Personalized Care for Prenatal Stress Reduction & Prevention of Preterm Birth (PTB) Disparities

N/ANot Yet RecruitingNCT06915428

University of North Carolina, Chapel Hill1,228 enrolled

Overview

The goal of this clinical trial is to learn if a personalized prenatal support program \[(Personalized Toolkit Building a Comprehensive Approach to Resource optimization and Empowerment in Pregnancy \& Beyond, (PTBCARE+)\] works to lower stress and lower the risk of early delivery in pregnant individuals at high-risk for delivering preterm. The main question\[s\] it aims to answer are: * Does the PTBCARE+ patient support program lower patient-reported stress levels during pregnancy? * Does the PTBCARE+ patient support program improve biologic measures of stress during pregnancy? * Does the PTBCARE+ patient support program result in a higher chance of delivering a healthy baby at or close to full term? Researchers will compare people who participate in the PTBCARE+ patient support program to those receive usual care to see if the PTBCARE+ patient support program lowers patient-reported stress, improves biologic measures of stress, and increases the chance of delivering a healthy baby at or close to full term. Participants will be randomly assigned to receive the PTBCARE+ patient support program or usual prenatal care. All participants will be asked to: * complete 2 study visits during pregnancy - including completing electronic surveys, providing a blood and urine sample, measuring the heart rate variability by a clip or the ear or finger, and body composition evaluation using a simple scale-like device. * complete one study visit postpartum that includes completing electronic surveys, and measuring heart rate variability. Blood and urine sample collection and body composition evaluation via InBody scale are optional at the postpartum visit. People who are randomly assigned to receive the PTBCARE+ support program will receive several resources to help them during pregnancy. These things include items such as: * a stress reduction toolkit; * access to an online website that can also be downloaded as a smart phone app; * the option to receive an electronic massage while in clinic, and more. * additional support gifts provided at routine clinical appointments People who are randomly assigned to receive usual prenatal care will not receive any additional support resources from the study during pregnancy.

This project addresses the major public health problem of preterm birth (PTB), delivery \<37 weeks, by deploying a novel, personalized, comprehensive 3-tier PTB prevention program \[University of North Carolina (UNC) PTBCARE+\]. PTB affects 1 in 10 infants born in the United States (US) and is the leading cause of neonatal morbidity and mortality; survivors are at high risk for lifelong adverse health sequelae. Stress is an established risk factor for both spontaneous PTB (sPTB) and medically indicated PTB miPTB). Of significant public health concern, Black patients have 49% higher rates of PTB, are more likely to have early PTB, and increased perceived stress in pregnancy compared to patients of other races. Stress may alter biology, including stress-related gene expression in maternal blood and allostatic load index. Evidence from other fields of medicine supports incorporation of both stress reduction programs and 'patient navigators' as effective approaches to improve health outcomes, and data in obstetrics supports improved outcomes with PTB specialty clinics. However, such programs are not routinely employed in obstetrics. The effect of a specialty prenatal care program targeting stress reduction as a strategy to reduce PTB and PTB disparities remains unknown, representing a critical knowledge gap. The central hypothesis of this project is that enrollment in a personalized, comprehensive PTB support program (UNC PTBCARE+) is associated with reduced perceived stress, stress-related gene expression, allostatic load, and lower rates of PTB \<35 weeks. This hypothesis is supported by published and preliminary data as follows: First, UNC pregnant patients at high risk for PTB have high rates of stress and life stressors (e.g., financial insecurity, racism). Second, biologic stress markers including gene transcript levels differ by PTB status in mid-pregnancy blood. Third, specialty PTB care reduces stress in a NC cohort. Building upon prior work and that of others, this exciting proposal evaluates the efficacy of the novel UNC PTBCARE+ program. The investigation focus on PTB \<35 weeks due to its relative frequency, higher association with neonatal morbidity and mortality as compared to later PTB, to include PTB in the 34th week of gestation (because the delivery gestational age considered 'standard of care' for delivery among individuals with stable but severe preeclampsia and preterm membrane rupture), and to align with multiple other published PTB RCTs. This study will recruit 1,350 pregnant patients between 8+0 and 19+6 weeks gestation with an elevated a priori risk of either medically-indicated preterm birth or spontaneous preterm birth. Subjects will be randomized 2:1 to receive UNC PTBCARE+ vs. usual care. Randomization will be stratified based on maternal race and ethnicity (individuals who identify only as White and non-Hispanic vs. individuals who identify as belonging to one or more other races and/or Hispanic ethnicity and (b) perceived stress scores (those with perceived stress scores ≥20 vs. those with lower perceived stress scores scores). All participants, regardless of randomization assignment, will have 2 study visits during pregnancy. * Visit 1 (V1) will occur at randomization, 8+0 - 19+6 weeks gestation. * Visit 2 (V2) will occur in mid pregnancy, between 22+0 and 29+6 weeks gestation. At both visits, patients will complete validated surveys evaluating a broad spectrum of stressors, discrimination, adverse childhood experiences, perceived social support, resiliency, medication barriers and adherence, care access and satisfaction,, intervention fidelity and sustainability, use of stress relief modalities, and have blood collected to measure biologic stress markers. The UNC PTBCARE+ program is personalized. All patients randomized to UNC PTBCARE+ receive a stress reduction toolkit and will work with a PTB Care Coordinator who will provide support, facilitate clinician-prescribed medical care, and serve as a patient-provider liaison. Additional benefits / support items and support elements are provided to some participants on an "as needed" basis, per study protocol, and are not included in the initial registration to preserve scientific integrity and protect the rights of research participants. This study registration will be updated with complete intervention details after the study is fully enrolled and all participants have delivered. Psychosocial and financial stressor screening results from V1 will determine UNC PTBCARE+ tier assignment. Thus, participants are randomized only after Visit 1 surveys are completed. This solutions-oriented RCT of UNC PTBCARE+ vs. usual care provides an ideal forum to test the primary hypothesis and study stress-related PTB pathophysiology through the following Aims: * Aim 1. Evaluate the effects of the UNC PTBCARE+ program on perceived stress and resilience in pregnant patients at high risk for PTB. Hypothesis: Patients randomized to UNC PTBCARE+ will have lower levels of perceived stress and higher levels of resilience at V2 vs. V1; those randomized to usual care will have no change. * Aim 2. Quantify the extent to which the UNC PTBCARE+ program is associated with improved biologic stress measures during pregnancy. Hypothesis: Patients randomized to UNC PTBCARE+ will have reduced stress-related gene expression and allostatic load scores in maternal blood at V2 vs. V1 compared to those randomized to usual care who will have no change, increasing insight into PTB pathophysiology. * Aim 3. Determine the effects of the UNC PTBCARE+ program on PTB \<35 weeks. Hypothesis: Patients randomized to UNC PTBCARE+ will have lower rates of early PTB compared to those randomized to usual care. This study provides tangible, personalized solutions to the major public health problem of PTB and carries enormous potential to provide generalizable, low-risk strategies to reduce PTB and related disparities.

