Additionally, rates of preterm birth by subgroup were examined. As previously described,pregnancies resulting in spontaneous preterm birth were considered to be those where birth certificate or hospital discharge records indicated premature rupture of membranes , premature labor, or those for whom tocolytic medications were administered. Pregnancies resulting in provider initiated preterm births were considered to be those without PROM, premature labor or tocolytic administration for which there was a code for “induction” or “artificial rupture of membranes”; or for which there was a cesarean delivery without any of the aforementioned codes. Counts and rates were not reported when n < 16 to protect the identity of individuals in the dataset. All analyses were performed using Statistical Analysis Software version 9.4 . Methods and protocols for the study were approved by the Committee for the Protection of Human Subjects within the Health and Human Services Agency of the State of California. Data used for the study were received by the California Preterm Birth Initiative at the University of California San Francisco by June 2016.In this study of preterm births in Fresno County, we found that differences in the type and magnitude of risk and protective factors differed by the residence in which women reside. Black women and women with diabetes, hypertension, infection,ebb and flow trays fewer than three prenatal care visits, previous preterm birth or interpregnancy interval less than six months were at increased risk of preterm birth, regardless of location of residence.
Public insurance, maternal education less than 12 years, underweight BMI, and interpregnancy interval of five years or more were identified as risk factors only for women in urban residences. Women living in urban locations who were born in Mexico and who were overweight by BMI were at lower risk for preterm birth; WIC participation was protective for women in both urban and rural locations. Taken together, these findings suggest targeted place-based interventions and policy recommendations can be pursued. The preterm birth risk factors identified in these analyses are not unique to Fresno County: previous work has also shown that women of color, lower education, lower socioeconomic status, women with co-morbidities such as hypertension and diabetes, smoking, and short interpregnancy interval are at elevated risk of preterm birth.In Fresno County, however, we observed that these risks differ in magnitude. This is critical, as the percentage of women in each region with the risk factor can vary greatly. Hispanic women were at increased risk of preterm birth in rural residence. The degree of risk was mild – only a 1.1-fold increase in risk. However, 72% of the population giving birth in rural Fresno County is Hispanic, suggesting that focusing interventions reaching this population may provide the most impact. Similarly,Black women were at elevated risk of preterm birth regardless of location of residence. Since urban residences have the highest percentage of Black women and rural has the lowest , focusing prevention efforts for Black women in urban residences may be an effective approach. Others have found that with pre-pregnancy initiation of Medicaid , has been associated with earlier initiation of prenatal care, a factor that may reduce preterm birth rates.In addition, participation in the WIC program also has shown a moderate reduction of the risk of a small for gestational age infant and has been associated with reduced infant mortality in Black populations.
Fresno women from both urban and rural residences who participated in the WIC program were less likely to deliver preterm, while those women living in urban locations who were publicly insured through Medi-Cal coverage for delivery were at increased risk for preterm birth. Low income is a criterion for both public assistance programs, and over 32% of families in this region lives below the poverty line; it is apparent that social economic status is a complex risk factor for preterm birth. A key take away message from this study is that women who accessed prenatal care more frequently – three or more prenatal care visits – were less likely to deliver preterm. Fresno County may be able to improve preterm birth rates by addressing factors that encourage prenatal care access, which may include enrollment in Medi-Cal during the preconception period and increasing WIC participation. Identifying regions where a high percentage of women do not access three or more prenatal care visits may suggest locations for an intervention such as home visits or mobile clinic. Using a large administrative database allows for examination of rates and risks that would not be possible with other data sources. Despite these strengths, the study has some critical limitations. By design, the findings are very specific to one area of California and may not be as applicable to other areas of the state, country, or world. In fact, we recently conducted a similar study examining preterm birth risk factors by sub-type for all of California.Similar to the entire California population, we demonstrated increased risk of preterm birth for Fresno County women who were of Black race/ethnicity, who had diabetes or hypertension during pregnancy, or who had a previous preterm birth. However, Fresno County was different from the whole state in a few ways.
