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1.  The Voices of Limited English Proficiency Latina Mothers on Pediatric Primary Care: Lessons for the Medical Home 
The objective of this study is to inform medical home implementation in practices serving limited English proficiency Latino families by exploring limited English proficiency Latina mothers’ experiences with, and expectations for, pediatric primary care. In partnership with a federally-qualified community health center in an urban Latino neighborhood, we conducted semi-structured interviews with 38 low-income Latina mothers. Eligible participants identified a pediatric primary care provider for their child and had at least one child 3 years old or younger, to increase the probability of frequent recent interactions with health care providers. Interview transcripts were coded and analyzed through an iterative and collaborative process to identify participants’ satisfaction with and expectations for pediatric primary care. About half of the mothers interviewed were satisfied with their primary care experiences. Mothers suggested many ways to improve the quality of pediatric primary care for their children to better meet the needs of their families. These included: encouraging providers to invest more in their relationship with families, providing reliable same-day sick care, expanding hours, improving access to language services, and improving care coordination services. Limited English proficiency Latina mothers expect high-quality pediatric primary care consistent with the medical home model. Current efforts to improve primary care quality through application of the medical home model are thus relevant to this population, but should focus on the parent-provider relationship and timely access to care. Promoting this model among practices that serve limited English proficiency Latino families could improve engagement and satisfaction with primary care.
PMCID: PMC4336198  PMID: 22350630
Disparities; Primary care; Latino; Qualitative research; Medical home
2.  Effects of a Psychosocial Couple-Based Prevention Program on Adverse Birth Outcomes 
Maternal and child health journal  2015;19(1):102-111.
Although maternal stress and depression have been linked to adverse birth outcomes (ABOs), few studies have investigated preventive interventions targeting maternal mental health as a means of reducing ABOs. This randomized controlled study examines the impact of Family Foundations (FF)—a transition to parenthood program for couples focused on promoting coparenting quality, with previously documented impact on maternal stress and depression—on ABOs. We also examine whether intervention buffers birth outcomes from the negative effect of elevated salivary cortisol levels. We use intent-to-treat analyses to assess the main effects of the FF intervention on ABOs (prematurity, birth weight, pregnancy complications, Cesarean section, and days in hospital for mothers and infants) among 148 expectant mothers. We also test the interaction of cortisol with intervention condition status in predicting ABOs. FF participation was associated with reduced risk of C-section (OR .357, p < 0.05, 95 % CI 0.149, 0.862), but did not have main effects on other ABOs. FF significantly buffered (p < 0.05) the negative impact of maternal cortisol on birth weight, gestational age, and days in hospital for infants; that is, among women with relatively higher levels of prenatal cortisol, the intervention reduced ABOs. These results demonstrate that a psycho-educational program for couples reduces incidence of ABOs among higher risk women. Future work should test whether reduced maternal stress and depression mediate these intervention effects.
PMCID: PMC4321726  PMID: 24969352
Prenatal cortisol; Birth weight; Prematurity; Gestational age; Caesarian section; Length of newborn hospital stay; Coparenting; Psychosocial intervention; Family Foundations
3.  Pediatric Poisonings and Risk Markers for Hospital Admission in a Major Emergency Department in Romania 
Maternal and child health journal  2012;16(2):495-500.
To identify the prevalence, characteristics, and risk markers for childhood poisonings treated in the emergency department of a large Romanian hospital. Trauma registry data using ICD-10 codes and case summaries were studied to identify poisonings among children aged 0–18. Multivariate logistic regression identified factors associated with hospital admission. Between 1999 and 2003, 1,173 pediatric trauma cases were seen in the emergency department; 437 (37.3%) were treated for poisoning, including medication (35%), alcohol (26%), chemical products (19%), and carbon monoxide (14%). Half of all poisonings were unintentional, primarily affecting children < 10 years. Half were intentional, mainly affecting children 10–18. Females were three times more likely than males to have documented suicidal intent (P < .0001). Over 30% of suicide attempts were among children ages 10–14 (P < .0001). We report significantly increased adjusted odds ratios (P < .05) of hospital admission for children 10–18, and for chemical substance poisoning, and suicidal intent. Pediatric poisoning is a serious public health issue in Romania, and we suggest these findings are relevant across other eastern European countries with limited resources. Poisonings result in morbidity and hospital admissions, yet there are few prevention resources available. Health education programs and consumer product safety policies are needed in Romania and eastern Europe.
PMCID: PMC4315338  PMID: 21290173
Injury; Trauma; Pediatric care; Poisonings; Hospital admissions
4.  [No title available] 
PMCID: PMC3883993  PMID: 23677685
5.  Proportion of Gestational Diabetes Mellitus Attributable to Overweight and Obesity Among Non-Hispanic Black, Non-Hispanic White, and Hispanic Women in South Carolina 
Maternal and child health journal  2014;18(8):1919-1926.