Interventions

Care coordinationBEHAVIORAL

Research team members will serve as research assistants and will also function as perinatal care coordinators. In the care coordination role, team members will provide emotional support, liaise with clinical staff, and execute regularly scheduled check-ins with each study participant. Team members also assist with helping participants with logistics, obtaining and remembering to take prescribed medications, and other similar related activities. Participants receive access to contact the research assistant / care coordinator by text, email, phone, or through the electronic medical record participant portal. \- Per protocol, the research staff will meet in person with participants at least twice (visit 1, visit 2) during pregnancy and once postpartum (0-10 weeks after delivery, for most participants). Research staff may also meet in person with participants prior to visit 1 for recruitment/enrollment purposes.

Electronic massageBEHAVIORAL

Participant is given the option to receive a 15-minute electronic massage / relaxation session in clinic via (a) a specialized massage chair or (b) a massage pad that is placed on top of a standard recliner chair. * the electronic massages provide gentle massages and are safe for most people to use throughout pregnancy. * participants are always be in control of the massage experience and will be given instructions on how to stop the massage at any time. * participants are advised to consult the primary obstetric provider before using the massage chair regarding any specific concerns or questions * during the session, participants may view relaxation videos (from free, publicly available sites online). * participants may choose to sign up for massage(s) at any obstetric visit in the clinic between visit 1 and delivery.

support gift #1BEHAVIORAL

* Small gift packet with encouraging items (example of items = coloring kit, tea lights, stickers, bookmarks, keychain fidget toy, printed support index cards, and other similar items). * Given between 14+0 and 23+6 weeks gestation at time of routine prenatal appointment

Support gift #2BEHAVIORAL

* Small gift packet with encouraging items (example of items = coloring kit, tea lights, stickers, bookmarks, keychain fidget toy, printed support index cards, and other similar items). * Given between 18+0 and 27+6 weeks gestation at time of routine prenatal appointment

Support gift #3BEHAVIORAL

* Small gift packet with encouraging items (example of items = coloring kit, tea lights, stickers, bookmarks, keychain fidget toy, printed support index cards, and other similar items). * Given between 22+0 and 29+6 weeks gestation at time of routine prenatal appointment

Support gift #4BEHAVIORAL

* Small gift packet with encouraging items (example of items = coloring kit, tea lights, stickers, bookmarks, keychain fidget toy, printed support index cards, and other similar items). * Given between 26+0 and 33+6 weeks gestation at time of routine prenatal appointment

Additional PTBCARE+ supportBEHAVIORAL

Additional benefits / support items and support elements are provided to some participants on an "as needed" basis, per study protocol. * Information / details intentionally withheld and not made public in order to preserve the scientific validity of the study and protect the rights of the research participants * participant eligibility for additional resources as a part of the PTBCARE+ program will be determined by the research staff on the day of Visit 1 after initial set of surveys are completed, and is per protocol

Stress reduction toolkit - Visit 1 (V1)BEHAVIORAL

In person check-in with research team member re: participant's needs; research team member provides support. Physical items that are included as part of this visit include: Tote bag with the following stress reduction items or similar: * eye mask * set of pocket index cards, printed back and front, on a variety of topics that influence pregnancy health, ranging from physical to emotional/mental * water bottles * small notebook * pill minder case * magnet and business card for Health Resources and Services Administration (HRSA) national maternal mental health hotline * log in codes for electronic resources * initial handouts with self care plan, introduction to stress reduction toolkit, etc.

