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1.  Healthy Start: Description of a Safety Net for Perinatal Support during Disaster Recovery 
Maternal and child health journal  2015;19(4):819-827.
Publicly funded programs and safety net organizations have key roles during post disaster recovery to care for vulnerable populations, including pregnant women with low resources. The objective of this study was to compare the health of prenatal women who accessed the New Orleans Healthy Start program to those women who only used traditional prenatal care (PNC) during long-term recovery from the Hurricane Katrina disaster.
During 2010-2012, this descriptive, cross-sectional study recruited 402 prenatal women (24-40 weeks) from prenatal clinics and classes. All women were enrolled in PNC, with 282 experiencing only traditional PNC, while 120 women added Healthy Start participation to their usual PNC. Measures were obtained to determine, past hurricane experience, hurricane recovery, perceptions of prenatal care, mental health, and birth outcomes.
Women accessing Healthy Start-New Orleans were more socially “at risk” (younger, lower income, not living with a partner, African American), lived through more hurricane trauma, and had a higher incidence of depression (40%) and PTSD (15%) than women in traditional PNC (29% depression; 6.1 % PTSD). Women using Healthy Start reported more mental health counseling and prenatal education than did women in only traditional PNC. Birth outcomes were similar in the two groups.
The Healthy Start participants with less resources and more mental health difficulties after disaster, represented a more vulnerable population in need of additional support. This study underscores the necessity for community and governmental programs to develop disaster response plans that address needs of vulnerable populations during prolonged recovery.
PMCID: PMC4303559  PMID: 25047787
2.  Personality and adolescent pregnancy outcomes 
Journal of advanced nursing  2014;71(1):148-159.
To examine the relationship between personality, pregnancy and birth outcomes in adolescents
Personality has been shown to be a strong predictor of many health outcomes. Adolescents who become pregnant have worse birth outcomes than adults.
Cross-sectional study using data from the National Longitudinal Study of Adolescent Health (baseline, 1994-1995; follow-up, 2007-2008).
The study sample was 6529 girls, 820 of whom reported on pregnancy outcomes for a teenage birth. Personality data was taken from the Mini International Personality Item Pool personality tool, which measures the five-factor personality traits of neuroticism, conscientiousness, intellect/imagination, extraversion and agreeableness. Logistic regression was used to predict teen pregnancy and linear regression was used to predict birth weight and gestational age with adjustment for confounders and stratification by race.
Agreeableness and intellect/imagination were associated with a reduced likelihood of becoming pregnant as an adolescent, while neuroticism, conscientiousness and extraversion were all associated with an increased likelihood of becoming pregnant. Higher neuroticism was associated with lower birth weight and gestational age among Black girls, but not non-Black. Conscientiousness was associated with lower gestational age among non-Black girls. No relationships were found with extraversion or agreeableness and birth outcomes. Receiving late or no prenatal care was associated with higher intellect/imagination.
Personality is understudied with respect to pregnancy and birth outcomes compared with other health outcomes. Such research could help professionals and clinicians design and target programs that best fit the characteristics of the population most likely to need them, such as those with high neuroticism.
PMCID: PMC4267964  PMID: 25040691
birth weight; continental population groups; pregnancy in adolescence; premature birth; prenatal care; nurses/midwives/nursing
3.  Parent-child Relationships, Parental Attitudes towards Sex, and Birth Outcomes among Adolescents 
Study objective
To examine how parent-child relationships, parental control, and parental attitudes towards sex were related to pregnancy outcomes among adolescent mothers.
Prospective cohort study. Parental report of relationship satisfaction, disapproval of adolescent having sex, discussion around sexual health, and sexual communication attitudes, and adolescent report of relationship satisfaction, parental control, and parental disapproval of sex were examined as predictors of self-reported birth outcomes. Weighted multivariable linear regression models were run incorporating interactions by race.
United States
632 females who participated in Waves I and IV of the National Longitudinal Study of Adolescent Health (Add Health), a nationally-representative sample of students enrolled in grades 7–12 in 1994–95 and followed up in 2007–2008
Main Outcome Measures
birthweight and gestational age
For Black adolescents, better parent-child relationship was associated with higher birthweight (0.14 kg, p<0.05) and gestational age (0.75 weeks, p<0.01), while higher parental disapproval of having sex (adjusted beta 0.15 kg, p<0.05) were associated with higher birthweight. For non-Black adolescents, a moderate amount of discussion of birth control was associated with higher birthweight (0.19 kg, p<0.01 and lower child-perceived parental disapproval of having sex was associated with higher birthweight (0.08 kg, p<0.05) and gestational age (0.37 weeks, p<0.05). Higher parental control was associated with a reduced likelihood of smoking during pregnancy and a greater likelihood of early prenatal care.