Objective was to estimate race-specific proportions of gestational diabetes mellitus (GDM) attributable to overweight and obesity in South Carolina. South Carolina birth certificate and hospital discharge data were obtained from 2004 to 2006. Women who did not have type 2 diabetes mellitus before pregnancy were classified with GDM if a diagnosis was reported in at least one data source. Relative risks (RR) and 95 % confidence intervals were calculated using the log-binomial model. The modified Mokdad equation was used to calculate population attributable fractions for overweight body mass index (BMI: 25.0–29.9 kg/m2), obese (30.0–34.9 kg/m2), and extremely obese (≥ 35 kg/m2) women after adjusting for age, gestational weight gain, education, marital status, parity, tobacco use, pre-pregnancy hypertension, and pregnancy hypertension. Overall, the adjusted RR of GDM was 1.6, 2.3, and 2.9 times higher among the overweight, obese, and extremely obese women compared to normal-weight women in South Carolina. RR of GDM for extremely obese women was higher among White (3.1) and Hispanic (3.4) women than that for Black women (2.6). The fraction of GDM cases attributable to extreme obesity was 14.0 % among White, 18.1 % among Black, and 9.6 % among Hispanic women. The fraction of GDM cases attributable to obesity was about 12 % for all racial groups. Being overweight (BMI: 25.0–29.9) explained 8.8, 7.8, and 14.4 % of GDM cases among White, Black, and Hispanic women, respectively. Results indicate a significantly increased risk of GDM among overweight, obese, and extremely obese women. The strength of the association and the proportion of GDM cases explained by excessive weight categories vary by racial/ethnic group.
PMCID: PMC4181606  PMID: 24531925
Health disparity; Racial difference; Population attributable fraction; Epidemiology
6.  Views of Women and Clinicians on Postpartum Preparation and Recovery 
Maternal and child health journal  2014;18(3):707-713.
To explore important domains of women’s postpartum experiences as perceived by postpartum mothers and obstetricians/midwives, and to investigate how postpartum care could enhance patient preparation for the postpartum period. Qualitative research study was conducted to explore women’s and clinicians’ perceptions of the postpartum experience. Four focus groups of postpartum women (n = 45) and two focus groups of obstetric clinicians (n = 13) were held at a large urban teaching hospital in New York City. All focus groups were audio recorded, transcribed, and analyzed using grounded theory. Four main themes were identified: lack of women’s knowledge about postpartum health and lack of preparation for the postpartum experience, lack of continuity of care and absence of maternal care during the early postpartum period, disconnect between providers and postpartum mothers, and suggestions for improvement. Mothers did not expect many of the symptoms they experienced after childbirth and were disappointed with the lack of support by providers during this critical time in their recovery. Differences existed in the major postpartum concerns of mothers and clinicians. However, both mothers and clinicians agreed that preparation during the antepartum period could be beneficial for postpartum recovery. Results from this study indicate that many mothers do not feel prepared for the postpartum experience. Study findings raise the hypothesis that capturing patient-centered domains that define the postpartum experience and integrating these domains into patient care may enhance patient preparation for postpartum recovery and improve postpartum outcomes.
PMCID: PMC4304667  PMID: 23775250
Focus groups; Postpartum women; Obstetric clinicians; Preparation
7.  A Qualitative Study of Factors Affecting Pregnancy Weight Gain in African American Women 
Maternal and child health journal  2013;17(3):432-440.
African Americans and overweight or obese women are at increased risk for excessive gestational weight gain (GWG) and postpartum weight retention. Interventions are needed to promote healthy GWG in this population; however, research on exercise and nutritional barriers during pregnancy in African American women is limited. The objective of this qualitative study is to better inform intervention messages by eliciting information on perceptions of appropriate weight gain, barriers to and enablers of exercise and healthy eating, and other influences on healthy weight gain during pregnancy in overweight or obese African American women. In-depth interviews were conducted with 33 overweight or obese African American women in Columbia, South Carolina. Women were recruited in early to mid-pregnancy (8–23 weeks gestation, n = 10), mid to late pregnancy (24–36 weeks, n = 15), and early postpartum (6–12 weeks postpartum, n = 8). Interview questions and data analysis were informed using a social ecological framework. Over 50 % of women thought they should gain weight in excess of the range recommended by the Institute of Medicine. Participants were motivated to exercise for personal health benefits; however they also cited many barriers to exercise, including safety concerns for the fetus. Awareness of the maternal and fetal benefits of healthy eating was high. Commonly cited barriers to healthy eating include cravings and availability of unhealthy foods. The majority of women were motivated to engage in healthy behaviors during pregnancy. However, the interviews also uncovered a number of misconceptions and barriers that can serve as future intervention messages and strategies.
PMCID: PMC4284051  PMID: 22527762
Pregnancy; Exercise; Healthy eating; Perceptions
8.  Performance Measurement: A Proposal to Increase Use of SBIRT and Decrease Alcohol Consumption during Pregnancy 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1257-2.
