnormalities occurred in isolation. Observed differences were not explicable to any maternal or infant characteristics.Pregnancies resulting in early PTB were more likely than term pregnancies to have elevated midpregnancy TNF-? levels in combination with lipid patterns suggestive of hyperlipidemia.

    View details for DOI 10.1016/j.ajog.2014.02.019

    View details for PubMedID 24831886

  • Combined elevated midpregnancy tumor necrosis factor alpha and hyperlipidemia in pregnancies resulting in early preterm birth AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Jelliffe-Pawlowski, L. L., Ryckman, K. K., Bedell, B., O'Brodovich, H. M., Gould, J. B., Lyell, D. J., Borowski, K. S., Shaw, G. M., Murray, J. C., Stevenson, D. K. 2014; 211 (2)
  • Maternal Prepregnancy Body Mass Index and Risk of Spontaneous Preterm Birth PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Shaw, G. M., Wise, P. H., Mayo, J., Carmichael, S. L., Ley, C., Lyell, D. J., Shachar, B. Z., Melsop, K., Phibbs, C. S., Stevenson, D. K., Parsonnet, J., Gould, J. B. 2014; 28 (4): 302-311


    Findings from studies examining risk of preterm birth associated with elevated prepregnancy body mass index (BMI) have been inconsistent.Within a large population-based cohort, we explored associations between prepregnancy BMI and spontaneous preterm birth across a spectrum of BMI, gestational age, and racial/ethnic categories. We analysed data for 989?687 singleton births in California, 2007-09. Preterm birth was grouped as 20-23, 24-27, 28-31, or 32-36 weeks gestation (compared with 37-41 weeks). BMI was categorised as <18.5 (underweight); 18.5-24.9 (normal); 25.0-29.9 (overweight); 30.0-34.9 (obese I); 35.0-39.9 (obese II); and ?40.0 (obese III). We assessed associations between BMI and spontaneous preterm birth of varying severity among non-Hispanic White, Hispanic, and non-Hispanic Black women.Analyses of mothers without hypertension and diabetes, adjusted for age, education, height, and prenatal care initiation, showed obesity categories I-III to be associated with increased risk of spontaneous preterm birth at 20-23 and 24-27 weeks among those of parity 1 in each race/ethnic group. Relative risks for obese III and preterm birth at 20-23 weeks were 6.29 [95% confidence interval (CI) 3.06, 12.9], 4.34 [95% CI 2.30, 8.16], and 4.45 [95% CI 2.53, 7.82] for non-Hispanic Whites, non-Hispanic Blacks, and Hispanics, respectively. A similar, but lower risk, pattern was observed for women of parity ?2 and preterm birth at 20-23 weeks. Underweight was associated with modest risks for preterm birth at ?24 weeks among women in each racial/ethnic group regardless of parity.The association between women's prepregnancy BMI and risk of spontaneous preterm birth is complex and is influenced by race/ethnicity, gestational age, and parity.

    View details for DOI 10.1111/ppe.12125

    View details for Web of Science ID 000337614300005

    View details for PubMedID 24810721

  • Baby-MONITOR: A Composite Indicator of NICU Quality PEDIATRICS Profit, J., Kowalkowski, M. A., Zupancic, J. A., Pietz, K., Richardson, P., Draper, D., Hysong, S. J., Thomas, E. J., Petersen, L. A., Gould, J. B. 2014; 134 (1): 74-82


    NICUs vary in the quality of care delivered to very low birth weight (VLBW) infants. NICU performance on 1 measure of quality only modestly predicts performance on others. Composite measurement of quality of care delivery may provide a more comprehensive assessment of quality. The objective of our study was to develop a robust composite indicator of quality of NICU care provided to VLBW infants that accurately discriminates performance among NICUs.We developed a composite indicator, Baby-MONITOR, based on 9 measures of quality chosen by a panel of experts. Measures were standardized, equally weighted, and averaged. We used the California Perinatal Quality Care Collaborative database to perform across-sectional analysis of care given to VLBW infants between 2004 and 2010. Performance on the Baby-MONITOR is not an absolute marker of quality but indicates overall performance relative to that of the other NICUs. We used sensitivity analyses to assess the robustness of the composite indicator, by varying assumptions and methods.Our sample included 9023 VLBW infants in 22 California regional NICUs. We found significant variations within and between NICUs on measured components of the Baby-MONITOR. Risk-adjusted composite scores discriminated performance among this sample of NICUs. Sensitivity analysis that included different approaches to normalization, weighting, and aggregation of individual measures showed the Baby-MONITOR to be robust (r = 0.89-0.99).The Baby-MONITOR may be a useful tool to comprehensively assess the quality of care delivered by NICUs.

    View details for DOI 10.1542/peds.2013-3552

    View details for Web of Science ID 000338774800052

    View details for PubMedID 24918221

  • Swedish and American studies show that initiatives to decrease maternal obesity could play a key role in reducing preterm birth(+) ACTA PAEDIATRICA Gould, J. B., Mayo, J., Shaw, G. M., Stevenson, D. K. 2014; 103 (6): 586-591


    Maternal obesity is a major source of preventable perinatal morbidity, but studies of the relationship between obesity and preterm birth have been inconsistent. This review looks at two major studies covering just under 3.5 million births, from California, USA, and Sweden.Inconsistent findings in previous studies appear to stem from the complex relationship between obesity and preterm birth. Initiatives to decrease maternal obesity represent an important strategy in reducing preterm birth.

    View details for DOI 10.1111/apa.12616

    View details for Web of Science ID 000335754700012

  • Investigation of maternal environmental exposures in association with self-reported preterm birth REPRODUCTIVE TOXICOLOGY Patel, C. J., Yang, T., Hu, Z., Wen, Q., Sung, J., El-Sayed, Y. Y., Cohen, H., Gould, J., Stevenson, D. K., Shaw, G. M., Ling, X. B., Butte, A. J. 2014; 45: 1-7


    Identification of maternal environmental factors influencing preterm birth risks is important to understand the reasons for the increase in prematurity since 1990. Here, we utilized a health survey, the US National Health and Nutrition Examination Survey (NHANES) to search for personal environmental factors associated with preterm birth. 201 urine and blood markers of environmental factors, such as allergens, pollutants, and nutrients were assayed in mothers (range of N: 49-724) who answered questions about any children born preterm (delivery <37 weeks). We screened each of the 201 factors for association with any child born preterm adjusting by age, race/ethnicity, education, and household income. We attempted to verify the top finding, urinary bisphenol A, in an independent study of pregnant women attending Lucile Packard Children's Hospital. We conclude that the association between maternal urinary levels of bisphenol A and preterm birth should be evaluated in a larger epidemiological investigation.

    View details for DOI 10.1016/j.reprotox.2013.12.005

    View details for Web of Science ID 000336415800001

  • Cytomegalovirus infection among infants in California neonatal intensive care units, 2005-2010 JOURNAL OF PERINATAL MEDICINE Lanzieri, T. M., Bialek, S. R., Bennett, M. V., Gould, J. B. 2014; 42 (3): 393-399


    To assess the burden of congenital and perinatal cytomegalovirus (CMV) disease among infants hospitalized in neonatal intensive care units (NICUs).CMV infection was defined as a report of positive CMV viral culture or polymerase chain reaction at any time since birth in an infant hospitalized in a NICU reporting to California Perinatal Quality Care Collaborative during 2005-2010.One hundred and fifty-six (1.7 per 1000) infants were reported with CMV infection, representing an estimated 5% of the expected number of live births with symptomatic CMV disease. Prevalence was higher among infants with younger gestational ages and lower birth weights. Infants with CMV infection had significantly longer hospital stays and 14 (9%) died.Reported prevalence of CMV infection in NICUs represents a fraction of total expected disease burden from CMV in the newborn period, likely resulting from underdiagnosis and milder symptomatic cases that do not require NICU care. More complete ascertainment of infants with congenital CMV infection that would benefit from antiviral treatment may reduce the burden of CMV disease in this population.

    View details for DOI 10.1515/jpm-2013-0183

    View details for Web of Science ID 000338934600018

    View details for PubMedID 24334425

  • Population-Level Correlates of Preterm Delivery among Black and White Women in the US PLOS ONE Carmichael, S. L., Cullen, M. R., Mayo, J. A., Gould, J. B., Loftus, P., Stevenson, D. K., Wise, P. H., Shaw, G. M. 2014; 9 (4)
  • Population-level correlates of preterm delivery among black and white women in the U.S. PloS one Carmichael, S. L., Cullen, M. R., Mayo, J. A., Gould, J. B., Loftus, P., Stevenson, D. K., Wise, P. H., Shaw, G. M. 2014; 9 (4)


    This study examined the ability of social, demographic, environmental and health-related factors to explain geographic variability in preterm delivery among black and white women in the US and whether these factors explain black-white disparities in preterm delivery.We examined county-level prevalence of preterm delivery (20-31 or 32-36 weeks gestation) among singletons born 1998-2002. We conducted multivariable linear regression analysis to estimate the association of selected variables with preterm delivery separately for each preterm/race-ethnicity group.The prevalence of preterm delivery varied two- to three-fold across U.S. counties, and the distributions were strikingly distinct for blacks and whites. Among births to blacks, regression models explained 46% of the variability in county-level risk of delivery at 20-31 weeks and 55% for delivery at 32-36 weeks (based on R-squared values). Respective percentages for whites were 67% and 71%. Models included socio-environmental/demographic and health-related variables and explained similar amounts of variability overall.Much of the geographic variability in preterm delivery in the US can be explained by socioeconomic, demographic and health-related characteristics of the population, but less so for blacks than whites.

    View details for DOI 10.1371/journal.pone.0094153

    View details for PubMedID 24740117

  • Estimating the quality of neonatal transport in California JOURNAL OF PERINATOLOGY Gould, J. B., Danielsen, B. H., Bollman, L., Hackel, A., Murphy, B. 2013; 33 (12): 964-970


    Objective:To develop a strategy to assess the quality of neonatal transport based on change in neonatal condition during transport.Study Design:The Canadian Transport Risk Index of Physiologic Stability (TRIPS) score was optimized for a California (Ca) population using data collected on 21?279 acute neonatal transports, 2007 to 2009, using models predicting (2/3) and validating (1/3) mortality within 7 days of transport. Quality Change Point 10th percentile (QCP10), a benchmark of the greatest deterioration seen in 10% of the transports by top-performing teams, was established.Result:Compared with perinatal variables (0.79), the Ca-TRIPS had a validation receiver operator characteristic area for prediction of death of 0.88 in all infants and 0.86 in infants transported after day 7. The risk of death increased 2.4-fold in infants whose deterioration exceeded the QCP10.Conclusion:We present a practical, benchmarked, risk-adjusted, estimate of the quality of neonatal transport.

    View details for DOI 10.1038/jp.2013.57

    View details for Web of Science ID 000327689600013

    View details for PubMedID 24071907

  • Accounting for variation in length of NICU stay for extremely low birth weight infants. Journal of perinatology Lee, H. C., Bennett, M. V., Schulman, J., Gould, J. B. 2013; 33 (11): 872-876


    Objective:To develop a length of stay (LOS) model for extremely low birth weight (ELBW) infants.Study Design:We included infants from the California Perinatal Quality Care Collaborative with birth weight 401 to 1000?g who were discharged to home. Exclusion criteria were congenital anomalies, surgery and death. LOS was defined as days from admission to discharge. As patients who died or were transferred to lower level of care were excluded, we assessed correlation of hospital mortality rates and transfers to risk-adjusted LOS.Results:There were 2012 infants with median LOS 79 days (range 23 to 219). Lower birth weight, lack of antenatal steroids and lower Apgar score were associated with longer LOS. There was negligible correlation between risk-adjusted LOS and hospital mortality rates (r=0.0207) and transfer-out rates (r=0.121).Conclusion:Particularly because ELBW infants have extended hospital stays, identification of unbiased and informative risk-adjusted LOS for these infants is an important step in benchmarking best practice and improving efficiency in care.

    View details for DOI 10.1038/jp.2013.92

    View details for PubMedID 23949836

  • A Genome-Wide Association Study (GWAS) for Bronchopulmonary Dysplasia PEDIATRICS Wang, H., St Julien, K. R., Stevenson, D. K., Hoffmann, T. J., Witte, J. S., Lazzeroni, L. C., Krasnow, M. A., Quaintance, C. C., Oehlert, J. W., Jelliffe-Pawlowski, L. L., Gould, J. B., Shaw, G. M., O'Brodovich, H. M. 2013; 132 (2): 290-297


    Twin studies suggest that heritability of moderate-severe bronchopulmonary dysplasia (BPD) is 53% to 79%, we conducted a genome-wide association study (GWAS) to identify genetic variants associated with the risk for BPD.The discovery GWAS was completed on 1726 very low birth weight infants (gestational age = 25(0)-29(6/7) weeks) who had a minimum of 3 days of intermittent positive pressure ventilation and were in the hospital at 36 weeks' postmenstrual age. At 36 weeks' postmenstrual age, moderate-severe BPD cases (n = 899) were defined as requiring continuous supplemental oxygen, whereas controls (n = 827) inhaled room air. An additional 795 comparable infants (371 cases, 424 controls) were a replication population. Genomic DNA from case and control newborn screening bloodspots was used for the GWAS. The replication study interrogated single-nucleotide polymorphisms (SNPs) identified in the discovery GWAS and those within the HumanExome beadchip.Genotyping using genomic DNA was successful. We did not identify SNPs associated with BPD at the genome-wide significance level (5 × 10(-8)) and no SNP identified in previous studies reached statistical significance (Bonferroni-corrected P value threshold .0018). Pathway analyses were not informative.We did not identify genomic loci or pathways that account for the previously described heritability for BPD. Potential explanations include causal mutations that are genetic variants and were not assayed or are mapped to many distributed loci, inadequate sample size, race ethnicity of our study population, or case-control differences investigated are not attributable to underlying common genetic variation.