Parent-child relationships and attitudes about sex affect outcomes of pregnant adolescents.
PMCID: PMC4160400  PMID: 25023982
Adolescents; birthweight; gestational age; race; communication
4.  Disaster Research: A Nursing Opportunity 
Nursing inquiry  2013;21(3):259-268.
Nurses working or living near a community disaster have the opportunity to study health-related consequences to disaster or disaster recovery. In such a situation, the researchers need to deal with the conceptual and methodological issues unique to post-disaster research and know what resources are available to guide them, even if they have no specialized training or previous experience in disaster research. The purpose of this article is to review issues and challenges associated with conducting post-disaster research and encourage nurses to seek resources and seize opportunities to conduct research should the situation arise. Current disaster studies and the authors’ personal experiences conducting maternal-child research in post-Katrina New Orleans (2005–2013) provide real-life examples of how health professionals and nurses faced the challenges of doing post-disaster research. After catastrophic events, nurses need to step forward to conduct disaster research that informs and improves future disaster planning and health care responses.
PMCID: PMC3909020  PMID: 23899191
Disaster; post-traumatic stress disorder; resilience; mental health; ethics; research
5.  Stress Questionnaires and Stress Biomarkers during Pregnancy 
Journal of Women's Health  2009;18(9):1425-1433.
Both self-reported indicators of stress and hormones such as cortisol and corticotrophin-releasing hormone (CRH) have been examined in relation to preterm birth. Although these hormones have been interpreted as biomarkers of stress, it is unclear whether psychosocial measures are empirically associated with biomarkers of stress in pregnant women.
We analyzed data from 1,587 North Carolina pregnant women enrolled in the Pregnancy, Infection, and Nutrition study during 2000–2004 who provided at least one saliva sample for cortisol measurement or blood samples for CRH at 14–19 and 24–29 weeks' gestation. Cortisol measures were limited to those taken between 8 and 10 a.m. Perceived stress, state-trait anxiety, coping style, life events, social support, and pregnancy-specific anxiety were measured by questionnaires and interviews. Spearman correlations and multiple regressions were used to describe the relationship among the measures of stress.
No correlations larger than r = 0.15 were seen between reported psychosocial measures and cortisol or CRH. Women with demographic characteristics associated with poor pregnancy outcomes (unmarried, African-American, young, low pre-pregnancy body mass index) reported higher levels of stress but did not consistently have higher levels of stress hormones. Pre-eclampsia was associated with higher CRH, but not with higher cortisol.
The relationship between measurements of reported stress and biomarkers is not straightforward in large epidemiological studies of pregnancy. For online Supplementary Material, see
PMCID: PMC2825685  PMID: 19757520
6.  When Is Exposure to a Natural Disaster Traumatic? Comparison of a Trauma Questionnaire and Disaster Exposure Inventory 
PLoS ONE  2015;10(4):e0123632.
Few studies have compared the sensitivity of trauma questionnaires to disaster inventories for assessing the prevalence of exposure to natural disaster or associated risk for post-disaster psychopathology. The objective of this analysis was to compare reporting of disaster exposure on a trauma questionnaire (Brief Trauma Questionnaire [BTQ]) to an inventory of disaster experience. Between 2011 and 2014, a sample of 841 reproductive-aged southern Louisiana women were interviewed using the BTQ and completed a detailed inventory about exposure to hurricanes and flooding. Post-traumatic stress disorder (PTSD) symptomology was measured with the Post-Traumatic Stress Checklist, and depression with the Edinburgh Depression Scale. The single question addressing disaster exposure on the BTQ had a sensitivity of between 65% and 70% relative to the more detailed questions. Reporting disaster exposure on the BTQ was more likely for those who reported illness/injury due to a hurricane or flood (74%-77%) or danger (77-79%), compared to those who reported damage (69-71%) or evacuation (64-68%). Reporting disaster exposure on the BTQ was associated with depression (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.43-3.68). A single question is unlikely to be useful for assessing the degree of exposure to disaster across a broad population, and varies in utility depending on the mental health outcome of interest: the single trauma question is useful for assessing depression risk.
PMCID: PMC4390192  PMID: 25853820
7.  Childhood social hardships and fertility: A prospective cohort study 
Annals of epidemiology  2013;23(12):784-790.
To examine the effect of lifetime social hardships on fertility.
Using the British National Child Development Study, a longitudinal cohort study, the impact of exposure to childhood hardships on becoming pregnant, reported infertility, and time to pregnancy was investigated. 6477 women reported on whether they had become pregnant by age 41, and 5198 women had data on at least one pregnancy. Factor analysis was used to identify six types of childhood hardships (as reported by parent, child, social worker, or teacher); retrospective report of child abuse was also examined. Logistic regression and discrete failure-time analysis was used to adjust for potential confounders.
