1. VAGINAL INFECTIONS & ADVERSE BIRTH OUTCOMES: Findings from the 2004-2007 Mississippi PRAMS Kristin Z. Black, MPH UNC Gillings School of Global Public Health

2. STI Surveillance in the U.S.  19 million new cases of STIs every year  Chlamydia, Gonorrhea, & Syphilis are the only notifiable STIs reported to the CDC  Chlamydia is the most commonly reported STI  Young people ages 15-24, especially young women of color, are bearing the burden

3. Are vaginal infections (e.g., yeast, bacterial vaginosis, Chlamydia, Gonorrhea) associated with adverse birth outcomes (e.g., PTB, LBW) among Mississippi women after controlling for maternal factors? RESEARCH QUESTION:

4. 1) Women who reported having vaginal infections during their most recent pregnancy are more likely to have experienced adverse birth outcomes (e.g. PTB, LBW) than women who did not report having vaginal infections. 2) The relationship between vaginal infections and adverse birth outcomes will be partially explained by maternal factors. HYPOTHESES:

5. Mississippi PRAMS  Ongoing, population- based surveillance system  57 core & 12 state questions  Oversample VLBW infants  Phase V: 2004, 2006, & 2007  n = 3535  13-44 years old

6. Characteristics of Survey Participants CharacteristicUnweighted CountPercent (%) Race/Ethnicity Black/non-Hispanic176850.70% White/non-Hispanic171949.30% Age (years) ≤ 15441.24% 16-1957716.32% 20-34262074.12% 35+2948.32% Education Level Less than high school82723.45% High school113032.05% Greater than high school156944.50%

7. Characteristics of Survey Participants CharacteristicUnweighted CountPercent (%) Body Mass Index (BMI) < 18.52005.91% 18.5-24.9157046.39% 25-29.977522.90% 30-34.942212.47% 35+41712.32% Marital Status Not married or other182651.65% Married170948.35% Hypertensive Disorder Hypertensive87424.94% Normotensive263075.06%

8. Characteristics of Survey Participants CharacteristicUnweighted CountPercent (%) Initiation of Prenatal Care 1 st trimester256374.42% 2 nd trimester78022.65% 3 rd trimester381.10% None631.83% Tobacco Use 10+ cigarettes/day14616.19% 1-9 cigarettes/day39744.01% 0 cigarettes/day35939.80%

9. Characteristics of Survey Participants

10. Participants with Vaginal Infections by Outcome Variables

11. Logistic Regression Models Table 3 – Logistic Regression Modeling for Vaginal Infections and Adverse Birth Outcomes MODEL 1MODEL 2MODEL 3 Gestational Age Vaginal Infections Birthweight Vaginal Infections Gestational Age Vaginal Infections + Race/Ethnicity Vaginal Infections + Age Vaginal Infections + BMI Vaginal Infections + Education Level Vaginal Infections + Marital Status Vaginal Infections + Initiation of PNC Vaginal Infections + Tobacco Use Vaginal Infections + Hypertensive Disorder Birthweight (Same as above) Gestational Age Vaginal Infections + ALL Variables Birthweight Vaginal Infections + ALL Variables

12. Analyzing Risk

14. Strengths + Limitations STRENGTHS  Population-based sample  34% of the population had vaginal infections LIMITATIONS  Self-reported data  Low response rate in 2005 & 2007  Write-Ins

15. Conclusion + PH Implications  Both of my hypotheses were confirmed, yet the ORs were close to 1.00  Vaginal infection treatment during pregnancy hasn’t been shown to improve birth outcomes  Women should be screened and treated for STIs prior to becoming pregnant  Imperative that women receive preconception and preventive care throughout their lifecourse

16. Acknowledgements

17. References (1) Centers for Disease Control and Prevention. Sexually Transmitted Diseases in the United States, 2008: national surveillance data for Chlamydia, Gonorrhea, and Syphilis. 2009 Nov:1-7. (2) Cotch MF, Pastorek JG2, Nugent RP, Hillier SL, Gibbs RS, Martin DH, et al. Trichomonas vaginalis associated with low birth weight and preterm delivery. Sex.Transm.Dis. 1997 Jul;24(6):353-360. (3) Hillier SL, Nugent RP, Eschenbach DA, Krohn MA, Gibbs RS, Martin DH, et al. Association between bacterial vaginosis and preterm delivery of a low-birth-weight infant. N.Engl.J.Med. 1995 Dec;333(26):1737-1742. (4) Andrews WW, Goldenberg RL, Mercer B, Iams J, Meis P, Moawad A, et al. The Preterm Prediction Study: association of second- trimester genitourinary chlamydia infection with subsequent spontaneous preterm birth. Obstet.Gynecol. 2000;183(3):662-668. (5) Blas MM, Canchihuaman FA, Alva IE, Hawes SE. Pregnancy outcomes in women infected with Chlamydia trachomatis: a population- based cohort study in Washington State. Sex.Transm.Infect. 2007 Jul;83(4):314-318. (6) Johnson HL, Ghanem KG, Zenilman JM, Erbelding EJ. Sexually Transmitted Infections and Adverse Pregnancy Outcomes Among Women Attending Inner City Public Sexually Transmitted Diseases Clinics. Sex.Transm.Dis. 2010 Sep 16;37(12):1-5. (7) Mann JR, McDermott S, Gill T. Sexually transmitted infection is associated with increased risk of preterm birth in South Carolina women insured by Medicaid. J.Matern.Fetal.Neonatal Med. 2010 Jun;23(6):563-568. (8) Andrews WW, Klebanoff MA, Thorn EA. Midpregnancy genitourinary tract infection with Chlamydia trachomatis: association with subsequent preterm delivery in women with bacterial vaginosis and Trichomonas vaginalis. Obstet.Gynecol. 2006;194(2):493- 500. (9) Silveira MF, Ghanem KG, Erbelding EJ, Burke AE, Johnson HL, Singh RH, et al. Chlamydia trachomatis infection during pregnancy and the risk of preterm birth: a case-control study. Int.J.STD AIDS 2009 Jul;20(7):465-469. (10) Riggs MA, Klebanoff MA. Treatment of vaginal infections to prevent preterm birth: a meta-analysis. Clin.Obstet.Gynecol. 2004 Dec;47(4):796-807. (11) O'Brien RF. Bacterial vaginosis: many questions--any answers? Curr.Opin.Pediatr. 2005 Aug;17(4):473-479. (12) Carey JC, Klebanoff MA. What have we learned about vaginal infections and preterm birth? Semin.Perinatol. 2003 Jun;27(3):212-216.

18. QUESTIONS???