    View details for DOI 10.1542/peds.2013-0533

    View details for Web of Science ID 000322957300052

  • The Continuum of Maternal Sepsis Severity: Incidence and Risk Factors in a Population-Based Cohort Study PLOS ONE Acosta, C. D., Knight, M., Lee, H. C., Kurinczuk, J. J., Gould, J. B., Lyndon, A. 2013; 8 (7)


    To investigate the incidence and risk factors associated with uncomplicated maternal sepsis and progression to severe sepsis in a large population-based birth cohort.This retrospective cohort study used linked hospital discharge and vital statistics records data for 1,622,474 live births in California during 2005-2007. Demographic and clinical factors were adjusted using multivariable logistic regression with robust standard errors.1598 mothers developed sepsis; incidence of all sepsis was 10 per 10,000 live births (95% CI?=?9.4-10.3). Women had significantly increased adjusted odds (aOR) of developing sepsis if they were older (25-34 years: aOR?=?1.29; ?35 years: aOR?=?1.41), had ?high-school education (aOR?=?1.63), public/no-insurance (aOR?=?1.22) or a cesarean section (primary: aOR?=?1.99; repeat: aOR?=?1.25). 791 women progressed to severe sepsis; incidence of severe sepsis was 4.9 per 10,000 live births (95% CI?=?4.5-5.2). Women had significantly increased adjusted odds of progressing to severe sepsis if they were Black (aOR?=?2.09), Asian (aOR?=?1.59), Hispanic (aOR?=?1.42), had public/no-insurance (aOR?=?1.52), delivered in hospitals with <1,000 births/year (aOR?=?1.93), were primiparous (aOR?=?2.03), had a multiple birth (aOR?=?3.5), diabetes (aOR?=?1.47), or chronic hypertension (aOR?=?8.51). Preeclampsia and postpartum hemorrhage were also significantly associated with progression to severe sepsis (aOR?=?3.72; aOR?=?4.18). For every cumulative factor, risk of uncomplicated sepsis increased by 25% (95% CI?=?17.4-32.3) and risk of progression to severe sepsis/septic shock increased by 57% (95% CI?=?40.8-74.4).The rate of severe sepsis was approximately twice the 1991-2003 national estimate. Risk factors identified are relevant to obstetric practice given their cumulative risk effect and the apparent increase in severe sepsis incidence.

    View details for DOI 10.1371/journal.pone.0067175

    View details for Web of Science ID 000321341000034

    View details for PubMedID 23843991

  • Association of early-preterm birth with abnormal levels of routinely collected first- and second-trimester biomarkers AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Jelliffe-Pawlowski, L. L., Shaw, G. M., Currier, R. J., Stevenson, D. K., Baer, R. J., O'Brodovich, H. M., Gould, J. B. 2013; 208 (6)


    The purpose of this study was to examine the relationship between typically measured prenatal screening biomarkers and early-preterm birth in euploid pregnancies.The study included 345 early-preterm cases (<30 weeks of gestation) and 1725 control subjects who were drawn from a population-based sample of California pregnancies who had both first- and second-trimester screening results. Logistic regression analyses were used to compare patterns of biomarkers in cases and control subjects and to develop predictive models. Replicability of the biomarker early-preterm relationships that was revealed by the models was evaluated by examination of the frequency and associated adjusted relative risks (RRs) for early-preterm birth and for preterm birth in general (<37 weeks of gestation) in pregnancies with identified abnormal markers compared with pregnancies without these markers in a subsequent independent California cohort of screened pregnancies (n = 76,588).The final model for early-preterm birth included first-trimester pregnancy-associated plasma protein A in the ?5th percentile, second-trimester alpha-fetoprotein in the ?95th percentile, and second-trimester inhibin in the ?95th percentile (odds ratios, 2.3-3.6). In general, pregnancies in the subsequent cohort with a biomarker pattern that were found to be associated with early-preterm delivery in the first sample were at an increased risk for early-preterm birth and preterm birth in general (<37 weeks of gestation; adjusted RR, 1.6-27.4). Pregnancies with ?2 biomarker abnormalities were at particularly increased risk (adjusted RR, 3.6-27.4).When considered across cohorts and in combination, abnormalities in routinely collected biomarkers reveal predictable risks for early-preterm birth.

    View details for DOI 10.1016/j.ajog.2013.02.012

    View details for Web of Science ID 000320596600029

    View details for PubMedID 23395922

  • Hospital-wide breastfeeding rates vs. breastmilk provision for very-low-birth-weight infants ACTA PAEDIATRICA Lee, H. C., Jegatheesan, P., Gould, J. B., Dudley, R. A. 2013; 102 (3): 268-272


    To investigate the relationship between breastmilk feeding in very-low-birth-weight infants in the neonatal intensive care unit and breastmilk feeding rates for all newborns by hospital.This was a cross-sectional study of 111 California hospitals in 2007 and 2008. Correlation coefficients were calculated between overall hospital breastfeeding rates and breastmilk feeding rates of very-low-birth-weight infants. Hospitals were categorized in quartiles by crude and adjusted very-low-birth-weight infant rates to compare rankings between measures.Correlation between breastmilk feeding rates of very-low-birth-weight infants and overall breastfeeding rates varied by neonatal intensive care unit level of care from 0.13 for intermediate hospitals to 0.48 for regional hospitals. For hospitals categorized in the top quartile according to overall breastfeeding rate, only 46% were in the top quartile for both crude and adjusted very-low-birth-weight infant rates. On the other hand, when considering the lowest quartile for overall breastfeeding hospitals, three of 27 (11%) actually were performing in the top quartile of performance for very-low-birth-weight infant rates.Reporting hospital overall breastfeeding rates and neonatal intensive care unit breastmilk provision rates separately may give an incomplete picture of quality of care.

    View details for DOI 10.1111/apa.12096

    View details for Web of Science ID 000314656600022

    View details for PubMedID 23174012

  • Therapeutic hypothermia during neonatal transport: data from the California Perinatal Quality Care Collaborative (CPQCC) and California Perinatal Transport System (CPeTS) for 2010 JOURNAL OF PERINATOLOGY Akula, V. P., Gould, J. B., DAVIS, A. S., Hackel, A., Oehlert, J., Van Meurs, K. P. 2013; 33 (3): 194-197


    To evaluate cooling practices and neonatal outcomes in the state of California during 2010 using the California Perinatal Quality Care Collaborative and California Perinatal Transport System databases.Database analysis to determine the perinatal and neonatal demographics and outcomes of neonates cooled in transport or after admission to a cooling center.Of the 223 infants receiving therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE) in California during 2010, 69% were cooled during transport. Despite the frequent use of cooling in transport, cooling center admission temperature was in the target range (33-34?°C) in only 62 (44%). Among cooled infants, gestational age was <35 weeks in 10 (4.5%). For outborn and transported infants, chronologic age at the time of cooling initiation was >6 h in 20 (11%). When initiated at the birth hospital, cooling was initiated at <6 h of age in 131 (92.9%).More than half of the infants cooled in transport do not achieve target temperature by the time of arrival at the cooling center. The use of cooling devices may improve temperature regulation on transport.

    View details for DOI 10.1038/jp.2012.144

    View details for Web of Science ID 000315664700006

    View details for PubMedID 23223159

  • Variations in Definitions of Mortality Have Little Influence on Neonatal Intensive Care Unit Performance Ratings JOURNAL OF PEDIATRICS Profit, J., Gould, J. B., Draper, D., Zupancic, J. A., Kowalkowski, M. A., Woodard, L., Pietz, K., Petersen, L. A. 2013; 162 (1): 50-U320


    To measure the influence of varying mortality time frames on performance rankings among regional neonatal intensive care units (NICUs) in a large state.We performed a cross-sectional data analysis of very low birth weight infants receiving care at 24 level 3 NICUs. We tested the effect of 4 definitions of mortality: (1) death between admission and end of birth hospitalization or up to 366 days; (2) death between 12 hours of age and the end of birth hospitalization or up to 366 days; (3) death between admission and 28 days; and (4) death between 12 hours of age and 28 days. NICUs were ranked by quantifying their deviation from risk-adjusted expected mortality and dividing them into 3 tiers: top 6, bottom 6, and in between.There was wide interinstitutional variation in risk-adjusted mortality for each definition (observed minus expected z-score range, -6.08 to 3.75). However, mortality-based NICU rankings and classification into performance tiers were very similar for all institutions in each of our time frames. Among all 4 definitions, NICU rank correlations were high (>0.91). Few NICUs changed relative to a neighboring tier with changes in definitions, and none changed by more than one tier.The time frame used to ascertain mortality had little effect on comparative NICU performance.

    View details for DOI 10.1016/j.jpeds.2012.06.002

    View details for Web of Science ID 000312915900012

    View details for PubMedID 22854328

  • Correlation of Neonatal Intensive Care Unit Performance Across Multiple Measures of Quality of Care JAMA PEDIATRICS Profit, J., Zupancic, J. A., Gould, J. B., Pietz, K., Kowalkowski, M. A., Draper, D., Hysong, S. J., Petersen, L. A. 2013; 167 (1): 47-54


    To examine whether high performance on one measure of quality is associated with high performance on others and to develop a data-driven explanatory model of neonatal intensive care unit (NICU) performance.We conducted a cross-sectional data analysis of a statewide perinatal care database. Risk-adjusted NICU ranks were computed for each of 8 measures of quality selected based on expert input. Correlations across measures were tested using the Pearson correlation coefficient. Exploratory factor analysis was used to determine whether underlying factors were driving the correlations.Twenty-two regional NICUs in California.In total, 5445 very low-birth-weight infants cared for between January 1, 2004, and December 31, 2007.Pneumothorax, growth velocity, health care-associated infection, antenatal corticosteroid use, hypothermia during the first hour of life, chronic lung disease, mortality in the NICU, and discharge on any human breast milk.The NICUs varied substantially in their clinical performance across measures of quality. Of 28 unit-level correlations, 6 were significant (? < .05). Correlations between pairs of measures of quality of care were strong (? ? .5) for 1 pair, moderate (range, ? ? .3 to ? < .5) for 8 pairs, weak (range, ? ? .1 to ? < .3) for 5 pairs, and negligible (? < .1) for 14 pairs. Exploratory factor analysis revealed 4 underlying factors of quality in this sample. Pneumothorax, mortality in the NICU, and antenatal corticosteroid use loaded on factor 1; growth velocity and health care-associated infection loaded on factor 2; chronic lung disease loaded on factor 3; and discharge on any human breast milk loaded on factor 4.In this sample, the ability of individual measures of quality to explain overall quality of neonatal intensive care was modest.

    View details for DOI 10.1001/jamapediatrics.2013.418

    View details for Web of Science ID 000316797500010

    View details for PubMedID 23403539

  • Maternal morbidity during childbirth hospitalization in California JOURNAL OF MATERNAL-FETAL & NEONATAL MEDICINE Lyndon, A., Lee, H. C., Gilbert, W. M., Gould, J. B., Lee, K. A. 2012; 25 (12): 2529-2535


    To determine the incidence and risk factors for maternal morbidity during childbirth hospitalization.Maternal morbidities were determined using ICD9-CM and vital records codes from linked hospital discharge and vital records data for 1,572,909 singleton births in California during 2005-2007. Socio-demographic, obstetric and hospital volume risk factors were estimated using mixed effects logistic regression models.The maternal morbidity rate was 241/1000 births. The most common morbidities were episiotomy, pelvic trauma, maternal infection, postpartum hemorrhage and severe laceration. Preeclampsia (adjusted odds ratio [AOR]: 2.96; 95% confidence interval 2.8,3.13), maternal age over 35 years, (AOR: 1.92; 1.79,2.06), vaginal birth after cesarean, (AOR: 1.81; 1.47,2.23) and repeat cesarean birth (AOR: 1.99; 1.87,2.12) conferred the highest odds of severe morbidity. Non-white women were more likely to suffer morbidity.Nearly one in four California women experienced complications during childbirth hospitalization. Significant health disparities in maternal childbirth outcomes persist in the USA.

    View details for DOI 10.3109/14767058.2012.710280

    View details for Web of Science ID 000311678300011

    View details for PubMedID 22779781

  • Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery OBSTETRICS AND GYNECOLOGY Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., Gould, J. B. 2012; 120 (5): 1194-1198


    Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

    View details for DOI 10.1097/AOG.0b013e31826fc13d

    View details for Web of Science ID 000310512500027

    View details for PubMedID 23090538

  • Factors Associated with Failure to Screen Newborns for Retinopathy of Prematurity JOURNAL OF PEDIATRICS Bain, L. C., Dudley, R. A., Gould, J. B., Lee, H. C. 2012; 161 (5): 819-823


    To evaluate ROP screening rates in a population-based cohort; and to identify characteristics of patients that were missed.We used the California Perinatal Quality Care Collaborative data from 2005-2007 for a cross-sectional study. Using eligibility criteria, screening rates were calculated for each hospital. Multivariable regression was used to assess associations between patient clinical and sociodemographic factors and the odds of missing screening.Overall rates of missed ROP screening decreased from 18.6% in 2005 to 12.8% in 2007. Higher gestational age (OR = 1.25 for increase of 1 week, 95% CI, 1.21-1.29), higher birth weight (OR = 1.13; 95% CI, 1.10-1.15), and singleton birth (OR = 1.2; 95% CI, 1.07-1.34) were associated with higher probability of missing screening. Level II neonatal intensive care units and neonatal intensive care units with lower volume were more likely to miss screenings.Although ROP screening rates improved over time, larger and older infants are at risk for not receiving screening. Furthermore, large variations in screening rates exist among hospitals in California. Identification of gaps in quality of care creates an opportunity to improve ROP screening rates and prevent impaired vision in this vulnerable population.