Never-married women were more likely to have become pregnant at some point if they had experienced more childhood hardships. Retrospectively reported child abuse was associated with an increased likelihood of having been told one was unable to have children. Among ever-married women, childhood hardships were associated with reduced fecundability, but the association was weakened by adjustment for adult social class.
The relationship between childhood adversity and adult fertility is complex. Future research should investigate pathways between characteristics of adversities and fertility.
PMCID: PMC4100793  PMID: 24404568
adversity; fertility; pregnancy; socioeconomic status
8.  Symptomatic Dengue Infection during Pregnancy and Infant Outcomes: A Retrospective Cohort Study 
Dengue is a mosquito-borne disease that is common in many tropical and subtropical areas. Dengue infections can occur at any age and time in the lifespan, including during pregnancy. Few large scale studies have been conducted to determine the risk of preterm birth (PTB) and low birthweight (LBW) for infants born to women who had symptomatic dengue infection during pregnancy.
Methodology/Principal Findings
This study is a retrospective cohort study using medical records from 1992–2010 from pregnant women who attended a public regional referral hospital in western French Guiana. Exposed pregnancies were those with laboratory confirmed cases of dengue fever during pregnancy. Each of the 86 exposed infants was matched to the three unexposed births that immediately followed them to form a stratum. Conditional logistic regression was used to analyze these matched strata. Three groups were examined: all infants regardless of gestational age, only infants> = 17 weeks of gestational age and their strata, and only infants> = 22 weeks of age and their strata. Odds ratios were adjusted (aOR) for maternal age, maternal ethnicity, maternal gravidity, interpregnancy interval and maternal anemia. There was an increased risk of PTB among women with symptomatic dengue; (aOR all infants: 3.34 (1.13, 9.89), aOR 17 weeks: 1.89 (0.61, 5.87), aOR 22 weeks: 1.41 (0.39, 5.20)) but this risk was only statistically significant when all infants were examined (p value = 0.03). Adjusted results for LBW were similar, with an increased risk in the exposed group (aOR All infants: 2.23 (1.01, 4.90), aOR 17 weeks: 1.67 (0.71, 3.93), aOR 22 weeks: 1.43 (0.56, 3.70)) which was only statistically significant when all infants were examined (p value = 0.05).
Symptomatic dengue infection during pregnancy may increase the risk of PTB and LBW for infants. More research is needed to confirm these results and to examine the role of dengue fever in miscarriage.
Author Summary
Previous studies have reported that dengue fever during pregnancy may be related to preterm birth and low birthweight among infants. However, few studies have used an appropriate control group to compare the risk of these outcomes for infants whose mothers had dengue fever to infants whose mothers did not. We designed this study to provide information on the amount of risk (odds ratios) and the stability of this risk (confidence intervals) of being born preterm or with low birthweight to a mother with documented dengue infection during the pregnancy. In this study there was an increased risk among pregnant women with symptomatic dengue to deliver infants who are preterm or low birthweight, but both the amount of risk and the stability of this risk were affected by the inclusion or exclusion of miscarriages (infants born before 22 weeks of gestational age) This suggests that women who are pregnant should take extra precautions to avoid dengue infections during pregnancy, since it may cause an early delivery, or the birth of a small infant.
PMCID: PMC4191958  PMID: 25299383
9.  The Association Between Prepregnancy Parental Support and Control and Adolescent Girls’ Pregnancy Resolution Decisions 
To examine the influence of prepregnancy parental support and control on adolescent girls’ pregnancy resolution decisions.
Data from the National Longitudinal Study of Adolescent Health were analyzed. Girls whose first pregnancy reported in wave IV occurred after wave I and before age 20 were included (n = 1,107). Participants self-reported pregnancy disposition (abortion, ectopic or tubal pregnancy, miscarriage, stillbirth, live birth) for each pregnancy; responses were dichotomized as abortion versus other. Girls’ perceptions of parental support and control were measured at wave I. Controls were included for wave I age, age at pregnancy, year at the end of pregnancy, race/ethnicity, and parent characteristics (i.e., education, religious affiliation, age at first marriage, and educational expectations). Weighted multivariable logistic regression models were performed.
Approximately 18% of girls reporting a teen pregnancy reported having an abortion. In crude analyses, parental support was marginally negatively related to abortion (odds ratio [OR] =.83, p =.06) and parental control was significantly negatively related to abortion (OR = .78, p = .02). In multivariable analyses, higher parental control was significantly negatively related to abortion versus other pregnancy outcomes (adjusted OR .80, 95% confidence interval .66–.98). Perceived parental support was unassociated with pregnancy resolution decisions. The only other factor associated with abortion decisions was parent education: odds of choosing abortion versus other pregnancy outcomes were significantly higher for adolescent girls whose parents had a bachelor’s degree or greater versus those with lower educational attainment.