PTBCARE+ mobile application (app) and websiteBEHAVIORAL

Comprehensive, study-specific app that is available as a website or as a downloadable application that includes personalized, interactive modules and resources * no study related materials are available without a password * goal is to collate reputable sources of information to make investigating things online easier * includes optional educational modules for participants * also includes option of entering stress, well-being, blood sugar, blood pressure, etc. values with option to easily download recorded values for patient's clinical team * available online (computer/laptop), tablet, or smart phone. can be downloaded as a progressive web application (PWA) to a local device and used without internet access * Electronic access to the PTBCARE+ website will continue through 10 weeks postpartum unless the participant delivered \<16+0 weeks gestation in which case access will continue through 4 weeks postpartum

Sleep, meditation, and Wellness appBEHAVIORAL

* complimentary one-year subscription to Aura - an 'all-in-one' wellbeing app that contains an enormous library of meditations, stories, breath work, work wellness, music, sounds, and more! * Participants can access this app as needed throughout pregnancy and beyond, for up to one year after the date of enrollment

Emergency low blood sugar kitBEHAVIORAL

Pouch contains: * printed index card with information about signs and symptoms of low blood sugar * printed index card with information about what to do if blood sugar is low * 2-3 non-perishable, individually wrapped over the counter candy / glucose-raising options; use for low blood sugar treatment is described on the card Only participants who have a diagnosis of diabetes mellitus or glucose intolerance AND have been prescribed an oral medication for blood sugar control or have been prescribed insulin are eligible to receive this. Each participant can receive a maximum of two kits during pregnancy; first at enrollment, and the other at visit 2 or until delivery

Low dose aspirin (LDA)BEHAVIORAL

* Bottle of 90-100 pills (depending on manufacturer) * Provided at Visit 1 (after randomization) * Patients who received a bottle of low-dose aspirin at Visit 1 are offered a 2nd bottle at Visit 2. All patients whose provider recommends or prescribes either 81mg or 162mg of LDA during pregnancy are offered LDA as described herein. LDA must be on the patient's med list or specific notes from the patient's prenatal provider must explicitly note that it is recommended the patient take LDA in pregnancy for it to be offered. Individuals who are receiving LDA due to participation in another study are not eligible to receive LDA from PTBCARE+ Please note that this is listed as a "behavioral" intervention rather than "drug" intervention because the rational behind providing this over the counter medication is to help make the participant's life easier, and the focus is not on the efficacy of LDA. As such, it is being provided as a behavioral intervention.

Visit #2 Stress Reduction ToolkitBEHAVIORAL

In person check-in with research team member re: participant's needs; research team member provides support. Physical items that are included as part of this visit include the following stress reduction items or similar: 1. Frame + ultrasound photo + certificate of achievement! * Picture from anatomy ultrasound (or other subsequent ultrasound) is downloaded, printed, and placed in frame. * Certificate of achievement is printed and placed on other side of frame with ultrasound photo 2. other small items including stickers, printed index cards with supportive messaging, etc.