    View details for DOI 10.1016/j.jpeds.2012.04.020

    View details for Web of Science ID 000310370600013

    View details for PubMedID 22632876

  • Missed Opportunities in the Referral of High-Risk Infants to Early Intervention PEDIATRICS Tang, B. G., Feldman, H. M., Huffman, L. C., Kagawa, K. J., Gould, J. B. 2012; 129 (6): 1027-1034


    Using a statewide population-based data source, we describe current neonatal follow-up referral practices for high-risk infants with developmental delays throughout California.From a cohort analysis of quality improvement data from 66 neonatal follow-up programs in the California Children's Services and California Perinatal Quality Care Collaborative High-Risk Infant Follow-Up Quality of Care Initiative, 5129 high-risk infants were evaluated at the first visit between 4 and 8 months of age in neonatal follow-up. A total of 1737 high-risk infants were evaluated at the second visit between 12 and 16 months of age. We calculated referral rates in relation to developmental status (high versus low concern) based on standardized developmental testing or screening.Among infants with low concerns (standard score >70 or passed screen) at the first visit, 6% were referred to early intervention; among infants with high concerns, 28% of infants were referred to early intervention. Even after including referrals to other (private) therapies, 34% infants with high concerns did not receive any referrals. These rates were similar for the second visit.In spite of the specialization of neonatal follow-up programs to identify high-risk infants with developmental delays, a large proportion of potentially eligible infants were not referred to early intervention.

    View details for DOI 10.1542/peds.2011-2720

    View details for Web of Science ID 000304707000036

    View details for PubMedID 22614772

  • Therapeutic Hypothermia during Neonatal Transport: Current Practices in California AMERICAN JOURNAL OF PERINATOLOGY Akula, V. P., Davis, A. S., Gould, J. B., Van Meurs, K. 2012; 29 (5): 319-326


    Therapeutic hypothermia initiated at <6 hours of age reduces death and disability in newborns ? 36 weeks' gestation with moderate to severe hypoxic ischemic encephalopathy. Given the limited therapeutic window, cooling during transport becomes a necessity. Our goal was to describe the current practice of therapeutic hypothermia during transport used in the state of California. All level III neonatal intensive care units (NICUs) were contacted to identify those units providing therapeutic hypothermia. An electronic questionnaire was sent to obtain basic information. Responses were received from 28 (100%) NICUs performing therapeutic hypothermia; 26 NICUs were cooling newborns and two were in the process of program development. Eighteen (64%) centers had cooled a patient in transport, six had not yet cooled in transport, and two do not plan to cool in transport. All 18 centers use passive cooling, except for two that perform both passive and active cooling, and 17 of 18 centers recommend initiation of cooling at the referral hospital. Reported difficulties include overcooling, undercooling, and bradycardia. Cooling on transport is being performed by majority of NICUs providing therapeutic hypothermia. Clinical protocols and devices for cooling in transport are essential to ensure safety and efficacy.

    View details for DOI 10.1055/s-0031-1295661

    View details for Web of Science ID 000302962200001

    View details for PubMedID 22143969

  • Risk of bronchopulmonary dysplasia by second-trimester maternal serum levels of alpha-fetoprotein, human chorionic gonadotropin, and unconjugated estriol PEDIATRIC RESEARCH Jelliffe-Pawlowski, L. L., Shaw, G. M., Stevenson, D. K., Oehlert, J. W., Quaintance, C., Santos, A. J., Baer, R. J., Currier, R. J., O'Brodovich, H. M., Gould, J. B. 2012; 71 (4): 399-406


    Although maternal serum ?-fetoprotein (AFP), human chorionic gonandotropin (hCG), and estriol play important roles in immunomodulation and immunoregulation during pregnancy, their relationship with the development of bronchopulmonary dysplasia (BPD) in young infants is unknown despite BPD being associated with pre- and postnatal inflammatory factors.We found that these serum biomarkers were associated with an increased risk of BPD. Risks were especially high when AFP and/or hCG levels were above the 95th percentile and/or when unconjugated estriol (uE3) levels were below the 5th percentile (relative risks (RRs) 3.1-6.7). Risks increased substantially when two or more biomarker risks were present (RRs 9.9-75.9).Data suggested that pregnancies that had a biomarker risk and yielded an offspring with BPD were more likely to have other factors present that suggested early intrauterine fetal adaptation to stress, including maternal hypertension and asymmetric growth restriction.The objective of this population-based study was to examine whether second-trimester levels of AFP, hCG, and uE3 were associated with an increased risk of BPD.

    View details for DOI 10.1038/pr.2011.73

    View details for Web of Science ID 000301884500013

    View details for PubMedID 22391642

  • Do practicing clinicians agree with expert ratings of neonatal intensive care unit quality measures? JOURNAL OF PERINATOLOGY Kowalkowski, M., Gould, J. B., Bose, C., Petersen, L. A., Profit, J. 2012; 32 (4): 247-252


    To assess the level of agreement when selecting quality measures for inclusion in a composite index of neonatal intensive care quality (Baby-MONITOR) between two panels: one comprised of academic researchers (Delphi) and another comprised of academic and clinical neonatologists (clinician).In a modified Delphi process, a panel rated 28 quality measures. We assessed clinician agreement with the Delphi panel by surveying a sample of 48 neonatal intensive care practitioners. We asked the clinician group to indicate their level of agreement with the Delphi panel for each measure using a five-point scale (much too high, slightly too high, reasonable, slightly too low and much too low). In addition, we asked clinicians to select measures for inclusion in the Baby-MONITOR based on a yes or no vote and a pre-specified two-thirds majority for inclusion.In all, 23 (47.9%) of the clinicians responded to the survey. We found high levels of agreement between the Delphi and clinician panels, particularly across measures selected for the Baby-MONITOR. Clinicians selected the same nine measures for inclusion in the composite as the Delphi panel. For these nine measures, 74% of clinicians indicated that the Delphi panel rating was 'reasonable'.Practicing clinicians agree with an expert panel on the measures that should be included in the Baby-MONITOR, enhancing face validity.

    View details for DOI 10.1038/jp.2011.199

    View details for Web of Science ID 000302189200002

    View details for PubMedID 22241483

  • Trends in Cesarean Delivery for Twin Births in the United States: 1995-2008 Reply OBSTETRICS AND GYNECOLOGY Lee, H. C., Gould, J. B., Boscardin, W. J., El-Sayed, Y. Y., Blumenfeld, Y. J. 2012; 119 (3): 658-659
  • Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery. Obstetrics and gynecology Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., Gould, J. B. 2012

    View details for PubMedID 23044535

  • Trends in Cesarean Delivery for Twin Births in the United States 1995-2008 OBSTETRICS AND GYNECOLOGY Lee, H. C., Gould, J. B., Boscardin, W. J., El-Sayed, Y. Y., Blumenfeld, Y. J. 2011; 118 (5): 1095-1101


    To estimate trends and risk factors for cesarean delivery for twins in the United States.This was a cross-sectional study in which we calculated cesarean delivery rates for twins from 1995 to 2008 using National Center for Health Statistics data. We compared cesarean delivery rates by year and for vertex compared with breech presentation. The order of presentation for a given twin pair could not be determined from the available records and therefore analysis was based on individual discrete twin data. Multivariable logistic regression was used to estimate independent risk factors, including year of birth and maternal factors, for cesarean delivery.Cesarean delivery rates for twin births increased steadily from 53.4% to 75.0% in 2008. Rates rose for the breech twin category (81.5%-92.1%) and the vertex twin category (45.1%-68.2%). The relative increase in the cesarean delivery rate for preterm and term neonates was similar. After risk adjustment, there was an average increase noted in cesarean delivery of 5% each year during the study period (risk ratio 1.05, 95% confidence interval 1.04-1.05).Cesarean delivery rates for twin births increased dramatically from 1995 to 2008. This increase is significantly higher than that which could be explained by an increase in cesarean delivery for breech presentation of either the presenting or second twin.

    View details for DOI 10.1097/AOG.0b013e3182318651

    View details for Web of Science ID 000296292600018

    View details for PubMedID 22015878

  • Formal selection of measures for a composite index of NICU quality of care: Baby-MONITOR JOURNAL OF PERINATOLOGY Profit, J., Gould, J. B., Zupancic, J. A., Stark, A. R., WALL, K. M., Kowalkowski, M. A., Mei, M., Pietz, K., Thomas, E. J., Petersen, L. A. 2011; 31 (11): 702-710


    To systematically rate measures of care quality for very low birth weight infants for inclusion into Baby-MONITOR, a composite indicator of quality.Modified Delphi expert panelist process including electronic surveys and telephone conferences. Panelists considered 28 standard neonatal intensive care unit (NICU) quality measures and rated each on a 9-point scale taking into account pre-defined measure characteristics. In addition, panelists grouped measures into six domains of quality. We selected measures by testing for rater agreement using an accepted method.Of 28 measures considered, 13 had median ratings in the high range (7 to 9). Of these, 9 met the criteria for inclusion in the composite: antenatal steroids (median (interquartile range)) 9(0), timely retinopathy of prematurity exam 9(0), late onset sepsis 9(1), hypothermia on admission 8(1), pneumothorax 8(2), growth velocity 8(2), oxygen at 36 weeks postmenstrual age 7(2), any human milk feeding at discharge 7(2) and in-hospital mortality 7(2). Among the measures selected for the composite, the domains of quality most frequently represented included effectiveness (40%) and safety (30%).A panel of experts selected 9 of 28 routinely reported quality measures for inclusion in a composite indicator. Panelists also set an agenda for future research to close knowledge gaps for quality measures not selected for the Baby-MONITOR.

    View details for DOI 10.1038/jp.2011.12

    View details for Web of Science ID 000296590600003

    View details for PubMedID 21350429

  • The Impact of Statistical Choices on Neonatal Intensive Care Unit Quality Ratings Based on Nosocomial Infection Rates ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Lee, H. C., Chien, A. T., Bardach, N. S., Clay, T., Gould, J. B., Dudley, R. A. 2011; 165 (5): 429-434


    To examine the extent to which performance assessment methods affect the percentage of neonatal intensive care units (NICUs) and very low-birth-weight (VLBW) infants included in performance assessments, the distribution of NICU performance ratings, and the level of agreement in those ratings.Cross-sectional study based on risk-adjusted nosocomial infection rates.NICUs belonging to the California Perinatal Quality Care Collaborative 2007-2008.One hundred twenty-six California NICUs and 10 487 VLBW infants.Three performance assessment choices: (1) excluding "low-volume" NICUs (those caring for <30 VLBW infants per year) vs a criterion based on confidence intervals, (2) using Bayesian vs frequentist hierarchical models, and (3) pooling data across 1 vs 2 years.Proportion of NICUs and patients included in quality assessment, distribution of ratings for NICUs, and agreement between methods using the ? statistic.Depending on the methods applied, 51% to 85% of NICUs and 72% to 96% of VLBW infants were included in performance assessments, 76% to 87% of NICUs were considered "average," and the level of agreement between NICU ratings ranged from 0.23 to 0.89.The percentage of NICUs included in performance assessments and their ratings can shift dramatically depending on performance measurement method. Physicians, payers, and policymakers should continue to closely examine which existing performance assessment methods are most appropriate for evaluating pediatric care quality.

    View details for Web of Science ID 000290113500009

    View details for PubMedID 21536958

  • Hypothermia in very low birth weight infants: distribution, risk factors and outcomes JOURNAL OF PERINATOLOGY Miller, S. S., Lee, H. C., Gould, J. B. 2011; 31: S49-S56


    The objective of this study was to study the epidemiology of neonatal hypothermia in preterm infants using World Health Organization (WHO) temperature criteria.A population-based cohort of 8782 very low birth weight (VLBW) infants born in California neonatal intensive care units in 2006 and 2007. Associations between admission hypothermia and maternal and neonatal characteristics and outcomes were determined using logistic regression.In all, 56.2% of infants were hypothermic. Low birth weight, cesarean delivery and a low Apgar score were associated with hypothermia. Spontaneous labor, prolonged rupture of membranes and antenatal steroid administration were associated with decreased risk of hypothermia. Moderate hypothermia was associated with higher risk of intraventricular hemorrhage (IVH). Moderate and severe hypothermic conditions were associated with risk of death.Hypothermia by WHO criteria is prevalent in VLBW infants and is associated with IVH and mortality. Use of WHO criteria could guide the need for quality improvement projects targeted toward the most vulnerable infants.

    View details for DOI 10.1038/jp.2010.177

    View details for Web of Science ID 000289236900008

    View details for PubMedID 21448204

  • Nosocomial Infection Reduction in VLBW Infants With a Statewide Quality-Improvement Model PEDIATRICS Wirtschafter, D. D., Powers, R. J., Pettit, J. S., Lee, H. C., Boscardin, W. J., Subeh, M. A., Gould, J. B. 2011; 127 (3): 419-426


    To evaluate the effectiveness of the California Perinatal Quality Care Collaborative quality-improvement model using a toolkit supplemented by workshops and Web casts in decreasing nosocomial infections in very low birth weight infants.This was a retrospective cohort study of continuous California Perinatal Quality Care Collaborative members' data during the years 2002-2006. The primary dependent variable was nosocomial infection, defined as a late bacterial or coagulase-negative staphylococcal infection diagnosed after the age of 3 days by positive blood/cerebro-spinal fluid culture(s) and clinical criteria. The primary independent variable of interest was voluntary attendance at the toolkit's introductory event, a direct indicator that at least 1 member of an NICU team had been personally exposed to the toolkit's features rather than being only notified of its availability. The intervention's effects were assessed using a multivariable logistic regression model that risk adjusted for selected demographic and clinical factors.During the study period, 7733 eligible very low birth weight infants were born in 27 quality-improvement participant hospitals and 4512 very low birth weight infants were born in 27 non-quality-improvement participant hospitals. For the entire cohort, the rate of nosocomial infection decreased from 16.9% in 2002 to 14.5% in 2006. For infants admitted to NICUs participating in at least 1 quality-improvement event, there was an associated decreased risk of nosocomial infection (odds ratio: 0.81 [95% confidence interval: 0.68-0.96]) compared with those admitted to nonparticipating hospitals.The structured intervention approach to quality improvement in the NICU setting, using a toolkit along with attendance at a workshop and/or Web cast, is an effective means by which to improve care outcomes.