Alcohol consumption during pregnancy has negative implications for maternal and child health. Appropriate early universal Screening, Brief Intervention and Referral to Treatment (SBIRT) for pregnant women is necessary to identify women at risk and reduce the likelihood of continued drinking. Because SBIRT is not consistently used, the development and use of performance measures to assure implementation of SBIRT are key steps towards intervention and reduction of alcohol consumption during pregnancy.
Practice guidelines provide ample support for specific instruments designed for SBIRT in prenatal care. An examination of existing performance measures related to alcohol consumption during pregnancy, however, reveals no comprehensive published performance measure designed to quantify the use of SBIRT for alcohol use in prenatal care.
Process performance measures were developed that can determine the proportion of pregnant women who are screened during the course of prenatal care and the proportion of women requiring either brief intervention or referral to substance use disorder treatment who received those interventions. The measures require use of screening instruments validated for use with pregnant women.
The two proposed measures would represent a significant step in efforts to assure appropriate intervention for women who drink during pregnancy, hold accountable providers who do not employ SBIRT, and provide a basis from which necessary systemic changes might occur. Pregnancy is a time when many women are motivated to stop drinking. That opportunity should be seized, with timely intervention offering assistance for pregnant women who have not stopped drinking of their own accord.
PMCID: PMC3711957  PMID: 23483413
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1232-y.
The overall objective of this study was to further our understanding of the factors contributing to the high perinatal mortality rates at a busy rural, referral hospital in Liberia. The specific aims were to: 1) analyze the records of women who experienced a perinatal loss for both medical and nonmedical contributing factors; 2) describe the timing and causes of all documented stillbirths and early neonatal deaths; and 3) understand the factors surrounding stillbirth and early neonatal death in this context.
This case series study was conducted through a retrospective hospital-based record review of all perinatal deaths occurring at the largest rural referral hospital in north-central Liberia during the 2010 calendar year.
A record review of 1656 deliveries identified 196 perinatal deaths; 143 classified as stillbirth and 53 were classified as early neonatal death. The majority of stillbirths (56.6%) presented as antenatal stillbirths with no fetal heart tones documented upon admission. Thirty-one percent of cases had no maternal or obstetrical diagnosis recorded in the chart when a stillbirth occurred. Of the 53 early neonatal deaths, 47.2% occurred on day one of the infant’s life with birth asphyxia/poor Apgar scores being the diagnosis listed most frequently.
Clear and concise documentation is key to understanding the high perinatal death rates in low resource countries. Standardized, detailed documentation is needed to inform changes to clinical practice and develop feasible solutions to reduce the number of perinatal deaths worldwide.
PMCID: PMC3703491  PMID: 23417211
Perinatal mortality; stillbirth; early neonatal death; post-conflict; Liberia
10.  Measuring Stress Before and During Pregnancy: A Review of Population-Based Studies of Obstetric Outcomes 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1233-x.
Mounting evidence from clinic and convenience samples suggests that stress is an important predictor of adverse obstetric outcomes. Using a proposed theoretical framework, this review identified and synthesized the population-based literature on the measurement of stress prior to and during pregnancy in relation to obstetric outcomes.
Population-based, peer-reviewed empirical articles that examined stress prior to or during pregnancy in relation to obstetric outcomes were identified in the PubMed and PsycInfo databases. Articles were evaluated to determine the domain(s) of stress (environmental, psychological, and/or biological), period(s) of stress (preconception and/or pregnancy), and strength of the association between stress and obstetric outcomes.
Thirteen studies were evaluated. The identified studies were all conducted in developed countries. The majority of studies examined stress only during pregnancy (n=10); three examined stress during both the preconception and pregnancy periods (n=3). Most studies examined the environmental domain (e.g., life events) only (n=9), two studies examined the psychological domain only, and two studies examined both. No study incorporated a biological measure of stress. Environmental stressors before and during pregnancy were associated with worse obstetric outcomes, although some conflicting findings exist.
Few population-based studies have examined stress before or during pregnancy in relation to obstetric outcomes. Although considerable variation exists in the measurement of stress across studies, environmental stress increased the risk for poor obstetric outcomes. Additional work using a lifecourse approach is needed to fill the existing gaps in the literature and to develop a more comprehensive understanding of the mechanisms by which stress impacts obstetric outcomes.
PMCID: PMC3715581  PMID: 23447085
Maternal stress; stress measurement; lifecourse; obstetric outcomes; population-based; review
11.  A Regional Multilevel Analysis: Can Skilled Birth Attendants Uniformly Decrease Neonatal Mortality? 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1260-7.
Globally 40% of deaths to children under-five occur in the very first month of life with three-quarters of these deaths occurring during the first week of life. The promotion of delivery with a skilled birth attendant (SBA) is being promoted as a strategy to reduce neonatal mortality. This study explored whether SBAs had a protective effect against neonatal mortality in three different regions of the world.