Pregnant adolescents with less educated parents or parents exercising greater control were less likely to have an abortion.
PMCID: PMC3755627  PMID: 23763966
Adolescent pregnancy; Abortion; Parent support; Parent control
10.  Allostatic Load and Birth Outcomes Among White and Black Women in New Orleans 
Maternal and child health journal  2013;17(6):1025-1029.
As a marker of chronic stress, allostatic load has been theoretically recognized as a potential contributor to racial disparities in birth outcomes. The purpose of this investigation was to identify associations between allostatic load and birth outcomes and to assess differences in allostatic load and its relation to birth outcomes between white and black women.
Blood samples from 123 women at 26–28 weeks gestation were assayed for cholesterol, glycosylated hemoglobin, dehydroepiandrosterone-sulfate, and cortisol, with 42 women having complete data on all biomarkers and birth outcomes. Together with systolic blood pressure, these biomarkers were combined to create an allostatic load index. Multiple linear regression models were used to evaluate associations between allostatic load index and gestational age, birth weight, birth weight ratio, birth length, and head circumference.
Black women had a significantly lower allostatic load index than white women (P<0.05). Gestational age was the only outcome significantly associated with allostatic load in both unadjusted and adjusted models (P<0.05). Gestational age decreased significantly with increasing allostatic load (adjusted β: −0.18, 95% CI: −0.35, 0.00). A significant interaction with age indicated that the effect was less strong at higher maternal ages (adjusted interaction β: 0.04, 95% CI: 0.00, 0.08). There was no racial difference in the effect of allostatic load on birth outcomes.
These findings represent possible evidence of the effect of stress age on gestational age. As a measure of cumulative disadvantage, allostatic load may prove to be a contributor to the racial disparities in birth outcomes.
PMCID: PMC3504172  PMID: 22833335
Allostatic load; Stress; Pregnancy; Birth outcomes
11.  Is the Metabolic Syndrome a “Small Baby” Syndrome?: The Bogalusa Heart Study 
Metabolic syndrome has been called a “small baby syndrome,” but other analyses suggest that postnatal growth is more important than birthweight, or that large babies are also at risk. The aim of this analysis was to examine whether there was a relationship between both low and high birthweight and metabolic syndrome, using multiple definitions of metabolic syndrome, and to determine whether this relationship varied by body size across the life course.
Data from the Bogalusa Heart Study, a study of cardiovascular disease in children and young adults, were linked to birth certificate data. Metabolic syndrome was defined by the National Cholesterol Education Program, the International Diabetes Foundation, and the World Health Organization (WHO) definition. Small-for-gestational-age (SGA) was defined as birthweight <10th percentile by sex for gestational age and large-for-gestational-age (LGA) as birthweight >90th percentile. Birthweight-for-gestational-age was also examined as a continuous predictor. Chi-squared tests and logistic regression were used to examine the relationship between birth size and metabolic syndrome.
Higher birthweight-for-gestational-age was associated with a reduced risk of metabolic syndrome, especially by the WHO definition. After adjustment for body mass index (BMI), categorized birthweight was associated with metabolic syndrome, with the protective associations with LGA being stronger than the positive associations with SGA. Among the individual components of metabolic syndrome, higher waist circumference was associated with both SGA and LGA after BMI was controlled for. Effects of SGA and BMI at any age were largely independent rather than interactive.
SGA is associated with some, but not all, components of metabolic syndrome. The relationship between SGA and metabolic syndrome is partially confounded by later BMI.
PMCID: PMC3546360  PMID: 22831273
12.  A Prospective Study of Childhood Social Hardships and Age at Menarche 
Annals of epidemiology  2012;22(10):731-737.
To determine the role of type, timing, and cumulative childhood hardships on age at menarche in a prospective cohort study.
Longitudinal analysis of 4,524 female participants of the National Child Development Study cohort (1958 – 2003). Six types of childhood hardships were identified with a factor analysis methodology: financial, family dysfunction, caregiver low interest in education, lack of supportive caregiving, neglectful environment, and family structure disruption. Paternal absence/low involvement in childhood was an a priori hardship. Retrospective reports of abuse in childhood were explored in relation to age at menarche, also. Generalized logit regression analyses explored the impact of type, timing, and cumulative hardships on age at menarche (≤11, 12–13, ≥14 years).
Cumulative childhood hardships were associated with a graded increase in risk for later menarche with adjusted OR [AOR] of 1.37 (95%CI: 1.10, 1.70), 1.50 (95%CI: 1.18, 1.91), and 1.58 (95%CI: 1.29, 1.92) among those with 2, 3, and ≥4 adversities, respectively. More than 2 hardships in early life had the strongest association with late menarche (AOR=2.32, 95%CI: 1.12, 4.80). Sexual abuse was most strongly associated with early menarche (AOR=2.60, 95%CI: 1.40, 4.81).