    View details for DOI 10.1542/peds.2010-1449

    View details for Web of Science ID 000287845400043

    View details for PubMedID 21339273

  • Antenatal Steroid Administration for Premature Neonates in California OBSTETRICS AND GYNECOLOGY Lee, H. C., Lyndon, A., Blumenfeld, Y. J., Dudley, R. A., Gould, J. B. 2011; 117 (3): 603-609


    To estimate risk factors for premature neonates not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality-improvement collaborative project on antenatal steroid administration were sustained long-term.Clinical data for premature neonates born in 2005?2007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible neonates had a birth weight of less than 1,500 g or gestational age less than 34 weeks and were born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Sociodemographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a previous quality-improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors.Of 15,343 eligible neonates, 23.1% did not receive antenatal steroids in 2005?2007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of fetal distress (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes before delivery and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals that participated in a quality-improvement collaborative in 1999? 2000 had higher rates of antenatal steroid administration (85% compared with 69%, P<.001).A number of eligible mothers do not receive antenatal steroids. Quality-improvement initiatives to improve antenatal steroid administration could target specific high-risk groups.

    View details for DOI 10.1097/AOG.0b013e31820c3c9b

    View details for Web of Science ID 000287649400013

    View details for PubMedID 21446208

  • The Effect of Preterm Premature Rupture of Membranes on Neonatal Mortality Rates Blumenfeld, Y. J., Lee, H. C., Gould, J. B., Langen, E. S., Jafari, A., El-Sayed, Y. Y. LIPPINCOTT WILLIAMS & WILKINS. 2010: 1381-1386


    To estimate the effect of preterm premature rupture of membranes (PROM) on neonatal mortality.A cross-sectional study using a state perinatal database (California Perinatal Quality Care Collaborative) was performed. Prenatal data, including ruptured membranes, corticosteroid administration, maternal age, maternal race, maternal hypertension, mode of delivery, and prenatal care, were recorded. Mortality rates were compared for neonates born between 24 and 34 weeks of gestation without preterm PROM to those with recent (less than 18 hours before delivery) and prolonged (more than 18 hours before delivery) preterm PROM. Neonatal sepsis rates were also examined.Neonates born between 24 0/7 and 34 0/7 weeks of gestation from 127 California neonatal intensive care units between 2005 and 2007 were included (N=17,501). When analyzed by 2-week gestational age groups, there were no differences in mortality rates between those born with and without membrane rupture before delivery. The presence of prolonged preterm PROM was associated with decreased mortality at 24 to 26 weeks of gestation (18% compared with 31% for recent preterm PROM; odds ratio [OR] 1.79; confidence interval [CI] 1.25-2.56) but increased mortality at 28 to 30 weeks of gestation (4% compared with 3% for recent preterm PROM; OR 0.44; CI 0.22, 0.88) when adjusted for possible confounding factors. Sepsis rates did not differ between those with recent or prolonged preterm PROM at any gestational age.The presence of membrane rupture before delivery was not associated with increased neonatal mortality in any gestational age group. The effects of a prolonged latency period were not consistent across gestational ages.

    View details for DOI 10.1097/AOG.0b013e3181fe3d28

    View details for Web of Science ID 000284491000021

    View details for PubMedID 21099606

  • Low Apgar score and mortality in extremely preterm neonates born in the United States ACTA PAEDIATRICA Lee, H. C., Subeh, M., Gould, J. B. 2010; 99 (12): 1785-1789


    To investigate the relationship between low Apgar score and neonatal mortality in preterm neonates.Infant birth and death certificate data from the US National Center for Health Statistics for 2001-2002 were analysed. Primary outcome was 28-day mortality for 690, 933 neonates at gestational ages 24-36 weeks. Mortality rates were calculated for each combination of gestational age and 5-min Apgar score. Relative risks of mortality, by high vs. low Apgar score, were calculated for each age.Distribution of Apgar scores depended on gestational age, the youngest gestational ages having higher proportions of low Apgar scores. Median Apgar score ranged from 6 at 24 weeks, to 9 at 30-36 weeks gestation. The relative risk of death was significantly higher at Apgar scores 0-3 vs. 7-10, including at the youngest gestational ages, ranging from 3.1 (95% confidence interval 2.9, 3.4) at 24 weeks to 18.5 (95% confidence interval 15.7, 21.8) at 28 weeks.? Low Apgar score was associated with increased mortality in premature neonates, including those at 24-28 weeks gestational age, and may be a useful tool for clinicians in assessing prognosis and for researchers as a risk prediction variable.

    View details for DOI 10.1111/j.1651-2227.2010.01935.x

    View details for Web of Science ID 000283690300010

    View details for PubMedID 20626363

  • Maternal Nativity Status and Birth Outcomes in Asian Immigrants JOURNAL OF IMMIGRANT AND MINORITY HEALTH Qin, C., Gould, J. B. 2010; 12 (5): 798-805


    The study examines the relationship between maternal nativity, maternal risks and birth outcomes in six Asian sub-populations.U.S.- versus foreign-born immigrants of Chinese (67,222), Japanese (18,275) and Filipino (87,1208), Vietnamese (45,229), Cambodian/Laotian (21,237), and Korean (23,430) singleton live births were assessed for maternal risks and birth outcomes.U.S.-born Chinese and Japanese mothers had lower risk and increased preterm births but similar infant mortality, while U.S.-born Filipino mothers had higher risk and higher infant mortality. U.S.-born mothers of more recent Cambodian/Laotian and Vietnamese immigrants had higher risk and delivered more small and preterm births, while U.S.-born Korean mothers had higher risk but no differences in preterm and low birthweight delivery.Asians in America are a distinctly heterogenous population in terms of the relationship between maternal risk factors and birth outcomes and the influence of maternal nativity on this relationship.

    View details for DOI 10.1007/s10903-008-9215-6

    View details for Web of Science ID 000281506000022

    View details for PubMedID 19083097

  • Integration of Early Physiological Responses Predicts Later Illness Severity in Preterm Infants SCIENCE TRANSLATIONAL MEDICINE Saria, S., Rajani, A. K., Gould, J., Koller, D., Penn, A. A. 2010; 2 (48)


    Physiological data are routinely recorded in intensive care, but their use for rapid assessment of illness severity or long-term morbidity prediction has been limited. We developed a physiological assessment score for preterm newborns, akin to an electronic Apgar score, based on standard signals recorded noninvasively on admission to a neonatal intensive care unit. We were able to accurately and reliably estimate the probability of an individual preterm infant's risk of severe morbidity on the basis of noninvasive measurements. This prediction algorithm was developed with electronically captured physiological time series data from the first 3 hours of life in preterm infants (< or =34 weeks gestation, birth weight < or =2000 g). Extraction and integration of the data with state-of-the-art machine learning methods produced a probability score for illness severity, the PhysiScore. PhysiScore was validated on 138 infants with the leave-one-out method to prospectively identify infants at risk of short- and long-term morbidity. PhysiScore provided higher accuracy prediction of overall morbidity (86% sensitive at 96% specificity) than other neonatal scoring systems, including the standard Apgar score. PhysiScore was particularly accurate at identifying infants with high morbidity related to specific complications (infection: 90% at 100%; cardiopulmonary: 96% at 100%). Physiological parameters, particularly short-term variability in respiratory and heart rates, contributed more to morbidity prediction than invasive laboratory studies. Our flexible methodology of individual risk prediction based on automated, rapid, noninvasive measurements can be easily applied to a range of prediction tasks to improve patient care and resource allocation.

    View details for DOI 10.1126/scitranslmed.3001304

    View details for Web of Science ID 000288436900003

    View details for PubMedID 20826840

  • Prediction of Death for Extremely Premature Infants in a Population-Based Cohort PEDIATRICS Lee, H. C., Green, C., Hintz, S. R., Tyson, J. E., Parikh, N. A., Langer, J., Gould, J. B. 2010; 126 (3): E644-E650


    Although gestational age (GA) is often used as the primary basis for counseling and decision-making for extremely premature infants, a study of tertiary care centers showed that additional factors could improve prediction of outcomes. Our objective was to determine how such a model could improve predictions for a population-based cohort.From 2005 to 2008, data were collected prospectively for the California Perinatal Quality Care Collaborative, which encompasses 90% of NICUs in California. For infants born at GAs of 22 to 25 weeks, we assessed the ability of the Eunice Kennedy Shriver National Institute of Child Health and Human Development 5-factor model to predict survival rates, compared with a model using GA alone.In the study cohort of 4527 infants, 3647 received intensive care. Survival rates were 53% for the whole cohort and 66% for infants who received intensive care. In multivariate analyses of data for infants who received intensive care, prenatal steroid exposure, female sex, singleton birth, and higher birth weight (per 100-g increment) were each associated with a reduction in the risk of death before discharge similar to that for a 1-week increase in GA. The multivariate model increased the ability to group infants in the highest and lowest risk categories (mortality rates of >80% and <20%, respectively).In a population-based cohort, the addition of prenatal steroid exposure, sex, singleton or multiple birth, and birth weight to GA allowed for improved prediction of rates of survival to discharge for extremely premature infants.

    View details for DOI 10.1542/peds.2010-0097

    View details for Web of Science ID 000281535700047

    View details for PubMedID 20713479

  • Impact of Timing of Birth and Resident Duty-Hour Restrictions on Outcomes for Small Preterm Infants PEDIATRICS Bell, E. F., Hansen, N. I., Morriss, F. H., Stoll, B. J., Ambalavanan, N., Gould, J. B., Laptook, A. R., Walsh, M. C., Carlo, W. A., Shankaran, S., Das, A., Higgins, R. D. 2010; 126 (2): 222-231


    The goal was to examine the impact of birth at night, on the weekend, and during July or August (the first months of the academic year) and the impact of resident duty-hour restrictions on mortality and morbidity rates for very low birth weight infants.Outcomes were analyzed for 11,137 infants with birth weights of 501 to 1250 g who were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network registry in 2001-2005. Approximately one-half were born before the introduction of resident duty-hour restrictions in 2003. Follow-up assessments at 18 to 22 months were completed for 4508 infants. Mortality rate, short-term morbidities, and neurodevelopmental outcome were examined with respect to the timing of birth.There was no effect of the timing of birth on mortality rate and no impact on the risks of short-term morbidities except that the risk of retinopathy of prematurity (stage > or =2) was higher after the introduction of duty-hour restrictions and the risk of retinopathy of prematurity requiring operative treatment was lower for infants born during the late night than during the day. There was no impact of the timing of birth on neurodevelopmental outcome except that the risk of hearing impairment or death was slightly lower among infants born in July or August.In this network, the timing of birth had little effect on the risks of death and morbidity for very low birth weight infants, which suggests that staffing patterns were adequate to provide consistent care.

    View details for DOI 10.1542/peds.2010-0456

    View details for Web of Science ID 000280565700005

    View details for PubMedID 20643715

  • National Institutes of Health Consensus Development Conference: Lactose Intolerance and Health ANNALS OF INTERNAL MEDICINE Suchy, F. J., Brannon, P. M., Carpenter, T. O., Fernandez, J. R., Gilsanz, V., Gould, J. B., Hall, K., Hui, S. L., Lupton, J., Mennella, J., Miller, N. J., Osganian, S. K., Sellmeyer, D. E., Wolf, M. A. 2010; 152 (12): 792-?

    View details for Web of Science ID 000278827700005

    View details for PubMedID 20404261

  • The Role of Regional Collaboratives: The California Perinatal Quality Care Collaborative Model CLINICS IN PERINATOLOGY Gould, J. B. 2010; 37 (1): 71-?


    Improving the outcome of the infants cared for in one's neonatal intensive care unit is the main objective of improvement projects that are pursued independently or as a member of a national collaborative. Regional quality improvement collaborations represent the intersection of hospital-based and community-based medicine offering the possibility of coordinated improvement efforts conducted at both the hospital and community level. This article discusses the aspirations, workings, and achievements of the California Perinatal Quality Care Collaborative, a regional collaboration formed to improve perinatal care. While it is never easy to align the often differing fundamental positions held by the various member factions and stakeholder groups, the common goal of a universally agreed-upon mission statement can act as a magnet drawing the various components together. Rapid development of a first quality improvement initiative is an effective strategy to engage the participants in a way that allows them to demonstrate, share, and build upon their individual expertise, and provides them a strong sense of professional accomplishment.

    View details for DOI 10.1016/j.clp.2010.01.004

    View details for Web of Science ID 000277244200006

    View details for PubMedID 20363448

  • NIH consensus development conference statement: Lactose intolerance and health. NIH consensus and state-of-the-science statements Suchy, F. J., Brannon, P. M., Carpenter, T. O., Fernandez, J. R., Gilsanz, V., Gould, J. B., Hall, K., Hui, S. L., Lupton, J., Mennella, J., Miller, N. J., Osganian, S. K., Sellmeyer, D. E., Wolf, M. A. 2010; 27 (2): 1-27


    To provide health care providers, patients, and the general public with a responsible assessment of currently available data on lactose intolerance and health.A non-DHHS, nonadvocate 14-member panel representing the fields of internal medicine, pediatrics, pediatric and adult endocrinology, gastroenterology, hepatology, neonatology and perinatology, geriatrics, racial/ethnic disparities, radiology, maternal and fetal nutrition, vitamin and mineral metabolism, nutritional sciences, bone health, preventive medicine, biopsychology, biostatistics, statistical genetics, epidemiology, and a public representative. In addition, 22 experts from pertinent fields presented data to the panel and conference audience.Presentations by experts and a systematic review of the literature prepared by the University of Minnesota Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.? Lactose intolerance is a real and important clinical syndrome, but its true prevalence is not known. ? The majority of people with lactose malabsorption do not have clinical lactose intolerance. Many individuals who think they are lactose intolerant are not lactose malabsorbers. ? Many individuals with real or perceived lactose intolerance avoid dairy and ingest inadequate amounts of calcium and vitamin D, which may predispose them to decreased bone accrual, osteoporosis, and other adverse health outcomes. In most cases, individuals do not need to eliminate dairy consumption completely. ? Evidence-based dietary approaches with and without dairy foods and supplementation strategies are needed to ensure appropriate consumption of calcium and other nutrients in lactose-intolerant individuals. ? Educational programs and behavioral approaches for individuals and their healthcare providers should be developed and validated to improve the nutrition and symptoms of individuals with lactose intolerance and dairy avoidance.