Eligibility

Sex: FEMALEMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: 1. Viable, singleton pregnancy, 8+0 to 19+6 weeks, dated by last menstrual period ± ultrasound using standard obstetric criteria per American College of Obstetricians and Gynecologists. Gestational age at first ultrasound by last menstrual period (LMP) / Ultrasound method / Measurement agreement with LMP required • Up to 8 weeks 6 days / crown rump length / ± 5 days * 9 weeks 0 days to 13 weeks 6 days / crown rump length / ± 7 days * 14 weeks 0 days to 15 weeks 6 days / standard fetal biometry / ± 7 days * 16 weeks 0 days to 19 weeks 6 days / standard fetal biometry / ± 10 days * Gestational dating / fetal viability must be confirmed by ultrasound prior to enrollment / randomization. * Ultrasound report must include documentation of normal fetal heart rate of ≥ 120 beats per minute, or subsequent medical record documentation of auscultation of fetal heart rate ≥ 120 beats per minute. * Viability must be confirmed / re-confirmed within 7 days of randomization. If initial consent occurs early in pregnancy and V1/randomization occur later, viability must be reconfirmed to ensure ongoing eligibility prior to initiating V1 activities (including surveys) and proceeding with randomization. 2. No signs or symptoms of, or clinical diagnosis of, evolving miscarriage, active preterm labor, preterm prelabor rupture of membranes at the time of enrollment. * Cervical dilation at the time of enrollment is an exclusion criterion. However, cervical evaluation and digital cervical exam is not required prior to enrollment. (3a) High a priori risk for medically indicated preterm birth - must meet at least one of the following 3 criteria (maternal medical history, prior pregnancy history, or moderate risk factor history) * miPTB criteria #1: Maternal Medical History - any one of the following: o Known chronic hypertension requiring medications in the 3 months prior to conception or prior to 22 weeks gestation. o At least 2 blood pressure readings 6 hours apart, \<20 weeks gestation, with systolic ≥ 130 mmHg or diastolic ≥ 80 mmHg \*regardless of need for medication or formal diagnosis of hypertension in chart\* o Pre-gestational diabetes mellitus. * Diabetes diagnosed \<20 weeks gestation. * Maternal chronic or sub-acute renal disease, including chronic kidney failure, chronic renal insufficiency, glomerulonephritis, lupus nephritis, defined as any: \*biopsy proven chronic renal disease history; and/or \*serum creatinine ≥ 1.1 mg/dL at any time during pregnancy prior to enrollment, in the absence of other identifiable transient factors per clinician's assessment (e.g., extreme dehydration, cystitis, pyelonephritis); and/or \*chronic proteinuria, defined as baseline urine protein:creatinine ratio ≥ 0.30 mg/dL or 24 hour total urine protein ≥ 300 mg in the absence of other identifiable transient factors per clinician's assessment (e.g., extreme dehydration, cystitis, pyelonephritis) \*Systemic Lupus Erythematosus * Antiphospholipid Antibody Syndrome * miPTB criteria #2: Prior pregnancy history - any ONE of the following: o Previous pregnancy complicated by preeclampsia or hypertensive disorders of pregnancy at any gestational age, in a singleton gestation; the fetus must not have had major structural anomalies or aneuploidy. o Previous history of stillbirth ≥ 16+0 weeks in a singleton gestation; the fetus must not have had major structural anomalies or aneuploidy. The stillbirth etiology must not have been attributed to physical trauma (e.g., domestic violence, motor vehicle accident) or illicit drug use (e.g., cocaine use leading to abruption and stillbirth). * miPTB criteria #3: Any two or more of the following moderate risk factors: o Nulliparity, defined as no prior pregnancy to reach at least 20 weeks gestation note that this is the traditional / classic definition of 'nulliparous' and that there is overlap between nulliparity as defined this way and 'preterm birth' due to cervical insufficiency, which allows for deliveries in the 16-19 week gestational age range to be considered as 'preterm births' o Obesity: current or pre-pregnancy body mass index ≥30 kg/m\^2 o Family history: first degree relative with a history of preeclampsia o Advanced maternal age: maternal age ≥ 35 years at estimated date of confinement o Prior adverse obstetric history - one or more of the following: \- history of low birth weight or small for gestational age baby in a singleton gestation, defined as weight \<10% for gestational age and fetal sex; the fetus must not have had major structural anomalies or aneuploidy. \- history of adverse pregnancy outcome in a singleton gestation; the fetus must not have had major structural anomalies or aneuploidy. o Long interpregnancy interval: ≥ 10 year (3650 day) pregnancy interval, defined as the time (in days) between the date of delivery of the last pregnancy to reach ≥ 20 weeks gestation and the first day of the last menstrual period for the current pregnancy. o Black or African-American race (as a proxy for underlying racism) - self-reported. Participants who self-identify as being of more than one racial group will be considered to be of Black race for the purposes of this criterion if one of the racial groups is Black or African-American. * Low socioeconomic status, defined as one or more of the following: housing or food insecurity noted in chart within the last year, self-pay or Medicaid insurance, less than high school education and/or (3b) High a priori risk for spontaneous preterm birth - must meet at least one of the following 2 criteria (prior pregnancy history or current pregnancy course) * sPTB criteria #1: Prior pregnancy history * EITHER a history of a delivery of a singleton, non-anomalous baby between 16+0 and 34+6 weeks gestation or delivery of a twin, non-anomalous pregnancy between 160 /7and 276 /7 weeks gestation due to spontaneous preterm labor, preterm premature rupture of membranes, cervical insufficiency, or placental abruption - Chart documentation of prior preterm birth, the gestational age of the prior preterm birth (referred to