Cumulative childhood hardships increased risk for later age at menarche. Child abuse was associated with both early and late menarche, although associations varied by type of abuse. Critical period of exposure, type, and chronicity of hardships demonstrate varying degrees of influence on age at menarche.
PMCID: PMC3469794  PMID: 22959664
adversity; birth cohort; child abuse; hardship; life course; menarche; socioeconomic status
13.  Predictors of Birth Weight and Gestational Age Among Adolescents 
American Journal of Epidemiology  2012;176(Suppl 7):S150-S163.
Although pregnant adolescents are at high risk of poor birth outcomes, the majority of adolescents go on to have full-term, healthy babies. Data from the National Longitudinal Study of Adolescent Health, a longitudinal study of a nationally representative sample of adolescents in grades 7–12 in the United States who were surveyed from 1994–1995 through 2008, were used to examine the epidemiology of preterm birth and low birth weight within this population. Outcomes of pregnancies were reported by participants in the fourth wave of data collection (when participants were 24–32 years of age); data were compared between female participants who reported a first singleton livebirth at less than 20 years of age (n = 1,101) and those who were 20 years of age or older (n = 2,846). Multivariable modeling was used to model outcomes; predictors included demographic characteristics and maternal health and behavior. Among black adolescents, low parental educational levels and older age at pregnancy were associated with higher birth weight, whereas low parental educational levels and being on birth control when one got pregnant were associated with higher gestational age. In nonblack adolescents, lower body mass index was associated with lower birth weight, whereas being unmarried was associated with lower gestational age. Predictors of birth outcomes may differ by age group and social context.
PMCID: PMC3530360  PMID: 23035139
adolescent; continental population groups; infant; low birth weight; premature birth
14.  Childhood hardship, maternal smoking and birth outcomes: a prospective cohort study 
To determine the association between type, chronicity, and severity of childhood hardships and smoking status during pregnancy, preterm birth, and low birth weight.
Prospective cohort study
The National Child Development Study, a nationally representative study of births in Britain in 1958
4865 women with at least one singleton live birth
Main exposures
Hardship during childhood, indicated by several variables, including financial/structural hardship, lack of parental interest in education, family dysfunction, violence/mental health issues, and family structure.
Main outcome measures
Smoking in pregnancy, low birthweight (LBW), preterm birth (PTB).
A consistent and graded association was seen between all types of childhood hardships and smoking status during pregnancy (odd ratio (OR) and 95% confidence interval (CI) for 4 or more hardships 2.02, 1.58–2.58; p<0.001 for all comparisons). Most hardships were also associated with risk of LBW and PTB, with associations between number of hardships and both outcomes persisting after controlling for smoking status and adult social class (for LBW, OR 1.51, 95% CI 1.10–2.06; for PTB, OR 1.44, 95% CI 1.08–1.92).
Childhood hardships have an enduring impact on future pregnancy outcomes, in part through their association with smoking during pregnancy and adult socioeconomic position.
PMCID: PMC3506121  PMID: 20530303
15.  Pre-pregnancy stress reactivity and pregnancy outcome 
Stress has been proposed as a cause of preterm birth (PTB) and small for gestational age (SGA), but stress does not have the same effects on all women. It may be that a woman’s reaction to stress relates to her pregnancy health, and previous studies indicate higher reactivity is associated with reduced birthweight and gestational age. The objective of the study was to examine the relationship between pre-pregnancy cardiovascular reactivity to stress and pregnancy outcome. The sample included 917 women in the Coronary Artery Risk Development in Young Adults (CARDIA) Study who had cardiovascular reactivity measured in 1987–1988 and at least one subsequent singleton live birth within an 18-year period. Cardiovascular reactivity was measured using a video game, star tracing, and cold pressor test. Gestational age and birthweight were based on the women’s self-report, with PTB defined as birth <37 weeks’ gestation and SGA as weight <10th percentile for gestational age. Linear and poisson regression and generalised estimating equations were used to model the relationship between reactivity to stress and birth outcomes with control for confounders. Few associations were seen between reactivity and pregnancy outcomes. Higher pre-pregnancy diastolic blood pressure (adjusted relative risk, 1.14, 95% confidence interval 0.98–1.34) and mean arterial pressure (MAP) reactivity (1.15, 0.98–1.36) were associated with risk of PTB at first pregnancy, while SGA was associated with lower SBP reactivity (0.76, 0.60–0.95). No associations were seen with other measures of reactivity. Contrary to hypothesis, the association between heart rate reactivity and preterm birth in first pregnancy was stronger in whites (aRRs 1.39, 1.03–1.88) than in blacks (1.00, 0.83–1.20; p for interaction=0.08). Similar results were found for mean arterial pressure. No strong associations were found between higher pre-pregnancy stress reactivity and SGA or PTB, and stress reactivity did not have a stronger association with birth outcomes in blacks than whites.