    View details for PubMedID 20186234

  • The effect of ruptured membranes on early neonatal sepsis Blumenfeld, Y., Lee, H., Gould, J., Greenberg, M., Sung, J., El-Sayed, Y. MOSBY-ELSEVIER. 2009: S168-S168
  • Do ruptured membranes remote from term affect neonatal mortality? Blumenfeld, Y., Lee, H., Gould, J., Langen, E., Jafari, A., El-Sayed, Y. MOSBY-ELSEVIER. 2009: S167-S168
  • Factors Influencing Breast Milk versus Formula Feeding at Discharge for Very Low Birth Weight Infants in California JOURNAL OF PEDIATRICS Lee, H. C., Gould, J. B. 2009; 155 (5): 657-U94


    To investigate incidence and factors influencing breast milk feeding at discharge for very low birth weight infants (VLBW) in a population-based cohort.We used data from the California Perinatal Quality Care Collaborative to calculate incidence of breast milk feeding at hospital discharge for 6790 VLBW infants born in 2005-2006. Multivariable logistic regression was used to examine which sociodemographic and medical factors were associated with breast milk feeding. The impact of removing risk adjustment for race was examined.At initial hospital discharge, 61.1% of VLBW infants were fed breast milk or breast milk supplemented with formula. Breast milk feeding was more common with higher birth weight and gestational age. After risk adjustment, multiple birth was associated with higher breast milk feeding. Factors associated with exclusive formula feeding were Hispanic ethnicity, African American race, and no prenatal care. Hospital risk-adjusted rates of breast milk feeding varied widely (range 19.7% to 100%) and differed when race was removed from adjustment.A substantial number of VLBW infants were not fed breast milk at discharge. Specific groups may benefit from targeted interventions to promote breast milk feeding. There may be benefit to reporting risk-adjusted rates both including and excluding race in adjustment when considering quality improvement initiatives.

    View details for DOI 10.1016/j.jpeds.2009.04.064

    View details for Web of Science ID 000271570900014

    View details for PubMedID 19628218

  • From Paradox to Disparity: Trends in Neonatal Death in Very Low Birth Weight non-Hispanic Black and White Infants, 1989-2004 JOURNAL OF PEDIATRICS Bruckner, T. A., Saxton, K. B., Anderson, E., Goldman, S., Gould, J. B. 2009; 155 (4): 482-487


    To examine temporal trends in race-specific neonatal death in California to determine whether the overall decline in mortality attenuated the paradoxical survival advantage of very low birth weight (VLBW; birth weight < 1500 g) non-Hispanic black infants relative to VLBW non-Hispanic white infants.The data set comprised the California birth cohort file on non-Hispanic black and non-Hispanic white VLBW neonatal mortality for 1989-2004. Logistic regression methods were used to control for potentially confounding maternal characteristics.In 1989 and 1990, non-Hispanic black VLBW infants demonstrated a paradox of lower neonatal mortality (adjusted odds ratio [aOR] = 0.84; 95% confidence interval [CI] = 0.75-0.94). This survival advantage disappeared after 1991, however. In 2003 and 2004, the incidence of neonatal mortality increased in non-Hispanic black VLBW infants but decreased in non-Hispanic white VLBW infants, resulting in a racial disparity (aOR = 1.34; 95% CI = 1.14-1.56).An initial survival paradox transformed into a disparity. The magnitude of this non-Hispanic black/non-Hispanic white VLBW disparity rose to its highest levels in the last 2 years of the study period. Moreover, the steady mortality increase in VLBW non-Hispanic black VLBW infants since 2001 reversed the secular decline in neonatal mortality in this population. Our findings underscore the need to augment strategies to improve the health trajectory of gestation in non-Hispanic black women.

    View details for DOI 10.1016/j.jpeds.2009.04.038

    View details for Web of Science ID 000270497800008

    View details for PubMedID 19615693

  • Mortality and Morbidity by Month of Birth of Neonates Admitted to an Academic Neonatal Intensive Care Unit PEDIATRICS Soltau, T. D., Carlo, W. A., Gee, J., Gould, J., Ambalavanan, N. 2008; 122 (5): E1048-E1052


    Clinical expertise and skill of pediatric housestaff improve over the academic year, and performance varies despite supervision by faculty neonatologists. It is possible that variation in clinical expertise of housestaff affects important clinical outcomes in infants in ICUs.Our goal was to test the hypothesis that there is a decrease in morbidity and mortality in infants admitted to an NICU over the course of the academic year.A retrospective analysis was conducted using data on infants with birthweight 401 to 1500 g and >or=24 weeks' gestation (n = 3445) and infants with birth weights >1500 g (n = 7840) admitted to a regional NICU from January 1991 to June 2004. All infants were cared for by pediatric and neonatal housestaff supervised by neonatologists. Analysis of mortality and morbidity (intraventricular hemorrhage grades 3-4/periventricular leukomalacia, necrotizing enterocolitis >or= Bell stage 2, and bronchopulmonary dysplasia) over time were performed by repeated measures analysis of variance and the chi(2) test.Mortality rate in the 401 to 1500 g cohort, as well as the >1500 g cohort did not decrease over time during the academic year and was similar between the first (July-December) and second (January-June) halves of the academic year. There were no differences noted over the academic year for any of the morbidities.Morbidity and mortality in infants admitted to an academic NICU did not change significantly over the academic year. These observations suggest that the quality of care of critically ill neonates is not decreased early in the academic year.

    View details for DOI 10.1542/peds.2008-0412

    View details for Web of Science ID 000260542500061

    View details for PubMedID 18977953

  • Neonatal mortality among low birth weight infants during the initial months of the academic year JOURNAL OF PERINATOLOGY Bruckner, T. A., Carlo, W. A., Ambalavanan, N., Gould, J. B. 2008; 28 (10): 691-695


    Proper management of very low weight (<1500 g) infants requires specific expertise. During July and August, pediatric interns start new rotations and advance in responsibilities by postgraduate level. We test the hypothesis that low weight births in teaching hospitals exhibit increased neonatal mortality during the initial training months.Population-based cohort of 5184 very low weight and 15 232 moderately low weight infants in California from 19 regional teaching hospitals with medical training programs. Logistic regression methods controlled for both individual covariates and temporal patterns in neonatal mortality.We found no difference in neonatal mortality between very low weight infants born in teaching hospitals during July and August and those born in other months (adjusted odds ratio (AOR): 0.98, 95% confidence interval (CI), 0.78 to 1.23). Investigation of moderately low birth weight infants also indicated no increased neonatal mortality.Infants most likely to die in the neonatal period do not appear to be at elevated risk of neonatal mortality during July and August.

    View details for DOI 10.1038/jp.2008.72

    View details for Web of Science ID 000259675900007

    View details for PubMedID 18596712

  • School outcomes of late preterm infants: Special needs and challenges for infants born at 32 to 36 weeks gestation JOURNAL OF PEDIATRICS Chyi, L. J., Lee, H. C., Hintz, S. R., Gould, J. B., Sutcliffe, T. L. 2008; 153 (1): 25-31


    Because limited long-term outcome data exist for infants born at 32 to 36 weeks gestation, we compared school outcomes between 32- to 33-week moderate preterm (MP), 34-36 week late preterm (LP) and full-term (FT) infants.A total of 970 preterm infants and 13 671 FT control subjects were identified from the Early Childhood Longitudinal Study-Kindergarten Cohort. Test scores, teacher evaluations, and special education enrollment from kindergarten (K) to grade 5 were compared.LP infants had lower reading scores than FT infants in K to first grade (P < .05). Adjusted risk for poor reading and math scores remained elevated in first grade (P < .05). Teacher evaluations of math skills from K to first grade and reading skills from K to fifth grade were worse for LP infants (P < .05). Adjusted odds for below average skills remained higher for math in K and for reading at all grades (P < .05). Special education participation was higher for LP infants at early grades (odds ratio, 1.4-2.1). MP infants had lower test and teacher evaluation scores than FT infants and twice the risk for special education at all grade levels.Persistent teacher concerns through grade 5 and greater special education needs among MP and LP infants suggest a need to start follow-up, anticipatory guidance, and interventions for infants born at 32 to 36 weeks gestation.

    View details for DOI 10.1016/j.jpeds.2008.01.027

    View details for Web of Science ID 000257154800010

    View details for PubMedID 18571530

  • Population trends in cesarean delivery for breech presentation in the United States, 1997-2003 AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY Lee, H. C., El-Sayed, Y. Y., Gould, J. B. 2008; 199 (1)


    The objective of the study was to determine whether cesarean delivery for breech has increased in the United States.We calculated cesarean rates for term singletons in breech/malpresentation from 1997 to 2003 using National Center for Health Statistics data. We compared rates by sociodemographic groups and state. Multivariable logistic regression models were constructed to see whether factors associated with cesarean delivery differed over time.Breech cesarean rates increased overall from 83.8% to 85.1%. There was a significant increase in rates for most sociodemographic groups. There was little to no increase for mothers younger than 30 years old. There was wide variability in rates by state, 61.6-94.2% in 1997. Higher breech incidence correlated with lower cesarean rates, suggesting potential state bias in reporting breech.In the United States, breech infants are predominantly born by cesarean. There was a small increase in this trend from 1998 to 2002. There is wide variability by state, which is not explained by sociodemographic patterns and may be due to reporting differences.

    View details for DOI 10.1016/j.ajog.2007.11.059

    View details for Web of Science ID 000257205200021

    View details for PubMedID 18295181

  • Survival advantage associated with cesarean delivery in very low birth weight vertex neonates OBSTETRICS AND GYNECOLOGY Lee, H. C., Gould, J. 2007; 109 (5): 1203-1203

    View details for Web of Science ID 000246771600030

    View details for PubMedID 17470608

  • Implementing pay-for-performance in the neonatal intensive care unit PEDIATRICS Profit, J., Zupancic, J. A., Gould, J. B., Petersen, L. A. 2007; 119 (5): 975-982


    Pay-for-performance initiatives in medicine are proliferating rapidly. Neonatal intensive care is a likely target for these efforts because of the high cost, available databases, and relative strength of evidence for at least some measures of quality. Pay-for-performance may improve patient care but requires valid measurements of quality to ensure that financial incentives truly support superior performance. Given the existing uncertainty with respect to both the effectiveness of pay-for-performance and the state of quality measurement science, experimentation with pay-for-performance initiatives should proceed with caution and in controlled settings. In this article, we describe approaches to measuring quality and implementing pay-for-performance in the NICU setting.

    View details for DOI 10.1542/peds.2006-1565

    View details for Web of Science ID 000246153300014

    View details for PubMedID 17473099

  • Delivery mode by race for breech presentation in the US JOURNAL OF PERINATOLOGY Lee, H. C., El-Sayed, Y. Y., Gould, J. B. 2007; 27 (3): 147-153


    To determine if there are differential cesarean delivery rates by race and other socio-demographic factors for women with breech infants.We calculated cesarean delivery rates for 186 727 White, African American, Hispanic and Asian women delivering breech singletons with gestational age 26 to 41 weeks born in 1999 and 2000 using data from the National Center for Health Statistics. Multivariable logistic regression was used to determine differences in mode of delivery by race, adjusting for socio-demographic and medical factors.Cesarean rates for breech were >80% in most gestational age groups. In 14 of 18 groups, Whites had higher cesarean delivery rates than African Americans. However, this finding did not persist after risk adjustment. Hispanics were more likely to deliver by cesarean delivery than African Americans and Whites.Breech singleton infants are predominantly born by cesarean delivery. Although African-American women with breech presentation have lower cesarean delivery rates than Whites, this difference is not present after adjusting for socio-demographic and medical factors. Hispanics were more likely to be delivered by cesarean delivery and this difference was amplified after risk adjustment. Asians had slightly lower cesarean rates after risk adjustment, but this varied widely according to Asian subgroup.

    View details for DOI 10.1038/

    View details for Web of Science ID 000244420900003

    View details for PubMedID 17314983

  • Survival rates and mode of delivery for vertex preterm neonates according to small- or appropriate-for-gestational-age status PEDIATRICS Lee, H. C., Gould, J. B. 2006; 118 (6): E1836-E1844


    The goal was to characterize the relationship between cesarean section delivery and death for preterm vertex neonates according to intrauterine growth.Maternal and infant data from the National Center for Health Statistics for 1999 and 2000 were analyzed. Neonates with gestational ages of 26 to 36 weeks were characterized as small for gestational age (<10th percentile) or appropriate for gestational age (10th to 90th percentile). Mortality rates at 28 days and relative risks were calculated for each gestational age group according to mode of delivery.Cesarean section rates were higher for small-for-gestational-age neonates compared with appropriate-for-gestational-age neonates, most prominently from 26 weeks to 32 weeks of gestation, at which small-for-gestational-age neonates had cesarean section rates of 50% to 67%, whereas appropriate-for-gestational-age neonates had rates of 22% to 38%. Small-for-gestational-age neonates at gestational ages of <31 weeks had increased survival rates associated with cesarean section, whereas small-for-gestational-age neonates at >33 weeks and appropriate-for-gestational-age neonates overall had decreased survival rates associated with cesarean section. After adjustment for sociodemographic and medical factors, the survival advantage for small-for-gestational-age neonates at gestational ages of 26 to 30 weeks persisted.Cesarean section delivery was associated with survival for preterm small-for-gestational-age neonates but not preterm appropriate-for-gestational-age neonates. We speculate that vaginal delivery may be particularly stressful for small-for-gestational-age neonates. We found no evidence that prematurity alone is a valid indication for cesarean section for preterm appropriate-for-gestational-age neonates.

