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1.  An Investigation into the Influence of Socioeconomic Variables on Gestational Body Mass Index in Pregnant Women Living in a Peri-Urban Settlement, South Africa 
Maternal and child health journal  2012;16(8):1732-1741.
Maternal and child mortality rates are still unacceptably high in South Africa. The health status of women in peri-urban areas has been influenced by political and socio-economic factors. Examining socio-economic variables (SEV) in a population aids in the explanation of the impact of social structures on an individual. Risk factors can then be established and pregnant women in these higher risk groups can be identified and given additional support during pregnancy. The aim of this study was to investigate the association between SEV and gestational Body Mass Index (GBMI) in a peri-urban settlement, South Africa. This was a sub-study of the Philani Mentor Mothers’ Study (2009–2010). Maternal anthropometry and SEV were obtained from 1,145 participants. Multinomial regression was used to analyse the data. Household income was the only SEV that was significantly associated with GBMI. The odds of being underweight rather than normal weight during pregnancy increase by a factor of 2.145 (P < 0.05) for those who had a household income lower than R2000 per month. All other SEV were not significant. Logistic regression was therefore not carried out. Women who had a lower income were at risk of having a lower GBMI during pregnancy. This can lead to adverse birth outcomes such as premature birth, low birth weight, height and head circumference. Public health policy needs to be developed to include optimal nutrition health promotion strategies targeting women with a low income ante and post-natally. Once implemented, they need to be evaluated to assess the impact on maternal and child mortality.
PMCID: PMC4059349  PMID: 21894501
Socioeconomic variables; Peri-urban settlement; Gestational body mass index; Pregnancy
2.  Household exposure to secondhand smoke is associated with decreased physical and mental health of mothers in the USA 
Maternal and child health journal  2011;15(1):128-137.
Secondhand smoke is one of the most common toxic environmental exposures to children, and maternal health problems also have substantial negative effects on children. We are unaware of any studies examining the association of living with smokers and maternal health.
To investigate whether non-smoking mothers who live with smokers have worse physical and mental health than non-smoking mothers who live in homes without smokers.
Nationally representative data from the 2000–2004 Medical Expenditure Panel Survey were used. The health of non-smoking mothers with children <18 years (n=18,810) was assessed, comparing those living with one or more smokers (n=3,344) to those living in households with no adult smokers (n=14,836). Associations between maternal health, household smoking, and maternal age, race/ethnicity, and marital, educational, poverty and employment status were examined in bivariable and multivariable analyses using SUDAAN software to adjust for the complex sampling design. Scores on the Medical Outcomes Short Form-12 (SF-12) Physical Component Scale (PCS) and Mental Component Scale (MCS) were used to assess maternal health.
79.2% of mothers in the USA are non-smokers and 17.4% of them live with ≥1 adult smokers: 14.2% with 1 and 3.2% with ≥ 2 smokers. Among non-smoking mothers, the mean MCS score is 50.5 and mean PCS is 52.9. The presence of an adult smoker and increasing number of smokers in the home are both negatively associated with MCS and PCS scores in bivariable analyses (p<0.001 for each). Non-smoking mothers with at least one smoker in the household had an 11 % (95% CI=0.80–0.99) lower odds of scoring at or above the mean MCS score and a 19 % (95%CI=0.73–0.90) lower odds of scoring at or above the mean PCS score_compared to non-smoking mothers with no smokers in the household. There is an evidence of a dose response relationship with increasing number of smokers in the household for PCS (p<0.001).
These findings demonstrate a previously unrecognized child health risk: living with smokers is independently associated with worse physical and mental health among non-smoking mothers.
PMCID: PMC4049417  PMID: 20012677
maternal health; secondhand smoke
3.  Racial Disparities in Economic and Clinical Outcomes of Pregnancy Among Medicaid Recipients 
Maternal and child health journal  2013;17(8):1518-1525.