PMCID: PMC3506123  PMID: 20955234
16.  Hurricane Katrina Experience and the Risk of Post-Traumatic Stress Disorder and Depression among Pregnant Women 
Little is known about the effects of disaster exposure and intensity on the development of mental disorders among pregnant women. The aim of this study was to examine the effect of exposure to Hurricane Katrina on mental health in pregnant women.
Prospective cohort epidemiological study.
Tertiary hospitals in New Orleans and Baton Rouge, USA.
Women who were pregnant during Hurricane Katrina or became pregnant immediately after the hurricane.
Main outcome measures
Post-traumatic stress disorder (PTSD) and depression.
The frequency of PTSD was higher in women with high hurricane exposure (13.8%) than women without high hurricane exposure (1.3%), with an adjusted odds ratio (aOR) of 16.8; 95 % confidence interval (CI): 2.6-106.6; after adjustment for maternal race, age, education, smoking and alcohol use, family income, parity, and other confounders. The frequency of depression was higher in women with high hurricane exposure (32.3%) than women without high hurricane exposure (12.3%), with aOR of 3.3 (1.6-7.1). Moreover, the risk of PTSD and depression increased with an increasing number of severe experiences of the hurricane.
Pregnant women who had severe hurricane experiences were at a significantly increased risk for PTSD and depression. This information should be useful for screening pregnant women who are at higher risk of developing mental disorders after disaster.
PMCID: PMC3501144  PMID: 20701175
Depression; disaster; Hurricane Katrina; post-traumatic stress disorder; pregnancy
17.  Hurricane Katrina-related maternal stress, maternal mental health, and early infant temperament 
Maternal and child health journal  2009;14(4):511-518.
To investigate temperament in infants whose mothers were exposed to Hurricane Katrina and its aftermath, and to determine if high hurricane exposure is associated with difficult infant temperament. A prospective cohort study of women giving birth in New Orleans and Baton Rouge, LA (n=288) in 2006–2007 was conducted. Questionnaires and interviews assessed the mother’s experiences during the hurricane, living conditions, and psychological symptoms, two months and 12 months postpartum. Infant temperament characteristics were reported by the mother using the activity, adaptability, approach, intensity, and mood scales of the Early Infant and Toddler Temperament Questionnaires, and “difficult temperament” was defined as scoring in the top quartile for three or more of the scales. Logistic regression was used to examine the association between hurricane experience, mental health, and infant temperament. Serious experiences of the hurricane did not strongly increase the risk of difficult infant temperament (association with 3 or more serious experiences of the hurricane: adjusted odds ratio (aOR) 1.50, 95% confidence interval (CI) 0.63–3.58 at 2 months; 0.58, 0.15–2.28 at 12 months). Maternal mental health was associated with report of difficult infant temperament, with women more likely to report having a difficult infant temperament at one year if they had screened positive for PTSD (aOR 1.82, 95% confidence interval (CI) 0.61–5.41), depression, (aOR 3.16, 95% CI 1.22–8.20) or hostility (aOR 2.17, 95% CI 0.81–5.82) at 2 months. Large associations between maternal stress due to a natural disaster and infant temperament were not seen, but maternal mental health was associated with reporting difficult temperament. Further research is needed to determine the effects of maternal exposure to disasters on child temperament, but in order to help babies born in the aftermath of disaster, the focus may need to be on the mother’s mental health.
PMCID: PMC3472436  PMID: 19554438
infant temperament; natural disaster; postpartum depression; post-traumatic stress disorder
18.  Combined effects of Hurricane Katrina and Hurricane Gustav on the mental health of mothers of small children 
Few studies assessed the results of multiple exposures to disaster. Our objective was to examine the effect of experiencing Hurricane Gustav on mental health of women previously exposed to Hurricane Katrina. 102 women from Southern Louisiana were interviewed by telephone. Experience of the hurricanes was assessed with questions about injury, danger, and damage, while depression was assessed with the Edinburgh Depression Scale and post-traumatic stress disorder (PTSD) using the Post-traumatic Checklist. Minor stressors, social support, trait resilience, and perceived benefit had been measured previously. Mental health was examined with linear and log-linear models. Women who had a severe experience of both Gustav and Katrina scored higher on the mental health scales, but finding new ways to cope after Katrina or feeling more prepared was not protective. About half the population had better mental health scores after Gustav than at previous measures. Improvement was more likely among those who reported high social support or low levels of minor stressors, or were younger. Trait resilience mitigated the effect of hurricane exposure. Multiple disaster experiences are associated with worse mental health overall, though many women are resilient. Perceiving benefit after the first disaster was not protective.