The analysis pooled data from nine diverse countries for which recent Demographic and Health Survey (DHS) data were available. Multilevel logistic regression was used to understand the influence of skilled delivery on two outcomes – neonatal mortality during the first week of life and during the first day of life. Control variables included age, parity, education, wealth, residence (urban/rural), geographic region (Africa, Asia and Latin America/Caribbean), antenatal care (ANC) and tetanus immunization.
The direction of the effect of skilled delivery on neonatal mortality was dependent on geographic region. While having a SBA at delivery was protective against neonatal mortality in Latin America/Caribbean, in Asia there was only a protective effect for births in the first week of life. In Africa SBAs were associated with higher neonatal mortality for both outcomes, and the same was true for deaths on the first day of life in Asia.
Many women in Africa and Asia deliver at home unless a complication occurs, and thus skilled birth attendants may be seeing more women with complications than their unskilled counterparts. In addition there are issues with the definition of a SBA with many attendants in both Africa and Asia not actually having the needed training and equipment to prevent neonatal mortality. Considerable investment is needed in terms of training and health infrastructure to enable these providers to save the youngest lives.
PMCID: PMC3735623  PMID: 23504132
antenatal care; early neonatal mortality; health systems strengthening; scale-up and skilled birth attendant
12.  Validation of a food frequency questionnaire for retrospective estimation of diet during the first 2 years of life 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1263-4.
This study aims to validate a Food Frequency Questionnaire (FFQ), specifically designed to retrospectively estimate dietary intake and supplement consumption during the first two years of life in children from resource poor households in semi-rural Mexico.
The FFQ querying about diet during the first 2 years of life was administered to mothers of children (N=84), who participated in a prospective study 3 to 5 years earlier, in which complementary feeding practice questionnaires and 24-hour recall (24hrR) were collected at several time points during the first 2 years of life to evaluate dietary and vitamin supplement intake. The resulting FFQ data were compared to intake data collected during the original study using Spearman correlations, deattenuated correlations and Wilcoxon signed-rank tests.
Total energy intake, as estimated by the retrospective and original instruments, did not differ in the second year (Yr2); correlations between the measures were significant (r=0.40, p<0.001). The 24hrR and FFQ-Yr2 were significantly correlated for dietary intake of vitamins B6, B12 (p<0.001) and folate (p<0.01); however, after including vitamin supplement intake, the two dietary instruments were correlated only for vitamins A and B12 (p<0.05).
The FFQ provides a reasonable estimate of a child’s dietary intake of energy and key micronutrients during the second year of life, and permits accurate ranking of intake 3 to 5 years after birth.
PMCID: PMC3752306  PMID: 23532627
Validation Food Frequency Questionnaire; 24hour recalls; children; vitamins; Micronutrients; Dietary supplements
13.  Development of a Linked Perinatal Data Resource From State Administrative and Community-Based Program Data 
Maternal and child health journal  2014;18(1):316-325.
To demonstrate a generalizable approach for developing maternal-child health data resources using state administrative records and community-based program data. We used a probabilistic and deterministic linking strategy to join vital records, hospital discharge records, and home visiting data for a population-based cohort of at-risk, first time mothers enrolled in a regional home visiting program in Southwestern Ohio and Northern Kentucky from 2007 to 2010. Because data sources shared no universal identifier, common identifying elements were selected and evaluated for discriminating power. Vital records then served as a hub to which other records were linked. Variables were recoded into clinically significant categories and a cross-set of composite analytic variables was constructed. Finally, individual-level data were linked to corresponding area-level measures by census tract using the American Communities Survey. The final data set represented 2,330 maternal-infant pairs with both home visiting and vital records data. Of these, 56 pairs (2.4 %) did not link to either maternal or infant hospital discharge records. In a 10 % validation subset (n = 233), 100 % of the reviewed matches between home visiting data and vital records were true matches. Combining multiple data sources provided more comprehensive details of perinatal health service utilization and demographic, clinical, psychosocial, and behavioral characteristics than available from a single data source. Our approach offers a template for leveraging disparate sources of data to support a platform of research that evaluates the timeliness and reach of home visiting as well as its association with key maternal-child health outcomes.
PMCID: PMC3936676  PMID: 23420307
Home visiting; Early childhood development; Data linking
14.  Mental health disorders among caregivers of preschool children in the Asenze Study in KwaZulu-Natal, South Africa 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1254-5.
Given the existing evidence linking parental depression with infant and early child development, our aim was to describe the burden of mental health disorders among caregivers of young children aged 4–6 years living in an environment of poverty and high HIV seroprevalence.
We analyzed baseline data from an epidemiologic study of the health and psychosocial needs of preschool-aged children. Primary caregivers of index children recruited from a household survey were screened for common mental disorders using the Client Diagnostic Questionnaire (CDQ). Sociodemographic, HIV and general health surveys were also conducted.