To explore racial-ethnic disparities in adverse pregnancy outcomes among Medicaid recipients, and to estimate excess Medicaid costs associated with the disparities. Cross-sectional study of adverse pregnancy outcomes and Medicaid payments using data from Medicaid Analytic eXtract files on all Medicaid enrollees in fourteen southern states. Compared to other racial and ethnic groups, African American women tended to be younger, more likely to have a Cesarean section, to stay longer in the hospital and to incur higher Medicaid costs. African-American women were also more likely to experience preeclampsia, placental abruption, preterm birth, small birth size for gestational age, and fetal death/stillbirth. Eliminating racial disparities in adverse pregnancy outcomes (not counting infant costs), could generate Medicaid cost savings of $114 to $214 million per year in these 14 states. Despite having the same insurance coverage and meeting the same poverty guidelines for Medicaid eligibility, African American women have a higher rate of adverse pregnancy outcomes than White or Hispanic women. Racial disparities in adverse pregnancy outcomes not only represent potentially preventable human suffering, but also avoidable economic costs. There is a significant financial return-on-investment opportunity tied to eliminating racial disparities in birth outcomes. With the Affordable Care Act expansion of Medicaid coverage for the year 2014, Medicaid could be powerful public health tool for improving pregnancy outcomes.
PMCID: PMC4039287  PMID: 23065298
Disparities; Medicaid; Economic burden; Adverse maternal-child health outcomes and eliminating disparities
4.  The Role of Gender Empowerment on Reproductive Health Outcomes in Urban Nigeria 
Maternal and child health journal  2014;18(1):307-315.
To date, limited evidence is available for urban populations in sub-Saharan Africa, specifically research into the association between urban women’s empowerment and reproductive health outcomes. The objective of this study is to investigate whether women’s empowerment in urban Nigerian settings is associated with family planning use and maternal health behaviors. Moreover, we examine whether different effects of empowerment exist by region of residence.
This study uses baseline household survey data from the Measurement, Learning & Evaluation Project (MLE) for the Nigerian Urban Reproductive Health Initiative (NURHI) being implemented in six major cities. We examine four dimensions of empowerment: economic freedom, attitudes towards domestic violence, partner prohibitions and decision-making. We determine if the empowerment dimensions have different effects on reproductive health outcomes by region of residence using multivariate analyses.
Results indicate that more empowered women are more likely to use modern contraception, deliver in a health facility and have a skilled attendant at birth. These trends vary by empowerment dimension and by city/region in Nigeria.
We conclude by discussing the implications of these findings on future programs seeking to improve reproductive health outcomes in urban Nigeria and beyond.
PMCID: PMC4022125  PMID: 23576403
Maternal Health; Gender; Family Planning; Reproductive Health; Nigeria; Urban
5.  Labor Epidural Anesthesia, Obstetric Factors and Breastfeeding Cessation 
Maternal and child health journal  2013;17(4):689-698.
Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia’s association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction.
A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data.
Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within one month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95%confidence interval 1.10, 1.44], p<.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01,1.41], p<.04; non-BFH: 1.65 [1.31, 2.08], p<.01).
A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.
PMCID: PMC3622113  PMID: 22696104
6.  Social support during the postpartum period: Mothers’ views on needs, expectations, and mobilization of support 
Maternal and child health journal  2013;17(4):616-623.
Research has indicated that social support is a major buffer of postpartum depression. Yet little is known concerning women’s perceptions on social support during the postpartum period. The objective of this study was to explore postpartum women’s views and experiences with social support following childbirth.
Four focus groups were conducted with an ethnically diverse sample of women (n=33) in a large urban teaching hospital in New York City. Participants had completed participation in a postpartum depression randomized trial and were 6 to 12 months postpartum. Data transcripts were reviewed and analyzed for themes.
The main themes identified in the focus group discussions were mother’s major needs and challenges postpartum, social support expectations and providers of support, how mothers mobilize support, and barriers to mobilizing support. Women across all groups identified receipt of instrumental support as essential to their physical and emotional recovery. Support from partners and families was expected and many women believed this support should be provided without asking. Racial/ethnic differences existed in the way women from different groups mobilized support from their support networks.
Instrumental support plays a significant role in meeting women’s basic needs during the postpartum period. In addition, women’s expectations surrounding support can have an impact on their ability to mobilize support among their social networks. The results of this study suggest that identifying support needs and expectations of new mothers is important for mothers’ recovery after childbirth. Future postpartum depression prevention efforts should integrate a strong focus on social support.
PMCID: PMC3518627  PMID: 22581378
7.  Protective Factors in American Indian Communities and Adolescent Violence 
Maternal and child health journal  2013;17(7):1199-1207.