PMCID: PMC3472438  PMID: 21418428
disaster; depression; post-traumatic stress disorder; women
19.  Experience of Hurricane Katrina and reported intimate partner violence 
Journal of interpersonal violence  2010;26(4):833-845.
Intimate partner violence (IPV) has been associated with stress, but few studies have examined the effect of natural disaster on IPV. In this study, we examine the relationship between experience of Hurricane Katrina and reported relationship aggression and violence in a cohort of 123 postpartum women. Hurricane experience was measured using a series of questions about damage, injury, and danger during the storm; IPV was measured using the Conflict Tactics Scale (CTS-2). Multiple log-poisson regression was used to calculate relative risks, adjusted for potential confounders. Most reported that they and their partners had explained themselves to each other, showed each other respect, and also insulted, swore, or shouted during conflicts with each other. Much smaller proportions reported physical violence, sexual force, or destroying property, though in each case at least 5% endorsed that it had happened at least once in the last six months. Similar proportions reported that they and their partners had carried out these actions. Experiencing damage due to the storm was associated with increased likelihood of most conflict tactics. Strong relative risks were seen for the relationship between damage due to the storm and aggression or violence, especially being insulted, sworn, shouted, or yelled at (adjusted relative risk [aRR]1.23, 1.02–1.48), pushed, shoved, or slapped (aRR 5.28, 95% CI 1.93–14.45), or being punched, kicked, or beat up (aRR 8.25, 1.68–40.47). Our results suggest that certain experiences of the hurricane are associated with an increased likelihood of violent methods of conflict resolution. Relief and medical workers may need to be aware of the possibility of increased IPV after disaster.
PMCID: PMC3472442  PMID: 20495099
20.  Preconception cardiovascular risk factors and pregnancy outcome 
Epidemiology (Cambridge, Mass.)  2011;22(5):724-730.
Pregnancy-related cardiovascular conditions are associated with both poorer pregnancy outcomes and cardiovascular disease later in life. Little is known about the relationship between preconception cardiovascular risk factor levels and pregnancy complications.
Data from the Cardiovascular Risk in Young Finns Study were linked with birth registry data for 1142 primiparous women. Age-standardized levels of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, blood pressure, insulin, and glucose from the study visit prior to last menstrual period were calculated. These factors were examined as predictors of gestational age, preterm birth (<37 weeks), birthweight, low birthweight (<2500 g), small-for-gestational-age (weight <10th percentile for gestational age), hypertensive disorders of pregnancy, and gestational diabetes, using linear and Poisson regression with adjustment for age, body mass index, smoking, and socioeconomic status.
Higher triglycerides were associated with a higher risk of hypertensive disorders (adjusted risk ratio [aRR]= 1.42 [95% confidence interval (CI) = 0.90–2.23]), pre-eclampsia (1.70 [1.08–2.65]), and gestational diabetes (1.68 [1.25–2.25]). After removing women with pregnancy complications (n=30), the estimated aRR for the association between systolic blood pressure and preterm birth was 1.23 (95% CI= 0.99–1.54); for HDL-c and low birthweight, 0.97 (0.73–1.28); for diastolic blood pressure and small-for-gestational-age, 0.98 (0.81–1.20); and for systolic blood pressure and small-for-gestational-age, 1.18 (0.97–1.45).
High lipid levels before pregnancy predict an increased risk of pre-eclampsia and gestational diabetes. Reported associations between these pregnancy complications and later cardiovascular disease of the mother are probably explained, at least in part, by maternal conditions that precede pregnancy. Interventions to improve cardiovascular health before pregnancy may reduce risk of pregnancy complications.
PMCID: PMC3157236  PMID: 21709559
21.  Resilience after Hurricane Katrina among pregnant and postpartum women 
Although disaster causes distress, many disaster victims do not develop long-term psychopathology. Others report benefits after traumatic experiences (post-traumatic growth). The objective of this study was to examine demographic and hurricane-related predictors of resilience and post-traumatic growth.
222 pregnant southern Louisiana women were interviewed, and 292 postpartum women completed interviews at delivery and eight weeks later. Resilience was measured by scores lower than a non-affected population, using the Edinburgh Depression Scale and the Post-Traumatic Stress Checklist (PCL). Post-traumatic growth was measured by questions about perceived benefits of the storm. Women were asked about their experience of the hurricane, addressing danger, illness/injury, and damage. Chi-square tests and log-Poisson models were used to calculate associations and relative risks (RR) for demographics, hurricane experience, and mental health resilience and perceived benefit.