as the 'qualifying delivery') should be determined. If the gestational age at delivery is obtained directly from the medical record and more than one gestational age appears, the greater of the two will be used assuming that neither is the 'source document' (i.e. an ultrasound report with a due date, a c-section report, a delivery note, etc). Use the following table as a validation of the previous delivery. For example, if the infant was male and weighed more than 2763 grams (6 pounds, 1.5 ounces) then the patient would be ineligible based on history of a preterm birth criteria. This table should only be used to determine whether the qualifying delivery is most likely to be preterm less than 35 weeks gestation when the gestational age CANNOT be verified/calculated by review of the medical records or is not available in the medical records. Gestational age 90th percentile - boys 90th percentile - girls 33 weeks \> 2488g 5 lbs 7.8 oz \> 2116g 4 lbs 10.6 oz 34 weeks \> 2763g 6 lbs 1.5 oz \> 2379g 5 lbs 3.9 oz 35 weeks \> 3084g 6 lbs 12.8 oz \> 2661g 5 lbs 13.9 oz * Documented history of a prior pregnancy complicated by asymptomatic cervical shortening \<25mm between 16+0 and 23+6 weeks gestation or cervical dilation ≥ 0.5cm requiring cervical cerclage placement prior to 24+0 weeks gestation, even if delivery ultimately occurred ≥ 35 weeks gestation or at term. • sPTB criteria #2: Current pregnancy course * Asymptomatic cervical shortening \<25mm in the current pregnancy, diagnosed by transvaginal ultrasound that is performed ≥14+0 weeks gestation, per Registered Diagnostic Medical Sonographer(RDMS) certified Sonographer or physician with transvaginal ultrasound training program (or similar) qualifications * Cervical cerclage in situ in the current pregnancy due to concern for risk of preterm birth, at the discretion of the primary obstetric provider (4) Ability to provide written, informed consent in English or Spanish (5) Planned prenatal care at the University of North Carolina at Chapel Hill obstetrics clinics and planned delivery at the University of North Carolina Women's Hospital (Chapel Hill, NC). Exclusion Criteria: 1. Participation in another intervention based clinical trial during pregnancy that is deemed, at the discretion of the investigative team for the current study or the other concurrent study, to conflict with this research and/or confound the study results. o There are some concurrent studies, even those designed to test an intervention, which may be compatible with the current study; this will be reviewed by the investigative leadership team on a case-by-case basis. 2. Previous participation in the PTBCARE+ program in another pregnancy, with randomization to the PTBCARE+ (active intervention) group. 3. Current, ongoing, illicit drug use ≥ 12 weeks gestation. * Use of tobacco and/or marijuana products is not an exclusion. * Receiving treatment for opioid use disorder with methadone, suboxone, or similar in an approved treatment program is not an exclusion. 4. History of radical trachelectomy 5. Planned voluntary termination of pregnancy. 6. Heavy vaginal bleeding or large subchorionic hemorrhage - defined as: * Bleeding as primary reason for unplanned clinic evaluation or emergency room visit within 14 days of potential enrollment * Subjective bleeding accompanied by ≥ 4 point drop in the hematocrit within 14 days of potential enrollment * Subchorionic hemorrhage or abruption on formal ultrasound with a volume ≥ 64 cubic cm (4cm x 4cm x 4cm) within 14 days of potential enrollment 7. Major congenital anomaly such as major structural deficit of the heart, lungs, brain, or other major organ system 1. Mild renal abnormalities, clubfoot, isolated cleft lip/palate, etc. in the fetus are not a reason for exclusion. 2. Isolated 'soft markers' for aneuploidy (such as choroid plexus cysts, echogenic bowel, etc.) are not a reason for exclusion. 3. If a major congenital anomaly is diagnosed \*after\* enrollment, the patient will continue to participate in the study, however, the investigators will plan to analyze the study results with and without these individuals included. 8. Positive aneuploidy screening test (traditional biochemical assay, e.g., quad screen - risk of aneuploidy of 1:25 or higher or cell free deoxynucleic acid (DNA) test result that is screen positive for trisomy 13, trisomy 18, trisomy 21, or sex chromosome abnormality) in the absence of definitive fetal karyotype evaluation. * Definitive fetal karyotype evaluation can only be obtained through direct testing of the tissue from the conceptus - by chorionic villus sampling or amniocentesis during pregnancy. * The term "suspected aneuploidy" is commonly used in the medical record but this is not a diagnosis and by itself is not informative and not an exclusion criteria. 9. Cystic hygroma or abnormally thickened nuchal translucency ≥ 3 mm at any time in the current gestation, regardless of subsequent diagnostic testing results. * Note that a cystic hygroma remains an exclusion criterion regardless of subsequent diagnostic testing results because fetuses with this history carry an elevated risk of major congenital heart disease. * Fetal echocardiogram is most accurately performed at 22-24 weeks gestation, which is later than the enrollment gestational age window. 10. Polyhydramnios at or prior to enrollment. o Polyhydramnios is defined as a maximum vertical pocket ≥ 8.0 cm, given that polyhydramnios \<22 weeks has a high likelihood of being associated with congenital anomalies/aneuploidy and/or preterm birth due to preterm prelabor rupture of membranes. 11. For potential participants who meet eligibility criteria ONLY due to prior spontaneous or medically indicated preterm birth: if the prior preterm birth was in a pregnancy complicated by twins, confirmed fetal aneuploidy, or major congenital fetal anomalies in the absence of another pregnancy meeting inclusion criteria they are not eligible. 12. Known HIV positive with viral load greater than 1,000 copies/mL or cluster of differentiation 4 (CD4) count less than 350/mm\^3 13. Unwillingness to undergo randomization.

