Neonatal abstinence syndrome (NAS) is a postnatal drug withdrawal syndrome that occurs primarily among opioid-exposed infants shortly after birth, often manifested by central nervous system irritability, autonomic overreactivity, and gastrointestinal tract dysfunction (1). During 2000-2012, the incidence of NAS in the United States significantly increased (2,3). Several recent publications have provided national estimates of NAS (2,3); however, data describing incidence at the state level are limited. CDC examined state trends in NAS incidence using all-payer, hospital inpatient delivery discharges compiled in the State Inpatient Databases of the Healthcare Cost and Utilization Project (HCUP) during 1999-2013. Among 28 states with publicly available data in HCUP during 1999-2013, the overall NAS incidence increased 300%, from 1.5 per 1,000 hospital births in 1999, to 6.0 per 1,000 hospital births in 2013. During the study period, significant increases in NAS incidence occurred in 25 of 27 states with at least 3 years of data, with annual incidence rate changes ranging from 0.05 (Hawaii) to 3.6 (Vermont) per 1,000 births. In 2013, NAS incidence ranged from 0.7 cases per 1,000 hospital births (Hawaii) to 33.4 cases per 1,000 hospital births (West Virginia). The findings underscore the importance of state-based public health programs to prevent unnecessary opioid use and to treat substance use disorders during pregnancy, as well as decrease the incidence of NAS.
This research suggests that normal gestational length is shorter in Black and Asian women compared with white European women and that fetal maturation may occur earlier.
3 4 An evaluation of caesarean sections by the American College of Obstetricians and Gynecologists reported that first time mothers with term singleton cephalic pregnancies and women with a previous caesarean section account for the greatest increase in rates of caesarean section and much of the variation between institutions.5 Higher rates of caesarean delivery are associated with increased maternal and neonatal morbidity. 6 Rising rates of caesarean deliveries are assumed to have been driven by obstetricians, reflecting medicolegal concerns about vaginal birth after previous caesarean section (VBAC), vaginal breech delivery, and fetal distress in labour. In contrast, over a similar time period there has been increased emphasis on involvement of patients in making medical decisions.7-9 The traditional paternalistic model of care is based on the premise that the obstetrician knows best and by taking the lead on decisions could reduce anxiety and risk for the mother and her baby. 10 The shared model of medical decision making, in which clinician and patient exchange information, reveal preferences for treatment, and jointly come to a decision, is now promoted in preference to other models. [10][11][12] Decision aids are designed to help people select between various treatment strategies by providing information on the options and outcomes relevant to a person's health. A Cochrane review has reported that decision aids can improve knowledge and realistic expectations, reduce decisional conflict, and increase active participation in decision making. 13 A recent consensus process identified key aspects of quality of patients' decision aids relating to content, development, and effectiveness. 14 Determining the optimal mode of delivery for a woman who has experienced a previous caesarean section requires consideration of the risks and benefits of
A careful exploration of risk factors may allow us to identify reasons for the increasing rates of Caesarean section and the marked variation between institutions.
Objectives To determine if the risks of perinatal mortality and antepartum stillbirth associated with post term birth increase earlier during pregnancy in South Asian and black women than in white women, and to investigate differences in the factors associated with antepartum stillbirth between the racial groups.
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