Many caregivers (449/1434; 31.3%) screened positive for at least one psychiatric disorder on the CDQ, with post-traumatic-stress-disorder being the most common. Caregivers who screened positive for any disorder were more likely to be older, to have no individual sources of income and to have less formal education. Presence of a disorder was also significantly associated with lower employment levels within the household and death of a young child within the household. Known HIV-infected caregivers were more likely to have any mood disorder than caregivers who previously tested negative.
The data support the need for mental health treatment interventions in South Africa, particularly interventions directed at PTSD and depression, and that take into account the high burden of poverty, HIV and childhood mortality. Given the limited formal mental health structure in South Africa to address these highly prevalent disorders; community-based mental health supports, available through decentralized health systems many be critical to delivering accessible interventions.
PMCID: PMC3708993  PMID: 23467845
Caregivers; mental health; depression; post-traumatic-stress-disorder; HIV
15.  Coping and Psychological Distress in Mothers of Adolescents with Type 1 Diabetes 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1239-4.
To describe coping in mothers of adolescents with type 1 diabetes and to examine the association among mothers’ diabetes-related stress and coping strategies and maternal psychological distress (e.g., symptoms of anxiety and depression), adolescent adjustment (e.g., symptoms of depression, quality of life), diabetes-related family conflict, and glycemic control.
One hundred and eighteen mother-adolescent dyads completed measures of diabetes-related stress, coping, symptoms of anxiety and depression, quality of life, and family conflict. Data on glycemic control were collected from adolescents’ medical charts.
Single/divorced mothers and mothers of color were significantly more likely to use disengagement coping strategies (e.g., avoidance) than White and married/partnered mothers. Mothers’ use of primary control coping (e.g., problem solving) and secondary control coping (e.g., acceptance) strategies was related to fewer symptoms of anxiety (r = −.51, −.39) and depression (r = −.32, −.37) and less family conflict (r = −.22, −.30, all p < .05). Mothers’ use of disengagement coping strategies was related to greater symptoms of anxiety (r = .30) and depression (r = .27, both p < .01). Further, secondary control coping was found to mediate the relationship between diabetes-related stress and maternal symptoms of anxiety and depression. Maternal coping was not significantly associated with adolescent outcomes.
The ways in which mothers of adolescents with type 1 diabetes cope with diabetes-related stress are associated with psychological distress and family conflict. By identifying and improving mothers’ coping through screening and targeted interventions, we may have the potential to improve both maternal and adolescent outcomes.
PMCID: PMC3746006  PMID: 23420308
coping; mothers; type 1 diabetes mellitus; adjustment
16.  Racial and Ethnic Disparities in Personal Capital During Pregnancy: Findings from the 2007 Los Angeles Mommy and Baby (LAMB) Study 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1256-3.
To determine if racial and ethnic differences in personal capital during pregnancy exist and to estimate the extent to which any identified racial and ethnic differences in personal capital are related to differences in maternal sociodemographic and acculturation characteristics.
Data are from the 2007 Los Angeles Mommy and Baby (LAMB) study (n=3,716). Personal capital comprised internal resources (self-esteem and mastery) and social resources (partner, social network, and neighborhood support) during pregnancy. The relationships between race/ethnicity and personal capital were assessed using multivariable generalized linear models, examining the impact of sociodemographic and acculturation factors on these relationships.
Significant racial and ethnic disparities in personal capital during pregnancy exist. However, socioeconomic status (i.e., income and education) and marital status completely explained Black-White disparities and Hispanic-White disparities in personal capital, whereas acculturation factors, especially nativity and language spoken at home, partially mediated the disparities in personal capital between Asian/Pacific Islander women and White women.
Findings suggest that the risks associated with low socioeconomic status, single motherhood, and low acculturation, rather than race or ethnicity, contribute to low personal capital for many pregnant women. As personal capital during pregnancy may influence subsequent maternal and child health outcomes, the development of interventions should consider addressing sociodemographic and acculturation factors in order to reduce racial and ethnic disparities in personal capital and ultimately in poor maternal and child health outcomes.
PMCID: PMC3748227  PMID: 23504131
Maternal and child health; personal capital; racial and ethnic disparities; pregnancy
17.  The Prevalence and Trends of Antiviral Medication Use during Pregnancy in the U.S. A population-based study of 664,297 deliveries in 2001-2007 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1234-9.
To evaluate the prevalence, trends, timing and duration of exposure to antiviral medications during pregnancy within a US cohort of pregnant women and to evaluate the proportion of deliveries with a viral infection diagnosis among women given antiviral medication during pregnancy.
Live-born deliveries between 2001 and 2007, to women aged 15 to 45 years, were included from the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP), a collaborative research program between the U.S. Food and Drug Administration and eleven health plans. They were evaluated for prevalence, timing, duration, and temporal trends of exposure to antiviral medications during pregnancy. We also calculated the proportion of deliveries with a viral infection diagnosis among those exposed to antiviral medications.