Outcomes

Primary Outcomes

Self-reported Perceived Stress Scores

Perceived Stress Scale participant survey * Scores range 0-40 * Higher scores = higher stress

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Self-reported resilience scores

Brief Resilience Scale validated participant survey * score range = 1-5 * higher scores = higher resilience

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Maternal blood-based stress-related gene transcript levels

Each participant's fold change in blood-based stress-related gene transcript levels during pregnancy, calculated as a ratio: (visit 2 gene expression - visit 1 gene expression) divided by visit 1 gene expression.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Number of participants with preterm birth or fetal death at 14 weeks 0 days or greater and less than 35 weeks gestation

Number of participants who either delivered or experienced a fetal death at a gestational age between 14 weeks 0 days and 35 weeks 0 days gestation. Pregnancies that are lost in the first trimester (prior to 14 weeks of gestation) are excluded from analysis.

Time frame: Between 14 weeks 0 days and 35 weeks 0 days gestation (delivery at 34 weeks 6 days gestation meets the primary outcome; delivery at 35 weeks 0 days gestation does not) , a period of up to 27 weeks from enrollment.

Secondary Outcomes

Self-reported (subjective) allostatic load

Allostatic load = balance between stress and stress-protective factors. This is a single outcome determined by a comprehensive, study-specific calculation from weighted normalized (0-1 scale) data from participant surveys. Subjective allostatic load = \[(Normalized Stress - Normalized Stress-protective factors)/2\] * score range -1 to +1 * higher scores = higher allostatic load (more stress than protective factors)

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Self-reported composite "negative" stress

Subjectively reported composite "negative" stress, which is a single outcome measure calculated by considering participant responses on three surveys. Each survey score total is normalized on a 0-1 scale based on each individual's score in relation to the max possible score for that survey. The 3 normalized scores are then averaged to obtain the single composite negative stress score (range is 0-1), whereby a higher scores = higher negative stress.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Number of participants with composite severe maternal morbidity

Diagnosis of severe maternal morbidity during pregnancy or the initial postpartum period, defined using indicators by the Centers of Disease Control and Prevention (CDC). Individuals who are diagnosed with one or more of the following by a clinician and with appropriate radiologic / laboratory findings to support the diagnosis are considered to have this outcome: acute myocardial infarction, aneurysm, acute renal failure, adult respiratory distress syndrome, amniotic fluid embolism, cardiac arrest / ventricular fibrillation, conversion of cardiac rhythm, disseminated intravascular coagulation, eclampsia, heart failure / arrest during surgery or procedure, puerperal cerebrovascular disorders, pulmonary edema / acute heart failure, severe anesthesia complications, sepsis, shock, sickle cell disease with crisis, air and thrombotic embolism, hysterectomy, temporary tracheostomy, or ventilation. Need for blood transfusion is considered separately, as per prior work.

Time frame: Enrollment through the postpartum followup period of 10 weeks after delivery, a period of up to 45 weeks from enrollment (assuming latest possible delivery gestational age is 43 weeks)

Perceived Social Support scores

Social support is quantified by the Medical Outcomes Study (MOS) social support survey * score range: 0 to 100 * High score: Indicates a strong perception of social support, with readily available people to provide assistance and emotional support. * Low score: Suggests a perceived lack of social support, potentially indicating a need for additional social connections or support systems.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Satisfaction with medical care

Determined by the self-administered Patient Satisfaction Questionnaire - 18 question (PSQ-18) survey, which measures satisfaction with medical care across 7 different domains: (1) General satisfaction (2) Technical quality; (3) Interpersonal manner; (4) Communication; (5) Financial aspects; (6) Time spent with doctor; (7) Accessibility and convenience * score range = 18 to 90 * score interpretation: a higher score indicates greater patient satisfaction with their healthcare provider

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Self-reported anxiety symptoms

Each participant's subjectively reported anxiety, assessed by the self-administered Generalized Anxiety Disorder - 7 (GAD-7) survey Score range: 0 to 21 Score interpretation: higher scores = higher anxiety

Time frame: Mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Self-reported perinatal depression symptoms

Depression symptoms are assessed by the Edinburgh Postnatal Depression Scale (EPDS). Scoring: range 0-30 Interpretation: higher scores are associated with higher possibility of depression

Time frame: Initial pregnancy intake (administered during routine clinical care during pregnancy, as early as 4 weeks pregnant to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 26 weeks from enrollment

Self-reported pregnancy experiences

The self-administered pregnancy experiences scale and includes: * 10 questions on 'Hassles' with a total hassles score ranging from 0 to 30. Higher Scores: Higher scores on the hassles dimension indicate greater perceived stress and negative experiences during pregnancy. * 10 questions on 'uplifts' with a total uplifts score ranging from 0 to 30. Higher scores on the uplifts dimension indicate more positive experiences and emotional upliftment. The Composite Measure Score=Total Uplifts Score-Total Hassles Score; Score range = -30 to +30. Interpretation: A positive composite score indicates that the positive experiences (uplifts) outweigh the negative experiences (hassles), suggesting a more positive overall pregnancy experience. Conversely, a negative composite score indicates that hassles outweigh uplifts.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Self-assessed generalized self-efficacy