    View details for DOI 10.1542/peds.2006-1327

    View details for Web of Science ID 000242478900081

    View details for PubMedID 17142505

  • Mexican women in California: differentials in maternal morbidity between foreign and US-born populations PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Guendelman, S., Thornton, D., Gould, J., Hosang, N. 2006; 20 (6): 471-481


    In the US, the majority of deaths and serious complications of pregnancy occur during childbirth and are largely preventable. We conducted a population-based study to assess disparities in maternal health between Mexican-born and Mexican-American women residing in California and to evaluate the extent to which immigrants have better outcomes. Mothers in these two populations deliver 40% of infants in the state. We compared maternal mortality ratios and maternal morbidities during labour and delivery in the two populations using linked 1996-98 hospital discharge and birth certificate data files. For maternal morbidities, we calculated frequencies and observed and adjusted odds (OR) ratios using pre-existing maternal health, sociodemographic characteristics and quality of health care as covariates. Approximately 19% of Mexican-born women suffered a maternal disorder compared with 21% of Mexican-American women (Observed OR = 0.89, [95% CI 0.88, 0.90]). Despite their lower education and relative poverty, Mexican-born women still experienced a lower odds of any maternal morbidity than Mexican-American women, after adjusting for covariates (OR = 0.92, [95% CI 0.90, 0.93]). These findings suggest a paradox of more favourable outcomes among Mexican immigrants similar to that found with birth outcomes. Nevertheless, the positive aggregate outcome of Mexican-born women did not extend to maternal mortality, nor to certain conditions associated with suboptimal intrapartum obstetric care.

    View details for Web of Science ID 000241246000003

    View details for PubMedID 17052282

  • Operational research on perinatal epidemiology, care and outcomes JOURNAL OF PERINATOLOGY Gould, J. B. 2006; 26: S34-S37


    Traditionally, neonatal-perinatal medicine has been concerned with two areas of research: basic and translational. A third area, perinatal epidemiology/health outcomes research addresses those factors that impede and promote the clinical actualization of the advances developed by basic and translational research. Unfortunately, research and training in perinatal epidemiology and outcomes analysis have not kept pace with our need to understand the interplay between risk, intervention, structure and outcome. This knowledge is essential to the development of the clinical/organizational and training strategies that will enable perinatal medicine to fully realize the promise of basic and translational research.

    View details for DOI 10.1038/

    View details for Web of Science ID 000241844600009

    View details for PubMedID 16801967

  • The Asian birth outcome gap PAEDIATRIC AND PERINATAL EPIDEMIOLOGY Qin, C., Gould, J. B. 2006; 20 (4): 279-289


    Asians are often considered a single group in epidemiological research. This study examines the extent of differences in maternal risks and birth outcomes for six Asian subgroups. Using linked birth/infant death certificate data from the State of California for the years 1992-97, we assessed maternal socio-economic risks and their effect on birthweight, preterm delivery (PTD), neonatal, post-neonatal and infant mortality for Filipino (87,120), Chinese (67,228), Vietnamese (45,237), Korean (23,431), Cambodian/Laotian (21,239) and Japanese (18,276) live singleton births. The analysis also included information about non-Hispanic whites and non-Hispanic blacks in order to give a sense of the magnitude of risks among Asians. Logistic regression models explored the effect of maternal risk factors and PTD on Asian subgroup differences in neonatal and post-neonatal mortality, using Japanese as the reference group. Across Asian subgroups, the differences ranged from 2.5- to 135-fold for maternal risks, and 2.2-fold for infant mortality rate. PTD was an important contributor to neonatal mortality differences. Maternal risk factors contributed to the disparities in post-neonatal mortality. Significant differences in perinatal health across Asian subgroups deserve ethnicity-specific interventions addressing PTD, teen pregnancy, maternal education, parity and access to prenatal care.

    View details for Web of Science ID 000239531200002

    View details for PubMedID 16879500

  • Obstetric complications during labor and delivery: Assessing ethnic differences in California WOMENS HEALTH ISSUES Guendelman, S., Thornton, D., Gould, J., Hosang, N. 2006; 16 (4): 189-197


    We sought to compare obstetric complications during labor and delivery among white non-Latina (white), black, Asian, and Latina women who delivered in California hospitals. Many intrapartum complications are preventable.We used linked 1996-1998 state hospital discharge and birth certificate data to examine obstetric complications International Classification of Diseases, 9th Revision, Clinical Modification codes considered relevant for population surveillance. We compared the observed and adjusted odds of experiencing a complication among women of color, using white women as the reference group.One out of 5 deliveries had >or=1 complication. White (21.3%) and Asian women (21.1%) had similar prevalence rates, whereas black women (24.2%) had higher and Latina women (19.6%) had lower rates. After adjusting for covariates, the odds of experiencing >or=1 complication was lower for Asians (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.93, 0.96) and Latinas (OR = 0.97; 95% CI = 0.96, 0.98) than whites; the odds for black women remained elevated (OR = 1.25; 95% CI = 1.23, 1.27). Asian women stood a higher risk of deliveries with major lacerations, postpartum hemorrhage, and major puerperal infections. Rates for the latter complication were higher among all women of color.The burden of morbidity is high for all women, regardless of ethnicity. Yet, compared to white women, blacks suffer more aggregate morbidities, and Asians stand a high risk of all 3 intrapartum care-sensitive conditions. Furthermore, all women of color experience disproportionate rates of puerperal infections. Collective action is needed to reduce these disparities and improve maternal health.

    View details for DOI 10.1016/j.whi.2005.12.004

    View details for Web of Science ID 000240051800006

    View details for PubMedID 16920523

  • Promoting antenatal steroid use for fetal maturation: Results from the California Perinatal Quality Care Collaborative JOURNAL OF PEDIATRICS Wirtschafter, D. D., Danielsen, B. H., Main, E. K., Korst, L. M., Gregory, K. D., Wertz, A., Stevenson, D. K., Gould, J. B. 2006; 148 (5): 606-612


    The California Perinatal Quality Care Collaborative (CPQCC) was formed to seek perinatal care improvements by creating a confidential multi-institutional database to identify topics for quality improvement (QI). We aimed to evaluate this approach by assessing antenatal steroid administration before preterm (24 to 33 weeks of gestation) delivery. We hypothesized that mean performance would improve and the number of centers performing below the lowest quartile of the baseline year would decrease.In 1998, a statewide QI cycle targeting antenatal steroid use was announced, calling for the evaluation of the 1998 baseline data, dissemination of recommended interventions using member-developed educational materials, and presentations to California neonatologists in 1999-2000. Postintervention data were assessed for the year 2001 and publicly released in 2003. A total of 25 centers voluntarily participated in the intervention.Antenatal steroid administration rate increased from 76% of 1524 infants in 1998 to 86% of 1475 infants in 2001 (P < .001). In 2001, 23 of 25 hospitals exceeded the 1998 lower-quartile cutoff point of 69.3%.Regional collaborations represent an effective strategy for improving the quality of perinatal care.

    View details for DOI 10.1016/j.jpeds.2005.12.058

    View details for Web of Science ID 000237885500019

    View details for PubMedID 16737870

  • Sociocultural factors that affect pregnancy outcomes in two dissimilar immigrant groups in the United States JOURNAL OF PEDIATRICS Madan, A., Palaniappan, L., Urizar, G., Wang, Y., Fortmann, S. P., Gould, J. B. 2006; 148 (3): 341-346


    To compare perinatal risks and outcomes in foreign- and U.S.-born Asian-Indian and Mexican women.We evaluated 6.4 million U.S. vital records for births during 1995-2000 to white, foreign- and U.S.-born Asian-Indian and Mexican women. Risks and outcomes were compared by use of chi2 and logistic regression.With the exception of increased teen pregnancy and tobacco use, the favorable sociodemographic profile and increased rate of adverse outcomes seen in foreign-born Asian Indians persisted in their U.S.-born counterparts. In contrast, foreign-born Mexicans had an adverse sociodemographic profile but a low incidence of low birth weight (LBW), whereas U.S.-born Mexicans had an improved sociodemographic profile and increased LBW, prematurity and neonatal death.Perinatal outcomes deteriorate in U.S.-born Mexican women. In contrast, the paradoxically increased incidence of LBW persists in U.S.-born Asian-Indian women. Further research is needed to identify the social and biologic determinants of perinatal outcome.

    View details for DOI 10.1016/j.peds.2005.11.028

    View details for Web of Science ID 000236718700015

    View details for PubMedID 16615964

  • Prospective evaluation of postnatal steroid administration: A 1-year experience from the california perinatal quality care collaborative PEDIATRICS Finer, N. N., Powers, R. J., Ou, C. H., Durand, D., Wirtschafter, D., Gould, J. B. 2006; 117 (3): 704-713


    Postnatal steroids (PNSs) are used frequently to prevent or treat chronic lung disease (CLD) in the very low birth weight (VLBW) infant, and their use continues despite concerns regarding an increased incidence of longer-term neurodevelopmental abnormalities in such infants. More recently, there has been a suggestion that corticosteroids may be a useful alternative therapy for hypotension in VLBW infants, but there have been no prospective reports of such use for a current cohort of VLBW infants.The California Perinatal Quality Care Collaborative (CPQCC) requested members to supplement their routine Vermont Oxford Network data collection with additional information on any VLBW infant treated during their hospital course with PNS, for any indication. The indication, actual agent used, total initial daily dose, age at treatment, type of respiratory support, mean airway pressure, fraction of inspired oxygen, and duration of first dosing were recorded.From April 2002 to March 2003 in California, 22 of the 62 CPQCC hospitals reported supplemental data, if applicable, from a cohort of 1401 VLBW infants (expanded data group [EDG]), representing 33.2% of the VLBW infants registered with the CPQCC during the 12-month period. PNSs for CLD were administered to 8.2% of all VLBW infants in 2003, 8.6% of infants in the 42 hospitals that did not submit supplemental data (routine data-set group, compared with 7.6% in EDG hospitals). Of the 1401 VLBW infants in the EDG, 19.3% received PNSs; 3.6% received PNSs for only CLD, 11.8% for only non-CLD indications, and 4.0% for both indications. At all birth weight categories, non-CLD use was significantly greater than CLD use. The most common non-CLD indication was hypotension, followed by extubation stridor, for which 36 (16.3%) infants were treated. For hypotension, medications used were hydrocortisone followed by dexamethasone. Infants treated with PNSs exclusively for hypotension had a significantly higher incidence of intraventricular hemorrhage, periventricular leukomalacia, and death when compared with infants treated only for CLD or those who did not receive PNSs.The common early use of hydrocortisone for hypotension and the high morbidity and mortality in children receiving such treatment has not been recognized previously and prospective trials evaluating the short- and long-term risk/benefit of such treatment are urgently required.

    View details for DOI 10.1542/peds.2005-0796

    View details for Web of Science ID 000235709000041

    View details for PubMedID 16510650

  • Survival advantage associated with cesarean delivery in very low birth vertex neonates OBSTETRICS AND GYNECOLOGY Lee, H. C., Gould, J. B. 2006; 107 (1): 97-105


    To identify the indications for and any survival advantage associated with very low birth weight (VLBW) neonates delivered by cesarean.Maternal and infant data from the National Center for Health Statistics linked birth/death data set for 1999 to 2000 were analyzed. Maternal conditions associated with cesarean delivery were compared among birth weight groups for vertex neonates. Birth weight-specific 28-day mortality rates and relative risks were calculated with 95% confidence intervals. Multivariate logistic regression was performed to adjust for other factors that may be associated with survival.Cesarean delivery occurred frequently, more than 40% in most VLBW birth weight groups. Conditions associated with cesarean delivery in VLBW vertex neonates differed from those seen in non-VLBW vertex neonates. A survival advantage was associated with cesarean delivery in the birth weight analysis up to 1,300 g (P < .05). This decreased mortality for VLBW neonates delivered by cesarean persisted after adjusting for other factors associated with mortality.Very low birth weight vertex neonates are often born by cesarean delivery and have different maternal risk profiles from non-VLBW vertex neonates born by this route. Neonatal mortality was decreased in VLBW neonates delivered by cesarean. Further study is warranted to determine whether this may be a causal relationship or a marker of quality of care.II-2.

    View details for Web of Science ID 000234287700016

  • Social disparities in maternal morbidity during labor and delivery between Mexican-born and US-born white Californians, 1996-1998 AMERICAN JOURNAL OF PUBLIC HEALTH Guendelman, S., Thornton, D., Gould, J., Hosang, N. 2005; 95 (12): 2218-2224


    To assess maternal health disparities, we compared maternal morbidities during labor and delivery among Mexican-born and US-born White, non-Latina women residing in California.This population-based study used linked hospital discharge and birth certificate data for 1996-1998 (862,723 deliveries). We calculated the frequency, and observed and adjusted odds ratios for obstetric complications. Covariates included maternal age, parity, education, prenatal care initiation and payment source, and hospital quality of care.Approximately 1 in 5 deliveries resulted in a obstetric complication. After control for covariates, Mexican-born women were significantly less likely to have 1 or more maternal morbidities than White, non-Latina women but more likely to have complications that reflect the quality of intrapartum care.Maternal morbidities during labor and delivery are a substantial burden for women in California. The favorable overall outcome of Mexican-born women over US-born White, non-Latinas is surprising given their lower educational attainment, relative poverty, and greater barriers to health care access. The favorable outcomes obscure vulnerabilities in those complications that are sensitive to the quality of intrapartum care.

    View details for DOI 10.2105/AJPH.2004.051441

    View details for Web of Science ID 000233656000025

    View details for PubMedID 16257944

  • Time of birth and the risk of neonatal death OBSTETRICS AND GYNECOLOGY Gould, J. B., Qin, C., Chavez, G. 2005; 106 (2): 352-358


    To assess whether mortality is increased in the United States in infants born at night, we compared case-mix adjusted neonatal mortality for low- and high-risk infants born during the daytime (7 am to 6 pm), early night (7 pm to 12 am), and late night (1 am to 6 am).California linked birth-death certificate data on 3,363,157 infants, weighing more than 500 g and born without lethal congenital anomalies in 1992-1999, were analyzed. Logistic regression, adjusting for birth weight, gender, prenatal care initiation, maternal hypertension, eclampsia, diabetes, and placental abruption/previa, was used to estimate the relationship between neonatal mortality and time of birth.The overall neonatal mortality was 2.08 deaths per 1,000 live births. Neonatal mortality was 1.88 for daytime births, increasing to 2.37 for early night and 2.31 for late night births. After adjusting for case mix, early night births had a 12% increase and late night births a 16% increase in the odds of neonatal death, an excess that accounts for 9.6% of all neonatal deaths. Mortality was increased for night births that were less than 1,500 g or more than 1,500 g, singletons or multiples, and those delivered vaginally or by cesarean. The increased risk was identified in hospitals that provide intermediate, community, and regional neonatal intensive care, but not in hospitals that provide primary care.Identifying the causal factors and reducing the increased burden of mortality for infants born at night should be a major priority for perinatal medicine.