Among 664,297 live births, the overall prevalence of antiviral exposure during pregnancy was 4% (n=25,155). Between 2001 and 2007, antiviral medication exposure during pregnancy doubled from 2.5% to 5%. The most commonly used antiviral medication was acyclovir, with 3% of the deliveries being exposed and most of the exposure occurring after the 1st trimester. Most deliveries exposed to antiviral medications were exposed for less than 30 days (2% of all live births). Forty percent of the women delivering an infant exposed to antiviral medications had a herpes diagnosis.
Our findings highlight the increased prevalence of women delivering an infant exposed to antiviral medications over time. These findings support the need for large, well-designed studies to assess the safety and effectiveness of these medications during pregnancy.
PMCID: PMC3776000  PMID: 23420306
18.  Paid Leave Benefits Among a National Sample of Working Mothers with Infants in the United States 
Maternal and child health journal  2014;18(1):10.1007/s10995-013-1264-3.
To describe a range of employment benefits, including maternity and other paid leave, afforded to working women with infants; and to examine the geographic, socio-demographic correlates of such benefits to inform the workplace policy agenda in the US. Using data from the Listening to Mothers II Survey, a national sample of English-speaking women who gave birth in 2005, we conducted multivariable linear and logistic regression analyses to examine the associations between socio-demographic factors and employment leave variables (paid maternity, sick and personal leave). Forty-one percent of women received paid maternity leave for an average of 3.3 weeks with 31 % wage replacement. On average women took 10 weeks of maternity leave and received 10.4 days of paid sick leave and 11.6 days of paid personal time per year. Women who were non-Hispanic Black, privately insured, working full-time, and from higher income families were more likely to receive paid maternity leave, for more time, and at higher levels of wage replacement, when controlling for the other socio-demographic characteristics. Race/ethnicity, family income and employment status were associated with the number of paid personal days. Currently, the majority of female employees with young children in the US do not receive financial compensation for maternity leave and women receive limited paid leave every year to manage health-related family issues. Further, women from disadvantaged backgrounds generally receive less generous benefits. Federal policy that supports paid leave may be one avenue to address such disparities and should be modified to reflect accepted international standards.
PMCID: PMC3840152  PMID: 23584928
Maternal employment; Family health; Workplace policies; Socio-demographic disparities
19.  Measuring Early Childhood Health and Health Disparities: A New Approach 
Maternal and child health journal  2013;17(10):10.1007/s10995-012-1205-6.
Efforts to improve the health of U.S. children and reduce disparities have been hampered by lack of a rigorous way to summarize the multi-dimensional nature of children’s health. This research employed a novel statistical approach to measurement to provide an integrated, comprehensive perspective on early childhood health and disparities.
Nationally-representative data (n=8,800) came from the Early Childhood Longitudinal Study, Birth Cohort. Latent class analysis (LCA) was used to classify health at 48 months, incorporating health conditions, functioning, and aspects of physical, cognitive, and emotional development. Health disparities by gender, poverty, race/ethnicity, and birthweight were examined.
Over half of all children were classified as healthy using multidimensional latent class methodology; others fell into one of seven less optimal health statuses. The analyses highlighted pervasive disparities in health, with poor children at increased risk of being classified into the most disadvantaged health status consisting of chronic conditions and a cluster of developmental problems including low cognitive achievement, poor social skills, and behavior problems. Children with very low birthweight had the highest rate of being in the most disadvantaged health status (25.2%), but moderately low birthweight children were also at elevated risk (7.9% versus 3.4% among non-low birthweight children).
Latent class analysis provides a uniquely comprehensive picture of child health and health disparities that identifies clusters of problems experienced by some groups. The findings underscore the importance of continued efforts to reduce preterm birth, and to ameliorate poverty’s effects on children’s health through access to high-quality healthcare and other services.
PMCID: PMC3615056  PMID: 23225206
child health status; health disparities; socioeconomic status; low birth weight
20.  Self-reported Pre-pregnancy Weight Versus Weight Measured at First Prenatal Visit: Effects on Categorization of Pre-pregnancy Body Mass Index 
Maternal and child health journal  2013;17(10):10.1007/s10995-012-1210-9.
To compare classification of pre-pregnancy body mass index (BMI) using self-reported pre-pregnancy weight versus weight measured at the first prenatal visit.
Retrospective cohort of 307 women receiving prenatal care at the faculty and resident obstetric clinics at a Massachusetts tertiary-care center. Eligible women initiated prenatal care prior to 14 weeks gestation and delivered singleton infants between April 2007 and March 2008.