The Generalized Self-Efficacy Scale (GSE) is a 10-item, widely used tool to assess an individual's belief in their ability to handle various challenging situations. Each item is rated on a 4-point scale: Total Score: The scores for each item are summed to provide a total score, which ranges from 10 to 40. Interpretation: Higher Scores: Indicate a stronger belief in one's ability to cope with difficult situations and achieve goals. Lower Scores: Suggest lower confidence in one's ability to manage challenges and may indicate a need for interventions to boost self-efficacy.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Self-assessed overall health

Each participant's change in their perception of their overall physical health, as assessed by the 10 question Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Survey Rating: Each item is rated on a 5-point Likert scale. Responses are summed to create raw scores for physical and mental health. Raw scores are converted to T-scores using standardized tables. T-scores have a mean of 50 and a standard deviation (SD) of 10, based on the general population. Interpretation: T-Scores at 50 are Representative of the average score of the general population. Above 50: Indicates better than average health. Below 50: Indicates worse than average health.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Self-reported coping strategies

Coping strategies are assessed by the participant reported survey, Coping Strategies Inventory - Short Form (CSI-SF). The CSI-SF has 16 items, 4 per each of 4 sub-scales: 1. Problem-Focused Engagement 2. Problem-Focused Disengagement 3. Emotion-Focused Engagement 4. Emotion-Focused Disengagement Total for each subscale = 4-20. * Range for positive coping (adding 2 "engagement" sub-scales) is 8-40 * Range for negative coping (adding 2 "disengagement" sub-scales) is 8-40. The positive coping score is then divided by the negative coping score to provide a ratio of positive to negative coping, ranging from 0.2 to 5. Interpretation: Higher scores on each sub-scale indicate more frequent use of that coping strategy. Thus, a higher positive:negative coping strategy ratio suggests a more adaptive/positive coping style whereas lower ratios suggest less adaptive/more negative coping.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Self-assessed overall well-being

Overall wellbeing is self-assessed by the Positive Emotion, Engagement, Relationships, Meaning, and Accomplishment (PERMA) Profiler, which measures these 5 key well-being domains. The 5 PERMA domains are averaged to provide an assessment of overall health. The instrument also includes measures for Negative Emotion and Health. Scoring Range: each PERMA domain is assessed using three items, rated on a scale from 0 (Never) to 10 (Always). Scores for each domain are averaged to provide a domain score. The overall PERMA score is an average of all scores and ranges from 0-10. Negative Emotion and Health are also assessed using three items each, rated on the same 0 to 10 scale, and averaged. Scoring Interpretation: Higher scores indicate higher levels of well-being in the respective domain.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Subjective report of physical activity

Physical activity is quantified by the Pregnancy Physical Activity Questionnaire Short Form (PPAQ-SF). Scoring: The 10 question PPAQ-SF measures physical activity across several domains: (1) Household/Caregiving; (2) Occupational; (3) Sports/Exercise; (4) Transportation; (5) Locomotion. Each activity is categorized by intensity: Light activities = 1.5-2.9 metabolic equivalents (METs); moderate activities = 3.0-5.9 METs; vigorous activities = ≥ 6.0 METs. Score calculation / range / interpretation: MET hours/week = MET value of activity x hours spent on that activity/week. Higher scores = more active. Theoretically, the minimum score is 0 MET hours/week, indicating no physical activity; there is no strict upper limit, but extremely high scores (\>10,000) = uncommon, may indicate over-reporting.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Delivery gestational age

Participant's delivery gestational age or gestational age at time they are diagnosed with an in-utero fetal death. Delivery gestational age is considered continuously, in weeks and days of gestation. Pregnancies that are lost in the first trimester (prior to 14 weeks of gestation) are excluded from analysis. Therefore the possible range of gestational age entries is 14 weeks 0 days (earliest) through 43 weeks 0 days (generally the latest possible gestational age).

Time frame: From the time of enrollment (if > 14 weeks 0 days) or 14 weeks 0 days to delivery (may occur as late as 43+0 weeks), a period of up to 35 weeks from enrollment

Objective allostatic load index

Each participant's objective allostatic load index will be calculated using clinical parameters including blood pressure, pulse pressure, and body mass index, etc. based on the published literature. Score range = normalized, 0 to 100 scale. Score interpretation = higher allostatic load score = higher allostatic load

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Number of participants with preterm birth or fetal death less than 37 weeks gestation

Number of participants who either delivered or experienced a fetal death at a gestational age between 14 weeks 0 days and 37 weeks 0 days gestation. Pregnancies that are lost in the first trimester (prior to 14 weeks of gestation) are excluded from analysis.

Time frame: Between 14 weeks 0 days and 37 weeks 0 days gestation (delivery at 36 weeks 6 days gestation meets this outcome; delivery at 37 weeks 0 days gestation does not) , a period of up to 29 weeks from enrollment.

