Graduation Date

Spring 5-7-2016

Document Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

Dr. Shinobu Watanabe-Galloway


Human papillomavirus (HPV) is the most common sexually transmitted infection. The infection is higher in certain racial/ethnic groups and those who are immunocompromised including pregnant women. Because immune system is suppressed during pregnancy, women are at higher risk of various types of infection including HPV, a known risk factor for pregnancy complications. However, its role in adverse pregnancy outcomes is unclear. Another high risk population is Northern Plain American Indian. In the Northern Plains region, American Indian women have significantly higher rate of HPV infection than white counterparts and are infected with different types of HPVs than the general population. Because the prevalence of infection with these HPV types are higher in American Indian population, the impact of HPV vaccine on cervical cancer cases is expected to vary from other populations.

The objectives of this study were to explore the relationship between HPV infection and adverse pregnancy outcomes and to estimate the number of cervical cancer cases reduced by 9-valent vaccine among Northern Plains American Indian women. To achieve these objectives, an analysis was conducted using Pregnancy Risk Assessment and Monitoring System (PRAMS), in a population-based survey of pregnant women from 2004 to 2011. In addition, a hospital-based data analysis was conducted on women who delivered a live birth at Nebraska Medical Center between 2012 and 2014. HPV infection was diagnosed on the basis of a Pap test report. PROC SURVEYLOGISTIC (or logistic) procedures were used to examine the relationship between HPV infection and adverse pregnancy outcomes such as low birth weight, preeclampsia, preterm birth, and premature rupture of membrane. Additionally, to project the impact of 9-valent vaccine on the American Indian population, a compartmental deterministic model was developed. Our study found low prevalence of HPV infection among pregnant women. Significant associations were found between HPV infection and adverse pregnancy outcomes, including preeclampsia, preterm birth, and low birth weight. In addition, this study found that the 9-valent vaccine is associated with a greater reduction of cervical cancer cases among white women than among American Indian women. Overall, this study fills various gaps in knowledge about the impact of HPV infection on two vulnerable populations.