On average, self-reported weight was 4 pounds lighter than measured weight at the first prenatal visit (SD: 7.2 pounds; range: 19 pounds lighter to 35 pounds heavier). Using self-reported pre-pregnancy weight to calculate pre-pregnancy BMI, 4.2% of women were underweight, 48.9% were normal weight, 25.4% were overweight, and 21.5% were obese. Using weight measured at first prenatal visit, these were 3.6%, 45.3%, 26.4%, and 24.8%, respectively. Classification of pre-pregnancy BMI was concordant for 87% of women (weighted kappa = 0.86; 95% CI: 0.81 – 0.90). Women gained an average of 32.1 pounds (SD: 18.0 pounds) during pregnancy. Of the 13% of the sample with discrepant BMI classification, 74% gained within the same adherence category when comparing weight gain to Institute of Medicine recommendations.
For the vast majority of women, self-reported pre-pregnancy weight and measured weight at first prenatal visit resulted in identical classification of pre-pregnancy BMI. In absence of measured pre-pregnancy weight, we recommend that providers calculate both values and discuss discrepancies with their pregnant patients, as significant weight loss or gain during the first trimester may indicate a need for additional oversight with potential intervention.
PMCID: PMC3622142  PMID: 23247668
Gestational weight gain; pre-pregnancy BMI; self-reported weight; prenatal care
21.  Somatic Symptoms Among US Adolescent Females: Associations with Sexual and Physical Violence Exposure 
Maternal and child health journal  2013;17(10):10.1007/s10995-013-1221-1.
To examine the association between physical and sexual violence exposure and somatic symptoms among female adolescents.
We studied a nationally representative sample of 8,531 females, aged 11–21 years, who participated in the 1994–95 Wave I of the National Longitudinal Study of Adolescent Health (Add Health). Female adolescents were asked how often they had experienced 16 specific somatic symptoms during the past 12 months. Two summary categorical measures were constructed based on tertiles of the distributions for the entire female sample: a) total number of different types of symptoms experienced, and b) number of frequent (once a week or more often) different symptoms experienced. Groups were mutually exclusive. We examined associations between adolescents’ violence exposure and somatic symptoms using multinomial logistic regression analyses.
About 5% of adolescent females reported both sexual and non-sexual violence, 3% reported sexual violence only, 36% reported non-sexual violence only, and 57% reported no violence. Adolescents who experienced both sexual and non-sexual violence were the most likely to report many different symptoms and to experience very frequent or chronic symptoms. Likelihood of high symptomotology was next highest among adolescents who experienced sexual violence only, followed by females who experienced non-sexual violence only.
Findings support an exposure-response association between violence exposure and somatic symptoms, suggesting that symptoms can be markers of victimization. Treating symptoms alone, without addressing the potential violence experienced, may not adequately improve adolescents’ somatic complaints and well-being.
PMCID: PMC3689845  PMID: 23340952
somatic symptoms; violence; sexual violence; national sample
22.  Barriers to adequate prenatal care utilization in American Samoa 
Maternal and child health journal  2014;18(10):2284-2292.
To describe the utilization of prenatal care in American Samoan women and to identify socio-demographic predictors of inadequate prenatal care utilization.
Using data from prenatal clinic records, women (n=692) were categorized according to the Adequacy of Prenatal Care Utilization Index as having received adequate plus, adequate, intermediate or inadequate prenatal care during their pregnancy. Categorical socio-demographic predictors of the timing of initiation of prenatal care (week of gestation) and the adequacy of received services were identified using one way Analysis of Variance (ANOVA) and independent samples t-tests.
Between 2001 and 2008 85.4% of women received inadequate prenatal care. Parity (P=0.02), maternal unemployment (P=0.03), and both parents being unemployed (P=0.03) were negatively associated with the timing of prenatal care initation. Giving birth in 2007–2008, after a prenatal care incentive scheme had been introduced in the major hospital, was associated with earlier initiation of prenatal care (20.75 versus 25.12 weeks; P<0.01) and improved adequacy of received services (95.04% versus 83.8%; P=0.02).
The poor prenatal care utilization in American Samoa is a major concern. Improving healthcare accessibility will be key in encouraging women to attend prenatal care. The significant improvements in the adequacy of prenatal care seen in 2007–2008 suggest that the prenatal care incentive program implemented in 2006 may be a very positive step toward addressing issues of prenatal care utilization in this population.
PMCID: PMC3959630  PMID: 24045912
Pregnancy; Prenatal Care; Kotelchuck Index; American Samoa
23.  Factors associated with depressive symptoms in the early postpartum period among women with recent gestational diabetes mellitus 
Maternal and child health journal  2013;17(9):10.1007/s10995-012-1180-y.
Women with gestational diabetes mellitus (GDM) have a substantial risk of subsequently developing type 2 diabetes. This risk may be mitigated by engaging in healthy eating, physical activity, and weight loss when indicated. Since postpartum depressive symptoms may impair a woman's ability to engage in lifestyle changes, we sought to identify factors associated with depressive symptoms in the early postpartum period among women with recent GDM.