    View details for Web of Science ID 000230717800022

    View details for PubMedID 16055587

  • Fetal death sex ratios: a test of the economic stress hypothesis INTERNATIONAL JOURNAL OF EPIDEMIOLOGY Catalano, R., Bruckner, T., Anderson, E., Gould, J. B. 2005; 34 (4): 944-948


    The ratio of male to female live births (i.e. the sex ratio) reportedly falls when populations suffer rare and extreme ambient stressors such as the collapse of national economies. This association has been attributed to the death of male fetuses and to reduced conception of males. We assess the validity of the first of these mechanisms by testing the hypothesis that the fetal death sex ratio varies positively over time with the unemployment rate. Using the unemployment rate also allows us to determine if ambient economic stressors less extreme than collapsing national economies affect the fetal death sex ratio.We test our hypotheses by applying time-series methods to monthly counts of fetal deaths and the unemployment rate from the state of California beginning January 1989 and ending December 2001. The methods control for trends, seasonal cycles, and other forms of autocorrelation that could induce spurious associations.Results support the fetal death mechanism in that male fetal deaths increased above the values expected from female deaths and from history in months in which the unemployment rate also increased over its expected value.Our findings suggest that ambient stressors as common as increasing unemployment elevate the risk of fetal death among males. We discuss the social, economic, and health costs borne by parents and communities afflicted with these fetal deaths.

    View details for DOI 10.1093/ije/dyi081

    View details for Web of Science ID 000231360300042

    View details for PubMedID 15833788

  • Sex ratios in California following the terrorist attacks of September 11, 2001 HUMAN REPRODUCTION Catalano, R., Bruckner, T., Gould, J., Eskenazi, B., Anderson, E. 2005; 20 (5): 1221-1227


    Natural and man-made disasters as well as declining economies appear to coincide with reduced odds of male live births among humans (i.e. lower secondary sex ratio). This association has been attributed to excess death of males in gestation and to reduced conception of males. We attempt to empirically discriminate between these two attributions by testing the hypotheses that the attacks of September 11, 2001 were followed in California first by higher fetal death sex ratios and later by lower sex ratios among very low weight births and total live births.We apply interrupted time-series methods to the fetal death, very low birth weight, and secondary sex ratios. The methods control for trends, seasonal cycles, and other forms of autocorrelation that could induce spurious associations.Findings support the excess death explanation in that the fetal death sex ratio reached its highest level in the 6 year test period in October and November of 2001, while the very low weight birth sex ratio dropped to its lowest level in 14 years in December of 2001. The secondary sex ratio exhibited its second lowest value in 14 years in December of 2001. No support was found for the reduced conception explanation in that the sex ratio did not differ from expected values 9, 10 or 11 months after the attacks.We infer support for the excess death explanation at the expense of the reduced conception explanation. We also describe the implications of our findings for public health planning.

    View details for DOI 10.1093/humrep/deh763

    View details for Web of Science ID 000228636600014

    View details for PubMedID 15734763

  • Cesarean delivery rates and neonatal morbidity in a low-risk population OBSTETRICS AND GYNECOLOGY Gould, J. B., Danielsen, B., Korst, L. M., Phibbs, R., Chance, K., Main, E., Wirtschafter, D. D., Stevenson, D. K. 2004; 104 (1): 11-19


    To estimate the relationship between case-mix adjusted cesarean delivery rates and neonatal morbidity and mortality in infants born to low-risk mothers.This retrospective cohort study used vital and administrative data for 748,604 California singletons born without congenital abnormalities in 1998-2000. A total of 282 institutions was classified as average-, low-, or high-cesarean delivery hospitals based on their cesarean delivery rate for mothers without a previous cesarean delivery, in labor at term, with no evidence of maternal, fetal, or placental complications. Neonatal mortality, diagnoses, and therapeutic interventions determined by International Classification of Diseases, 9th Revision, Clinical Modification codes, and neonatal length of stay were compared across these hospital groupings.Compared with average-cesarean delivery-rate hospitals, infants born to low-risk mothers at low-cesarean delivery hospitals had increased fetal hemorrhage, birth asphyxia, meconium aspiration syndrome, feeding problems, and electrolyte abnormalities (P <.02). Infused medication, pressors, transfusion for shock, mechanical ventilation, and length of stay were also increased (P <.001). This suggests that some infants born in low-cesarean delivery hospitals might have benefited from cesarean delivery. Infants delivered at high-cesarean delivery hospitals demonstrated increased fetal hemorrhage, asphyxia, birth trauma, electrolyte abnormalities, and use of mechanical ventilation (P <.001), suggesting that high cesarean delivery rates themselves are not protective.Neonatal morbidity is increased in infants born to low-risk women who deliver at both low- and high-cesarean delivery-rate hospitals. The quality of perinatal care should be assessed in these outlier hospitals.III

    View details for DOI 10.1097/01.AOG.0000127035.64602.97

    View details for Web of Science ID 000225414600004

    View details for PubMedID 15228995

  • Neonatal mortality in weekend vs weekday births JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Gould, J. B., Qin, C., Marks, A. R., Chavez, G. 2003; 289 (22): 2958-2962


    Increases in neonatal mortality for infants born on the weekend were last noted several decades ago. Although the current health care environment has raised concern about the adequacy of weekend care, there have been no contemporary evaluations of daily patterns of births, obstetric intervention, and case mix-adjusted neonatal mortality.To compare the neonatal mortality of infants born on weekdays and weekends.Case series of 1 615 041 live births (weight >or=500 g) in California between 1995-1997 to determine patterns of births, cesarean deliveries, and neonatal deaths. Analyses were stratified by birth weight and delivery method. To assess the role of weekend differences in case mix, observed and birth weight-adjusted odds ratios (ORs) for increased weekend mortality were estimated using logistic regression.Birth weight-adjusted neonatal mortality.There was a 17.5% decrease in births on weekends, accompanied by a decrease in the proportion of cesarean deliveries from 22% on weekdays to 16% on weekends. Weekend decreases in births were least pronounced in smaller infants, resulting in a weekend concentration of high-mortality, very low-birth-weight (<1500 g) births. Observed neonatal mortality increased from 2.80 per 1000 weekday births to 3.12 per 1000 weekend births (OR, 1.12; 95% confidence interval [CI], 1.05-1.19; P =.001) for all births, and from 4.94 to 6.85 (OR, 1.39; 95% CI, 1.25-1.55; P<.001) for cesarean deliveries. After adjusting for birth weight, the increased odds of death for infants born on the weekend were no longer significant.The provision of optimal care regardless of the day of week is an important goal for perinatal medicine. Comparing the neonatal mortality of infants born on weekdays and weekends provides a straightforward assessment of this goal. After controlling for birth weight, we found no evidence that the quality of perinatal care in California was compromised during the weekend.

    View details for Web of Science ID 000183403400018

    View details for PubMedID 12799403

  • Perinatal outcomes in two dissimilar immigrant populations in the United States: A dual epidemiologic paradox PEDIATRICS Gould, J. B., Madan, A., Qin, C., Chavez, G. 2003; 111 (6): E676-E682


    Previous studies have addressed perinatal outcomes in Hispanic, black, and white non-Hispanic women and demonstrated that although foreign-born Mexican American women have many demographic and socioeconomic risk factors, their rates of low birth weight (LBW) infants and infant mortality are similar to those of white women. This phenomenon has been termed an epidemiologic paradox. There have been no population-based studies on women of Asian Indian origin, a relatively new, highly educated, and affluent immigrant group that has been reported to have a high rate of LBW infants. The objective of this study was to define the sociodemographic risk profile and perinatal outcomes in women of Asian Indian birth and to compare these outcomes to foreign-born Mexican American and US-born black and white women.The vital records for self-reported foreign-born Asian Indian (0.8%) and Mexican women (26.7%) and US-born black (31.2%) and white women (31.2%) were extracted from California's 1 622 324 births, 1995-1997. Sociodemographic risk profiles; the percentage of LBW, very low birth weight (VLBW), prematurity, and intrauterine growth retardation (less than third percentile); and percentage of fetal, neonatal, and postneonatal death rates were compared. Logistic models were used to estimate the importance of selected sociodemographic and medical factors to the prediction of LBW infants in each racial/ethnic group.When compared with whites, US-born blacks and foreign-born Mexican mothers were at increased risk for adverse perinatal outcomes on the basis of higher levels of inadequate prenatal care, teen births, Medi-Cal paid delivery, and lower levels of maternal and paternal education. Foreign-born Asian Indian mothers had good prenatal care, were rarely teenagers, had dramatically higher levels of both maternal and paternal education, and had the lowest percentage of deliveries paid for by Medi-Cal. Black infants had the highest rates of prematurity; intrauterine growth retardation; LBW; and fetal, neonatal, and postneonatal mortality. Paradoxically, despite their high-risk profile, Mexicans did not have elevated levels of LBW or neonatal mortality. Conversely, Asian Indian infants, although seemingly of low sociodemographic risk, had high levels of LBW, growth retardation, and fetal mortality. Logistic regression analysis of independent risk factors for giving birth to an LBW infant showed higher maternal education, early access to prenatal care, and having private insurance to be protective in white non-Hispanic and black but not in Asian Indian and Mexican-born women.Despite their high socioeconomic status and early entry into care, foreign-born Asian Indian women have a paradoxically higher incidence of LBW infants and fetal deaths when compared with US-born whites. Factors that protect from giving birth to an LBW infant in white women were not protective among Asian Indian women. Current knowledge regarding factors that confer a perinatal advantage or disadvantage is unable to explain this new epidemiologic paradox. These findings highlight the need for additional research into both epidemiologic and biological risk factors that determine perinatal outcomes.

    View details for Web of Science ID 000183696000007

    View details for PubMedID 12777585

  • Expansion of community-based perinatal care in California. Journal of perinatology Gould, J. B., Marks, A. R., Chavez, G. 2002; 22 (8): 630-640


    In California, hospitals with Community Neonatal Intensive Care Units (NICUs) increased from 17 in 1990 to 52 in 1997. The purpose of this study was to investigate the effects of their growth on level-specific distribution of births, acuity, and neonatal mortality.A total of 4,563,900 infants born from 1990 to 1997 were analyzed by levels of care. We examined shifts in birth location and acuity. Neonatal mortality for singleton very-low-birth-weight (VLBW) infants without congenital abnormalities was used to assess differences in level-specific survival.Live births at hospitals with Community NICUs increased from 8.6% to 28.6%, and VLBW births increased from 11.7% to 37.4%. Births and VLBW births at Regional NICUs decreased, whereas acuity was unchanged. There were no differences in neonatal mortality of VLBW infants born at Community or Regional NICU hospitals. Mortality for VLBW births at other levels of care was significantly higher.The rapid growth of monitored Community NICUs supported by a regionalized system of neonatal transport represents an evolving face of regionalization. Survival of VLBW births was similar at Community and Regional hospitals and higher than in other birth settings. Reducing VLBW births at Primary Care and Intermediate NICU hospitals continues to be an important goal of regionalization. doi:10.1038/

    View details for PubMedID 12478445

  • Incomplete birth certificates: A risk marker for infant mortality AMERICAN JOURNAL OF PUBLIC HEALTH Gould, J. B., Chavez, G., Marks, A. R., Liu, H. 2002; 92 (1): 79-81


    This study assessed the relationship between incomplete birth certificates and infant mortality.Birth certificates from California (n = 538 945) were assessed in regard to underreporting of 13 predictors of perinatal outcomes and mortality.Of the birth certificates studied, 7.25% were incomplete. Underreporting was most common in the case of women at high risk for poor perinatal outcomes and infants dying within the first day. Increasing numbers of unreported items were shown to be associated with corresponding increases in neonatal and postneonatal mortality rates.Incomplete birth certificates provide an important marker for identifying high-risk women and vulnerable infants. Because data "cleaning" will result in the removal of mothers and infants at highest risk, birth certificate analyses should include incomplete records.

    View details for Web of Science ID 000172875600024

    View details for PubMedID 11772766

  • Newborn discharge timing and readmissions: California, 1992-1995 PEDIATRICS Danielsen, B., Castles, A. G., Damberg, C. L., Gould, J. B. 2000; 106 (1): 31-39


    Hospital stays for newborns and their mothers after uncomplicated vaginal delivery have decreased from an average of 4 days in 1970 to 1.1 days in 1995. Despite the lack of population-based research on the quality-of-care implications of this trend, federal legislation passed in 1996 mandated coverage for 48-hour hospital stays after uncomplicated vaginal delivery.To assess the impact of very early discharge (defined as discharge on the day of birth) on the risk of infant readmission during the neonatal period in a California healthy newborn population.Retrospective cohort study, based on a linked dataset consisting of the birth certificate, newborn, and maternal hospitalization record, and linked infant readmission records for all healthy, vaginally delivered, and routinely discharged California newborns from 1992 to 1995.Very early discharge and infant readmission during the first 28 days of life.The percentage of infants discharged very early or early (after a 1-night stay) increased from 71% in 1992 to 85% in 1995. The percentage of infants discharged very early increased from 5.0% in 1992 to 5.7% in 1993 and 7.0% in 1994, then decreased to 6.7% in 1995. Characteristics that have been previously associated with suboptimal pregnancy outcomes were found to decrease the likelihood of very early discharge, eg, maternal complications, primiparity, and Hispanic, African American, South East Asian, or other Asian race/ethnicity. The rate of readmission in the neonatal period initially decreased from 27.6 infants per 1000 in 1992 to 25.67 infants per 1000 in 1994, then increased to 30.2 infants per 1000 in 1995. For infants discharged early, no statistically significant increase in the risk of readmission was observed, compared with infants discharged after a 2+-night stay. The adjusted odds ratio (OR) for readmission was statistically significantly higher for infants who were discharged very early, compared with infants discharged early (OR: 1.27), first order births (OR: 1.21), infants born to mothers who experienced complications (OR: 1.11), infants with Medicaid insurance (OR: 1.23), and infants born to mothers who received adequate plus prenatal care (OR: 1.15). The risk was statistically significantly lower for female infants (OR: 0.75). The proportion of infants rehospitalized for dehydration and low-risk infections over the 4 study years combined was statistically significantly higher in infants discharged very early (4.37 per thousand and 10.30 per thousand, respectively), compared with infants discharged early (3.59 per thousand and 8.16 per thousand, respectively) or after a 2+-night stay (2.91 per thousand and 7.95 per thousand, respectively). The proportion of infants rehospitalized for dehydration increased statistically significantly from 2.89 per thousand in 1992 to 4.52 per thousand in 1995.One-night stays with adequate antenatal and postnatal care outside the hospital do not increase the risk of readmission for healthy, vaginally delivered infants born in California. However, the decision to discharge infants on the day of birth should be applied conservatively because of the increased risk of infant readmission associated with very early discharge.