Unlike the state of California as a whole, Hispanic women, women over 34 years at delivery, and underweight women in urban residences in Fresno County were at increased risk for preterm birth. Also, education over 12 years did not provide protection against preterm birth in any of the Fresno County residences, although higher education did provide protection when we looked at the whole state of California. These differences point to specific pathways occurring in Fresno County that may be distinct from the state as a whole, and demonstrate the value of place-based investigation of risk factors when examining a complex outcome such as preterm birth. Other residences may benefit from similar analyses to identify risk and protective factors that are important on a local level. An additional limitation, as with most administrative databases, is that accuracy and ascertainment of variables is not easily validated. Previous studies of California birth certificate data suggests that race/ethnicity is a valid measure of self-identified race/ethnicity for all but Native Americans, and best obstetric estimate of gestation may underestimate preterm delivery rates.Previously reported rates of preterm birth in Fresno County are around 9.5% and was 8.4% overall in our population after removing multiple gestation pregnancies and pregnancies with major birth defects. Additionally, United States estimates for drug dependence/use during pregnancy is 5.0% to 5.4% and was only 2.5% in our population. This under ascertainment may mean that we are capturing the most severe diagnoses, potentially overestimating our risk calculations. Alternatively,4×8 flood tray under ascertainment also implies that drug users were likely in our referent population, which would underestimate our risk calculations. This examination of Fresno County preterm birth may provide important opportunities for local intervention. Several populations were identified as at risk, regardless of location of maternal residence, that deserve targeted interventions. Interventions focused on diabetes, hypertension, and drug or alcohol dependence/abuse across the county may be effective for preterm birth reduction. We identified several modifiable risk and resilience factors across the reproductive life course that can be addressed to reduce preterm birth rates. Given the complex clinical and social determinants that influence preterm birth, cross-sector collaborative efforts that take into account place-based contextual factors may be helpful and are actively being pursued in Fresno County. Ultimately, refining our understanding of risk and resilience and how these factors vary across a geography are fundamental steps in pursuing a precision public health approach to achieve health equity. Substance use, which has been associated with a wide range of negative health outcomes and societal consequences, is highly prevalent among gender and sexual minority populations, including trans*females . Weighted estimates of trans*female samples in the United States reveal high prevalence of crack and other illicit drug use and marijuana use as well as a higher prevalence of problems with alcohol and other drugs relative to the general population .
Furthermore, substance use has been associated with HIV-related sexual risk behaviors and HIV infection among trans*females, who have 34.21 fold greater odds of HIV infection compared to the US general adult population . Given the link between substance use and negative health outcomes in this population, including HIV infection, it is imperative to understand risk factors that may contribute to the use of illicit drugs. This is particularly important among trans*female youth, when events that develop early in life and cause later risk can be intervened upon. Based on limited data from non-probability-based estimates, there is a sharp increase in the prevalence of HIV infection between samples of trans*female youth and trans*female adults in the US , highlighting the critical nature of HIV risk factors that influence behaviors during adolescence and early adulthood . Furthermore, compared to both males and females, trans*females have the lowest five-year survival probability after AIDS in San Francisco, suggesting that this increase in prevalence from youth to adulthood cannot be fully explained by the increase in cumulative HIV prevalence in older age groups . Moreover, adolescent onset of drug and alcohol consumption has been shown to predict consumption levels in early and later adulthood . However, despite the high burden of substance use and HIV among the overall trans*female population, little is known about the prevalence and correlates of substance use in trans*female youth . Due to the limitations in the classification of gender in broader surveillance surveys in the US, significant gaps in the understanding of the unique health and risk patterns among trans*females remain . Compounding the problem, the limited data for trans*females are also rarely disaggregated by age . These gaps make gender minorities—particularly young gender minorities—a vastly understudied population, hindering the development of effective public health interventions that specifically target trans*female and youth-specific health issues . Trans*female youth may face a unique set of challenges that make them particularly vulnerable to substance use. Certain mental health outcomes, associated sequelae, and traumatic experiences may be more prevalent among young trans*females, including elevated prevalence of suicide, engagement in sex work, and victimization by violence and trauma . In turn, these co-morbidities have been associated with substance use; for example, post traumatic stress disorder , psychological distress and depression have been associated with the use of individual substances as well as multiple substances . Similarly, perceived discrimination has been linked to substance use in multiple populations . Additionally, drug and alcohol use of parents has been shown to predict adolescent drug and alcohol use . The role of these psychosocial conditions among trans*female youth has not yet been fully elucidated. This study sought to address these gaps in the literature by describing the prevalence of substance use in a sample of trans*female youth, age 16 to 24 years at enrollment, in an on-going cohort study. This study also sought to explore the relationships between psychosocial risk factors and substance use outcomes in this population. In this article, we have used the word “trans*females” throughout, but we should note that participants identified both as transgender, female, gender queer and a variety of other genders along the transgender spectrum. Our decision to use “trans*females” is the result of a community process that was undertaken in San Francisco, California, to agree on the most inclusive terms to capture the spectrum of male-to-female transgender identities while also respecting individuals along the age spectrum . The SHINE study is a longitudinal study of HIV risk and resilience among trans*female youth; the present analysis uses baseline data from enrollment visits between August, 2012 and December, 2013 as a cross-sectional sample. The target sample size for the study was 300. Study participants were initially recruited using a peer-referral method to obtain a diverse sample of this hard-to-reach population. Slow recruitment chains resulted in adaptations to the sampling methodology including allowance of e-referrals and expanding the number of referrals that successful recruiters could have . In total, 100 participants were recruited through peer referral. In addition to peer referral, participants were recruited through outreach on social networking sites and in person at events attended by trans*female youth as well as with referrals from both community-based organizations that provide social services to transgender women and youth and gender-specific health clinics. Individuals were eligible for the study if they self-identified as any gender other than that associated with their assigned male sex at birth, were 16–24 years of age, and lived in the San Francisco Bay Area.