The participants are part of the baseline cohort of the TEAM GDM (Taking Early Action for Mothers with Gestational Diabetes Mellitus) study, a one-year randomized trial of a lifestyle intervention program for women with a recent history of GDM, conducted in Boston, Massachusetts between June 2010 and September 2012. We administered the Edinburgh Postnatal Depression Scale (EPDS) at 4-15 weeks postpartum to women whose most recent pregnancy was complicated by GDM (confirmed by laboratory data or medical record review). An EPDS score ≥9 indicated depressive symptoms. We measured height and thyroid stimulating hormone, and administered a questionnaire to collect demographic data and information about breastfeeding and sleep. We calculated body mass index (BMI) using self-reported pre-pregnancy weight and measured height. We reviewed medical records to obtain data about medical history, including history of depression, mode of delivery, and insulin use during pregnancy. We conducted bivariable analyses to identify correlates of postpartum depressive symptoms, and then modeled the odds of postpartum depressive symptoms using multivariable logistic regression.
Our study included 71 women (mean age 33 years ±5; 59% White, 28% African-American, 13% Asian, with 21% identifying as Hispanic; mean pre-pregnancy BMI 30 kg/m2±6). Thirty-four percent of the women scored ≥9 on the EPDS at the postpartum visit. In the best fit model, factors associated with depressive symptoms at 6 weeks postpartum included cesarean delivery (aOR 4.32, 95% CI 1.46, 13.99) and gestational weight gain (aOR 1.21 [1.02, 1.46], for each additional 5 lbs gained). Use of insulin during pregnancy, breastfeeding, personal history of depression, and lack of a partner were not retained in the model.
Identifying factors associated with postpartum depression in women with GDM is important since depression may interfere with lifestyle change efforts in the postpartum period. In this study, cesarean delivery and greater gestational weight gain were correlated with postpartum depressive symptoms among women with recent GDM.
PMCID: PMC3580121  PMID: 23124798
Postpartum depression; gestational diabetes; diabetes prevention; cesarean delivery; gestational weight gain
24.  Demographic and Placement Variables Associated with Overweight and Obesity in Children in Long-Term Foster Care 
Maternal and child health journal  2013;17(9):10.1007/s10995-012-1181-x.
Overweight and obesity is a growing problem for children in foster care. This study describes the prevalence of overweight and obesity in an urban, ethnic minority population of children ages 2–19 in long-term foster care (N = 312) in Los Angeles, California. It also investigates whether demographics or placement settings are related to high body mass index.
The estimates of prevalence of overweight/obesity (≥ 85th percentile) and obesity (≥ 95th percentile) were presented for gender, age, ethnicity, and placement type. Multiple logistic regression was used to examine potential associations between demographic and placement variables and weight status.
The prevalence of overweight/obesity was 40% and obesity was 23% for the study population. Children placed in a group home had the highest prevalence of overweight/obesity (60%) and obesity (43%) compared to other types of placement. Within this study, older children (ages 12–19) were more likely to be overweight/obese than normal weight compared to children between 2 and 5 years old when controlling for gender, ethnicity and placement (OR = 2.10, CI =1.14–3.87).
These findings suggest that older age and long-term foster care in general may be risk factors for obesity. Child welfare agencies and health care providers need to work together to train caregivers with children in long-term foster care in obesity treatment interventions and obesity prevention strategies.
PMCID: PMC3586377  PMID: 23124799
childhood obesity; overweight; long-term foster care; group home
25.  Healthcare Providers’ Knowledge, Attitudes and Counselling on Injury Prevention for Preschool Children in Croatia 
Maternal and child health journal  2013;17(9):10.1007/s10995-012-1165-x.
Injuries are the leading cause of death for children and young adults in Croatia. Research has indicated that health care providers can be effective in reducing the risk for traumatic injury through anticipatory guidance, but successful guidance requires that providers have injury knowledge and informed safety attitudes. This is the first study in Croatia to identify health care provider’s knowledge, attitudes, and practices regarding anticipatory guidance on injury prevention for children. A stratified, random sample of licensed Croatian healthcare providers was mailed a survey, with a response of rate of 39.5 %. Participants included pediatricians, family physicians, gynecologists, each with a focus on primary care, and community nurses. Participants filled out a 15-minute paper-and-pencil survey that tested their knowledge of injury risks and prevention strategies, assessed their safety-prone attitudes, and measured the extent to which they counselled their patients on injury prevention. Pediatricians had the highest knowledge of injury risks and intervention approaches, with an average correct score of six out of ten (significantly higher than all other provider types). Knowledge was highest regarding infant fall risk and lowest for safe sleep positions. Pediatricians and community nurses had the highest safety-prone attitudes. Safety prone attitudes were strongest for transportation safety and weakest for safe sleeping position for all providers. Community nurses reported the highest level of patient counselling, followed by pediatricians. Both factual education and support in translating knowledge into everyday practice are necessary for health care providers. Implementing anticipatory guidance for child safety is a promising approach in Croatia.
PMCID: PMC3664128  PMID: 23086152
Children; Injury prevention; Anticipatory guidance; Health care providers

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