    View details for Web of Science ID 000087990400021

    View details for PubMedID 10878146

  • Mortality and time to death in very low birth weight infants: California, 1987 and 1993 PEDIATRICS Gould, J. B., Benitz, W. E., Liu, H. 2000; 105 (3)


    Recent advances in perinatal technology have dramatically increased the survival of very low birth weight (VLBW) infants (<1500 g). The possibility that these advances may also prolong the time to death and increase pain and suffering has been of concern, but there have been no population-based evaluations of this issue.Infant, neonatal, and postneonatal mortality rates and time to death for infants 500 to 749 g, 750 to 999 g, 1000 to 1499 g, and all VLBW infants born during 1987 were compared with those outcomes for infants born in 1993 using statewide California linked birth/death cohort files. To assess the effects of improved survival and changes in time until death, we calculated the total days of life preceding an infant death per 1000 live born infants (TDD).VLBW infants comprised.96% of California's live births in 1987 and.92% of those in 1993. Between 1987 and 1993, VLBW infant mortality rate decreased 28.4% (from 290.7 to 208.3 per 1000 live born VLBW infants), VLBW neonatal mortality rate decreased 30. 3% (from 244.5 to 170.4), and VLBW postneonatal mortality rate decreased 25.3% (from 61.2 to 45.7 per 1000 VLBW alive at 28 days; P <.05 for each rate). Infant mortality rates decreased by 18.8% (718. 1 to 583.0 per 1000) for infants 500 to 749 g, 43.3% (375.1 to 202. 6) for infants 750 to 999 g, and 40.1% (127.9 to 76.7) for infants 1000 to 1449 g (P <.05 for each group). Neonatal mortality and postneonatal mortality rates also decreased in all 3 VLBW subgroups. These reductions in mortality rates were not accompanied by a significant difference in the distribution of times to death or a significant increase in the average time to death for all VLBW infants (22.0 vs 23.6 days) or for those with birth weights of 500 to 749 g (12.7 vs 71.5 days). Reduced mortality in larger infants was accompanied by an increase in the average time to death, from 24. 3 to 32.5 days in infants 750 to 999 g and from 32.3 to 47.0 days in infants 1000 to 1449 g. TDD decreased from 6410 to 4908 days for all VLBW infants. TDD was also reduced 26.4% (2401 days), 24.3% (2115 days), and 22.5% (1043 days) for the 3 VLBW birth weight groups.Both mortality rate and timing of death are important when assessing the impact of advances in perinatal technology. Although the average time to death was significantly increased in VLBW infants weighing >750 g, between 1987 and 1993, advances in perinatal technology dramatically decreased VLBW mortality. In the State of California in 1993, this resulted in 452 fewer VLBW deaths and 8233 fewer days preceding a VLBW death than expected.

    View details for Web of Science ID 000085681100008

    View details for PubMedID 10699139

  • Risk factors for early-onset group B streptococcal sepsis: Estimation of odds ratios by critical literature review PEDIATRICS Benitz, W. E., Gould, J. B., Druzin, M. L. 1999; 103 (6)


    To identify and to establish the prevalence of ORs factors associated with increased risk for early-onset group B streptococcal (EOGBS) infection in neonates. streptococcal (EOGBS) infection in neonates.Literature review and reanalysis of published data.Risk factors for EOGBS infection include group B streptococcal (GBS)-positive vaginal culture at delivery (OR: 204), GBS-positive rectovaginal culture at 28 (OR: 9.64) or 36 weeks gestation (OR: 26. 7), vaginal Strep B OIA test positive at delivery (OR: 15.4), birth weight 18 hours (OR: 7.28), intrapartum fever >37.5 degrees C (OR: 4.05), intrapartum fever, PROM, or prematurity (OR: 9.74), intrapartum fever or PROM at term (OR: 11.5), chorioamnionitis (OR: 6.43). Chorioamnionitis is reported in most (88%) cases in which neonatal infection occurred despite intrapartum maternal antibiotic therapy. ORs could not be estimated for maternal GBS bacteriuria during pregnancy, with preterm premature rupture of membranes, or with a sibling or twin with invasive GBS disease, but these findings seem to be associated with a very high risk. Multiple gestation is not an independent risk factor for GBS infection.h Mothers with GBS bacteriuria during pregnancy, with another child with GBS disease, or with chorioamnionitis should receive empirical intrapartum antibiotic treatment. Their infants should have complete diagnostic evaluations and receive empirical treatment until infection is excluded by observation and negative cultures because of their particularly high risk for EOGBS infection. Either screening with cultures at 28 weeks gestation or identification of clinical risk factors, ie, PROM, intrapartum fever, or prematurity, may identify parturients whose infants include 65% of those with EOGBS infection. Intrapartum screening using the Strep B OIA rapid test identifies more at-risk infants (75%) than any other method. These risk identifiers may permit judicious selection of patients for prophylactic interventions.

    View details for Web of Science ID 000080613400006

    View details for PubMedID 10353974

  • Preventing early-onset group B streptococcal sepsis: Strategy development using decision analysis PEDIATRICS Benitz, W. E., Gould, J. B., Druzin, M. L. 1999; 103 (6)


    To evaluate recommended strategies for prevention of early-onset group B streptococcal infections (EOGBS) with reference to strategies optimized using decision analysis.The EOGBS attack rate, prevalence and odds ratios for risk factors, and expected effects of prophylaxis were estimated from published data. Population subgroups were defined by gestational age, presence or absence of intrapartum fever or prolonged rupture of membranes, and presence or absence of maternal group B streptococcus (GBS) colonization. The EOGBS prevalence in each subgroup was estimated using decision analysis. The number of EOGBS cases prevented by an intervention was estimated as the product of the expected reduction in attack rate and the number of expected cases in each group selected for treatment. For each strategy, the number of residual EOGBS cases, cost, and numbers of treated patients were calculated based on the composition of the prophylaxis group. Integrated obstetrical-neonatal strategies for EOGBS prevention were developed by targeting the subgroups expected to benefit most from intervention.Reductions in EOGBS rates predicted by this decision analysis were smaller than those previously estimated for the strategies proposed by the American Academy of Pediatrics in 1992 (32.9% vs 90.7%), the American College of Obstetricians and Gynecologists in 1992 (53.8% vs 88.8%), and the Centers for Disease Control and Prevention in 1996 (75.1% vs 86.0%). Strategies based on screening for GBS colonization with rectovaginal cultures at 36 weeks or on use of a rapid test to screen for GBS colonization on presentation for delivery, combining intrapartum prophylaxis for selected mothers and postpartum prophylaxis for some of their infants, would require treatment of fewer patients and prevent more cases (78.4% or 80.1%, respectively) at lower cost.No strategy can prevent all EOGBS cases, but the attack rate can be reduced at a cost <$12 000 per prevented case. Supplementing intrapartum prophylaxis with postpartum ampicillin in a few infants is more effective and less costly than providing intrapartum prophylaxis for more mothers. Better intrapartum screening tests offer the greatest promise for increasing efficacy. Integrated obstetrical and neonatal regimens appropriate to the population served should be adopted by each obstetrical service. Surveillance of costs, complications, and benefits will be essential to guide continued iterative improvement of these strategies.

    View details for Web of Science ID 000080613400005

    View details for PubMedID 10353973

  • Antimicrobial prevention of early-onset group B streptococcal sepsis: Estimates of risk reduction based on a critical literature review PEDIATRICS Benitz, W. E., Gould, J. B., Druzin, M. L. 1999; 103 (6)


    To identify interventions that reduce the attack rate for early-onset group B streptococcal (GBS) sepsis in neonates.Literature review and reanalysis of published data.The rate of early-onset GBS sepsis in high-risk neonates can be reduced by administration of antibiotics. Treatment during pregnancy (antepartum prophylaxis) fails to reduce maternal GBS colonization at delivery. With the administration of intravenous ampicillin, the risk of early-onset infection in infants born to women with preterm premature rupture of membranes is reduced by 56% and the risk of GBS infection is reduced by 36%; addition of gentamicin may increase the efficacy of ampicillin. Treatment of women with chorioamnionitis with ampicillin and gentamicin during labor reduces the likelihood of neonatal sepsis by 82% and reduces the likelihood of GBS infection by 86%. Universal administration of penicillin to neonates shortly after birth (postpartum prophylaxis) reduces the early-onset GBS attack rate by 68% but is associated with a 40% increase in overall mortality and therefore is contraindicated. Intrapartum prophylaxis, alone or combined with postnatal prophylaxis for the infants, reduces the early-onset GBS attack rate by 80% or 95%, respectively.Women with chorioamnionitis or premature rupture of membranes and their infants should be treated with intravenous ampicillin and gentamicin. Intrapartum antimicrobial prophylaxis may be appropriate for other women whose infants are at increased but less extreme risk, and supplemental postpartum prophylaxis may be indicated for some of their infants. Selection of appropriate candidates and prophylaxis strategies requires careful consideration of costs and benefits for each patient. group B streptococcus, neonatal sepsis, early-onset sepsis, prevention, prophylaxis.

    View details for Web of Science ID 000080613400007

    View details for PubMedID 10353975

  • Socioeconomic status, neighborhood social conditions, and neural tube defects AMERICAN JOURNAL OF PUBLIC HEALTH Wasserman, C. R., Shaw, G. M., Selvin, S., Gould, J. B., Syme, S. L. 1998; 88 (11): 1674-1680


    This study evaluated the contributions of lower socioeconomic status (SES) and neighborhood socioeconomic characteristics to neural tube defect etiology. The influence of additional factors, including periconceptional multivitamin use and race/ethnicity, was also explored.Data derived from a case-control study of California pregnancies from 1989 to 1991. Mothers of 538 (87.8% of eligible) case infants/fetuses with neural tube defects and mothers of 539 (88.2%) nonmalformed infants were interviewed about their SES. Reported addresses were linked to 1990 US census information to characterize neighborhoods.Twofold elevated risks were observed for several SES indicators. Risks were somewhat confounded by vitamin use, race/ethnicity, age, body mass index, and fever but remained elevated after adjustment. A risk gradient was seen with increasing number of lower SES indicators. Women with 1 to 3 and 4 to 6 lower SES indicators had adjusted odds ratios of 1.6 (1.1-2.2) and 3.2 (1.9-5.4), respectively, compared with women with no lower SES indicators.Both lower SES and residence in a SES-lower neighborhood increased the risk of an neural tube defect-affected pregnancy, with risks increasing across a gradient of SES indicators.

    View details for Web of Science ID 000076694100014

    View details for PubMedID 9807535

  • Racial disparities in outcomes of military and civilian births in California ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Barfield, W. D., Wise, P. H., Rust, F. P., RUST, K. J., Gould, J. B., Gortmaker, S. L. 1996; 150 (10): 1062-1067


    To examine racial disparities in prenatal care utilization, birth weight, and fetal and neonatal mortality in a population for whom financial barriers to health care services are minimal.Using linked birth, fetal death, and infant death certificate files, we examined prenatal care utilization, birth weight distribution, and fetal and neonatal mortality rates for all white and black births occurring in military hospitals in California from January 1, 1981, to December 31, 1985. These patterns were compared with the experience of their civilian counterparts during the same time period.Black mothers had higher percentages of births occurring in teenaged and unmarried mothers than did white mothers in military and civilian populations. First-trimester prenatal care initiation was lower for blacks in the military (relative risk, 0.79; 95% confidence interval, 0.75-0.82) and civilian (relative risk, 0.51; 95% confidence interval, 0.50-0.52) populations. However, the scale of the disparity in prenatal care utilization was significantly smaller (P < .001) in the military group. Rates of low birth weight and fetal and neonatal mortality among blacks were elevated in the military and civilian groups. However, the racial disparity in low birth weight was significantly smaller in the military group (P < .01 and P < .001, respectively).In populations with decreased financial barriers to health care, racial disparities in prenatal care use and low birth weight were reduced. However, the persistence of significant disparities suggests that more comprehensive strategies will be required to ensure equity in birth and neonatal outcome.

    View details for Web of Science ID A1996VM05900010

    View details for PubMedID 8859139



    Data from the Hispanic Health and Nutrition Examination Survey (HHANES) were used to examine a profile of social, medical, and behavioral characteristics associated with low birth-weight (LBW) and miscarriages in first and second generation Hispanics of Mexican descent. The percentage of LBW was 5.3 and of miscarriages was 12.7. LBW rates were higher for second generation primipara and multipara compared with first generation women. Using multivariate logistic regression techniques and adjusting for complex design effects, generation was found to be a significant predictor of LBW but not of miscarriages. The findings support existing evidence that a Mexican cultural orientation protects first generation. Mexico-born women against a risk for LBW. However, the findings do not show significant effects of generation on miscarriages, suggesting that cultural effects are not consistent for all pregnancy outcomes. Furthermore, we suggest that the higher rates of LBW in second generation women are not due to a higher rate of miscarriages as has been hypothesized.

    View details for Web of Science ID A1990EL50100011

    View details for PubMedID 9187584

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