35% of pregnant and 34% of the postpartum women were resilient from depression, while 56% and 49% were resilient from post-traumatic stress disorder. Resilience was most likely among white women, older women, and women who had a partner. A greater experience of the storm, particularly injury/illness or danger, was associated with lower resilience. Experiencing damage due to the storm was associated with increased report of some perceived benefits.
Many pregnant and postpartum women are resilient from the mental health consequences of disaster, and perceive benefits after a traumatic experience. Certain aspects of experiencing disaster reduce resilience, but may increase perceived benefit.
PMCID: PMC2822707  PMID: 20123173
resilience; depression; postpartum; pregnancy; disaster; post-traumatic stress disorder
22.  Telomere length, pre-eclampsia, and gestational diabetes 
BMC Research Notes  2010;3:113.
Telomere length is a marker of cumulative damage to the cell, and has been associated with cardiovascular disease, hypertension, and diabetes.
The association of telomere length with pre-eclampsia and gestational diabetes mellitus (GDM) was examined in a nested case-control study. Circulating leukocyte telomere length was measured by Quantitative-PCR. Mean and median telomere length among cases and controls was compared, and logistic regression was used to model the outcomes as a function of tertile telomere length, with control for effects of potential confounders. Mean telomere length in pre-eclampsia cases was 0.77 (SD 0.14), in GDM cases was 0.73 (SD 0.10), and in controls was 0.74 (SD 0.14). The adjusted odds ratio comparing the highest tertile to the lowest for pre-eclampsia was 0.92 (0.15-5.46), and for gestational diabetes was 0.65 (0.13-3.34).
Further study is necessary to determine if telomere length is associated with these pregnancy complications.
PMCID: PMC2873349  PMID: 20416088
23.  Exposure to Hurricane Katrina, Post-Traumatic Stress Disorder and Birth Outcomes 
Little is known about the effects of natural disasters on pregnancy outcomes. We studied mental health and birth outcomes among women exposed to Hurricane Katrina.
We collected data prospectively from a cohort of 301 women from New Orleans and Baton Rouge. Pregnant women were interviewed during pregnancy about their experiences during the hurricane, as well as whether they had experienced symptoms of post-traumatic stress disorder (PTSD) and/or depression. High hurricane exposure was defined as having three or more of the eight severe hurricane experiences, such as feeling that one's life was in danger, walking through floodwaters, or having a loved one die.
The frequency of low birth weight was higher in women with high hurricane exposure (14.0%) than women without high hurricane exposure (4.7%), with an adjusted odds ratio (aOR): 3.3; 95% confidence interval (CI): 1.13−9.89; p<0.01. The frequency of preterm birth was higher in women with high hurricane exposure (14.0%) than women without high hurricane exposure (6.3%), with aOR: 2.3; 95% CI: 0.82−6.38; p>0.05. There were no significant differences in the frequency of low birth weight or preterm birth between women with PTSD or depression and women without PTSD or depression (p>0.05).
Women who had high hurricane exposure were at an increased risk of having low birth weight infants. Rather than a general exposure to disaster, exposure to specific severe disaster events and the intensity of the disaster experience may be better predictors of poor pregnancy outcomes. To prevent poor pregnancy outcomes during and after disasters, future disaster preparedness may need to include the planning of earlier evacuation of pregnant women to minimize their exposure to severe disaster events.
PMCID: PMC2635112  PMID: 18703903
Depression; disaster; low birth weight; post-traumatic stress disorder; pregnancy
24.  Postpartum mental health after Hurricane Katrina: A cohort study 
Natural disaster is often a cause of psychopathology, and women are vulnerable to post-traumatic stress disorder (PTSD) and depression. Depression is also common after a woman gives birth. However, no research has addressed postpartum women's mental health after natural disaster.
Interviews were conducted in 2006–2007 with women who had been pregnant during or shortly after Hurricane Katrina. 292 New Orleans and Baton Rouge women were interviewed at delivery and 2 months postpartum. Depression was assessed using the Edinburgh Depression Scale and PTSD using the Post-Traumatic Stress Checklist. Women were asked about their experience of the hurricane with questions addressing threat, illness, loss, and damage. Chi-square tests and log-binomial/Poisson models were used to calculate associations and relative risks (RR).
Black women and women with less education were more likely to have had a serious experience of the hurricane. 18% of the sample met the criteria for depression and 13% for PTSD at two months postpartum. Feeling that one's life was in danger was associated with depression and PTSD, as were injury to a family member and severe impact on property. Overall, two or more severe experiences of the storm was associated with an increased risk for both depression (relative risk (RR) 1.77, 95% confidence interval (CI) 1.08–2.89) and PTSD (RR 3.68, 95% CI 1.80–7.52).
Postpartum women who experience natural disaster severely are at increased risk for mental health problems, but overall rates of depression and PTSD do not seem to be higher than in studies of the general population.
PMCID: PMC2702337  PMID: 19505322

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