Number of participants with preterm birth or fetal death less than 32 weeks gestation

Number of participants who either delivered or experienced a fetal death at a gestational age between 14 weeks 0 days and 32 weeks 0 days gestation. Pregnancies that are lost in the first trimester (prior to 14 weeks of gestation) are excluded from analysis.

Time frame: Between 14 weeks 0 days and 37 weeks 0 days gestation (delivery at 31 weeks 6 days gestation meets this outcome; delivery at 32 weeks 0 days gestation does not) , a period of up to 24 weeks from enrollment.

Number of participants with preterm birth or fetal death less than 28 weeks gestation

Number of participants who either delivered or experienced a fetal death at a gestational age between 14 weeks 0 days and 28 weeks 0 days gestation. Pregnancies that are lost in the first trimester (prior to 14 weeks of gestation) are excluded from analysis.

Time frame: Between 14 weeks 0 days and 28 weeks 0 days gestation (delivery at 27 weeks 6 days gestation meets this outcome; delivery at 28 weeks 0 days gestation does not) , a period of up to 20 weeks from enrollment.

Number of participants with preterm birth or fetal death less than 24 weeks gestation

Number of participants who either delivered or experienced a fetal death at a gestational age between 14 weeks 0 days and 24 weeks 0 days gestation. Pregnancies that are lost in the first trimester (prior to 14 weeks of gestation) are excluded from analysis.

Time frame: Between 14 weeks 0 days and 24 weeks 0 days gestation (delivery at 23 weeks 6 days gestation meets this outcome; delivery at 24 weeks 0 days gestation does not) , a period of up to 16 weeks from enrollment.

Number of participants with composite placental complications

Development of placental complications during pregnancy, defined as one or more of the following: 1. placental abruption (diagnosed clinically) ± birthweight \<3% for fetal sex and delivery gestational age ± 2. diagnosis of hypertensive disorders of pregnancy (including gestational hypertension, chronic hypertension with superimposed preeclampsia, preeclampsia, eclampsia) ± 3. intrauterine fetal demise

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) until delivery (may occur as late as 43+0 weeks), a period of up to 35 weeks from enrollment

Parasympathetic Nervous System Index

Parasympathetic Nervous System (PNS) function is assessed using participant heart rate variability data collected using a continuous heart rate sensor (finger or ear clip) using publicly available Kubios heart rate variability software. PNS Index range: -5 to +5. Interpretation: A PNS index value of zero indicates that the parameters reflecting parasympathetic activity are, on average, equivalent to those of the normal population. Positive index values signify higher parasympathetic nervous system activity and lower stress; lower values indicate lower parasympathetic activity and increased stress.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Sympathetic Nervous System Index

Sympathetic Nervous System function is assessed via the Sympathetic Nervous System (SNS) Index using participant heart rate variability data collected using a continuous heart rate sensor (finger or ear clip) using publicly available Kubios heart rate variability software. SNS Index range: typically -5 to +5, may fall outside of range. Interpretation: A SNS index of zero indicates average sympathetic activity compared to the norm. Positive values reflect sympathetic activity levels above the norm, while negative values indicate lower than average activity. During stress or intense exercise, the SNS index can range significantly higher, potentially reaching values between 5 and 35.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Number of participants with composite neonatal morbidity

Neonates born to participants are considered to have composite major neonatal morbidity, if, prior to initial hospital discharge from the delivery hospitalization, they are diagnosed by a clinician with one or more of the following diagnoses: 1. bronchopulmonary dysplasia 2. intraventricular hemorrhage grade III or IV 3. periventricular leukomalacia 4. necrotizing enterocolitis requiring surgery 5. death

Time frame: Neonatal outcomes are evaluated until initial hospital discharge or 45 weeks post menstrual age, a period of up to 37 weeks from maternal enrollment and up to 23 weeks of age for the neonate (if born at 22 weeks 0 days).

Heart Rate Variability

Heart Rate Variability (HRV) is assessed using data collected from participants by a continuous heart rate sensor (finger or ear clip) and calculated using publicly available HeartMath / EmWave Pro heart rate variability software. HRV values are reported as a continuous integer and range from 1 - 120 (typical expected upper limit, but may be higher in isolated situations). Interpretation: Higher HRV: Generally associated with better cardiovascular health and greater resilience to stress. Lower HRV: Can indicate higher stress levels, poor cardiovascular health, or other health issues

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) and mid-pregnancy followup (Visit 2 - 22+0 to 29+6 week), a period of up to 22 weeks from enrollment

Number of participants who are diagnosed with hypertensive disorders of pregnancy

Development of hypertensive disorders of pregnancy, one of the elements of the composite placental complications (outcome #24), defined as a diagnosis of gestational hypertension, chronic hypertension with superimposed preeclampsia, preeclampsia, and/or eclampsia through the postpartum followup period.

Time frame: Baseline (Visit 1 - 8+0 to 19+6 weeks) until delivery (may occur as late as 43+0 weeks), a period of up to 35 weeks from enrollment

Personalized Care for Prenatal Stress Reduction & Prevention of Preterm Birth (PTB) Disparities

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