While the BPSR were significantly reduced by the intervention in this RCT [16
], we did not detect an impact on pregnancy and neonatal outcomes. Greater numbers of adverse outcomes occurred in the UCG compared to the IG, but the differences were not statistically significant. Only STI was associated with one of the psychosocial risks targeted by the intervention (IPV). For most pregnancy and neonatal outcomes biomedical risks had the most impact, particularly diabetes, hypertension and previous PTB.
This report focuses on the relationship of BPSR risk factors to pregnancy and neonatal outcomes, and the ability of an integrated behavioral intervention to improve these outcomes in a large sample of African American women. The study differed from most prior clinical trials in testing the efficacy of an integrated behavioral intervention provided within the prenatal care setting and designed to reduce specific BPSR, thus improving pregnancy and neonatal outcomes.
Our findings have four implications for understanding the relationship between the targeted risks and pregnancy and neonatal outcomes and for designing future studies in this area:
First, positive outcomes occurred more frequently among the intervention participants, although differences in pregnancy and neonatal outcomes in the IG and UCG were not statistically significant. Although the intervention was effective in resolving participants'; BPSR risks, as reported previously [16
], the lack of significant impact on pregnancy and neonatal outcomes may have been due to the intent to power the study for risk reduction rather than the improvement of pregnancy and neonatal outcomes. Findings of previous studies of prenatal behavioral interventions to improve pregnancy outcomes have been inconsistent. Success in reducing PTB for AA intervention participants by providing education and support has been reported [33
], but there was no reduction in LBW. Similar to DC-HOPE, Klerman et al. [35
] found that AA women in the intervention group reduced behavioral risks such as smoking, but without impact on pregnancy outcomes. Differences in methodology and sample sizes make comparing these studies with the DC-HOPE intervention difficult.
Second, this study failed to find an effect of active smoking on pregnancy outcomes other than a slight reduction in birthweight. This fact may relate to a dose-response gradient [36
]. The definition of active smoking risk in DC-HOPE included women with low smoking frequency that may have fallen below the dose necessary for significant impact on pregnancy. With regard to the effect of ETSE on PTB and SGA, our findings concur with those from the meta-analysis of Leonardi-Bee et al. [7
] that did not demonstrate an effect of ETSE on gestational age at birth or SGA.
Third, DC-HOPE failed to find an impact of depression on pregnancy or neonatal outcomes. This may have been due to the present study defining depression risk by self-reported symptoms rather than diagnosis of major depressive disorder. Including women with milder degrees of symptoms may have diluted the effects of depression on pregnancy outcomes. Other studies that found significant contributions to PTB or LBW for smoking, depression, or IPV usually considered populations screened for one of these risks individually. Given that these risks often overlap, other studies that demonstrate the contribution of any of those single risks may not have controlled for the presence of other risks or cumulative risks that may have contributed to demonstrated effects.
Fourth, DC-HOPE found the prevalence of medical conditions, including hypertension, diabetes, and rates of both gestational and preexisting conditions, similar to previous reports for AA populations [37
]. Consistent with our results here, other studies also report medical factors to outweigh psychosocial and behavioral risks for low birthweight and preterm delivery in African American women [39
The DC-HOPE study had a number of limitations. Similar to Klerman et al. [35
], this trial found positive trends for the effect of the intervention on pregnancy outcomes but had inadequate sample size to detect statistically significant differences. Twelve to 17 percent of the data for each outcome were missing and were estimated with MI. Between-imputation variation reflected the uncertainty inherent in predicting unknown values, but might have limited our ability to detect differences between groups.
A feature of several successful programs was the inclusion of case management, in which a social services worker directly assisted clients in accessing needed community resources. The emphasis in DC-HOPE was on empowering women to access resources, rather than rely on a case manager. Whether including case management would have enhanced outcomes was beyond the scope of DC-HOPE but is an interesting design for future study. Additionally, life stresses and limited social support in low income AA women may continue to impact their health, despite reduction in some specific risks.
In the DC-HOPE study, inconsistent participant attendance at intervention sessions may also have reduced any impacts on pregnancy and neonatal outcomes. Despite co-location of intervention sessions with PNC, 25% of women failed to attend any prenatal intervention sessions. Typically within primary care settings, less than 50% percent of women with mental health problems pursue recommended mental health services when the services are not co-located within their primary care settings [40
]. In contrast to patients seeking care in mental health settings, patients in primary care may not acknowledge psychosocial or behavioral problems and may not want or expect intervention [41
]. In such cases, acceptance of the problem and motivation for treatment may be difficult to achieve. The complicated lives of these women also resulted in inconsistent prenatal care attendance, making it difficult to evaluate the relative contribution of intervention response versus prenatal care intensity.
Many potential psychosocial/behavioral factors affecting pregnancy outcomes were not addressed by this intervention, including unmet economic needs, low levels of education, and associated behavioral challenges including alcohol and drug use. The focus on low-income, urban AA women in this study may mean that findings cannot be generalized to other populations of pregnant women, but may apply only to urban, low income, pregnant AA women with BPSR. Because willingness to participate in intervention sessions was variable, broader supports may be needed to assure that women consistently attend prenatal care visits and take advantage of ameliorative interventions made available to them in prenatal care settings.
In this study, AA women with multiple BPSR experienced high rates of adverse pregnancy and neonatal outcomes. Efforts to understand adverse birth outcomes of AAs should focus on risks throughout their lives rather than only those occurring during pregnancy. The high rates of adverse outcomes in our low-income population suggest that poverty may contribute to adverse outcomes through mechanisms such as intergenerational health disadvantages or cumulative stress. Biomedical risks increase adverse birth outcomes in this low income AA population. Continued efforts to manage hypertension and diabetes should be addressed in this population to reduce adverse outcomes. In addition to prenatal care, low income AA women may need a variety of support services, outside of the prenatal setting, to improve outcomes. To explore the complex interactions of many of these key factors, large national collaborative studies would likely be needed.