With their distinct cultural heritage and rural boundaries, American Indian reservation communities offer a unique opportunity to explore protective factors that help buffer adolescents from potential risk behaviors such as violence. Prior published research on Indian communities has not explored three potential protective factors for violence - parental monitoring of adolescents and friends, adolescents’ self-efficacy to avoid fighting, and adolescents’ interest in learning more about their traditional culture. This paper explores the relationship between these factors and reduced risk of reported violence.
In 1998, 630 American Indian students in grades 6–12 were surveyed in five Midwestern, rural Indian reservation schools. Path analysis was used to identify the direct and indirect association of the three potential protective factors with reduced violence behavior.
There were significant gender differences both in perceived parental monitoring and in adolescents’ self-efficacy. For female adolescents, parental monitoring had the strongest inverse relationship with female adolescents’ involvement in violence. Female adolescents’ self-efficacy and their interest in learning more about their culture were also inversely associated with violence and therefore potentially important protectors. Male adolescents who reported more interest in learning the tribe’s culture had better self-efficacy to avoid violence. However, self-efficacy did not successfully predict their reported involvement in peer violence.
These findings support exploring gender differences, parental monitoring, self-efficacy training as well as cultural elements in future violence intervention studies. Further investigation is needed to identify protective factors for risk behaviors among male adolescents and test the generalizability to non-reservation based adolescents.
PMCID: PMC3997049  PMID: 22926269
American Indian adolescents; protective factors for peer violence; parental monitoring; self-efficacy; traditional culture
8.  Risk of Spontaneous Preterm Birth in Relation to Maternal Exposure to Intimate Partner Violence During Pregnancy in Peru 
Maternal and child health journal  2013;17(3):485-492.
Intimate partner violence (IPV) is increasingly recognized as an important cause of maternal and perinatal morbidity. We assessed the relation between IPV and risk of spontaneous preterm birth (PTB) among Peruvian women.
The study was conducted among 479 pregnant women who delivered a preterm singleton infant (<37 weeks gestation) and 480 controls (≥37 weeks gestation). Participants’ exposure to physical and emotional violence during pregnancy was collected during in-person interviews conducted after delivery and while patients were in hospital. Odds ratios (aOR) and 95% confidence intervals (CI) were estimated from logistic regression models.
The prevalence of any IPV during pregnancy was 52.2% among cases and 34.6% among controls. Compared with those reporting no exposure to IPV during pregnancy, women reporting any exposure had a 2.1-fold increased risk of PTB (95% CI 1.59–2.68). The association was attenuated slightly after adjusting for maternal age, pre-pregnancy weight, and other covariates (OR=1.99; 95% CI: 1.52–2.61). Emotional abuse in the absence of physical violence was associated with a 1.6-fold (95% CI 1.21–2.15) increased risk of PTB. Emotional and physical abuse during pregnancy was associated with a 4.7-fold increased risk of PTB (95% CI 2.74–7.92). Associations of similar directions and magnitudes were observed when PTB were sub-categorized according to clinical presentation or severity.
IPV among pregnant women is common and is associated with an increased risk of PTB. Our findings and those of others support recent calls for coordinated global health efforts to prevent violence against women.
PMCID: PMC3565008  PMID: 22527763
Preterm birth; intimate partner violence; pregnant women; Peru
9.  Prevalence and Associated Factors of Intimate Partner Violence Among Pregnant Women Attending Kisumu District Hospital, Kenya 
Maternal and child health journal  2013;17(3):441-447.
To determine prevalence and factors associated with intimate partner violence (IPV) among pregnant women seeking antenatal care. This was a cross-sectional study conducted at Kisumu District Hospital, Kenya amongst randomly selected pregnant women. A structured questionnaire was used to collect data. Participants self-reported about their own IPV experience (lifetime, 12 months prior to and during index pregnancy) and associated risk factors. Data were analyzed using Epi-info. The mean age of the 300 participants was 23.7 years. One hundred and ten (37 %) of them experienced at least one form of IPV during pregnancy. Psychological violence was the most common (29 %), followed by sexual (12 %), and then physical (10 %). Women who experienced IPV during pregnancy were more likely to have witnessed maternal abuse in childhood (aOR 2.27, 95 % CI = 1.05–4.89), been in a polygamous union (aOR 2.48, 95 % CI = 1.06–5.8), been multiparous (aOR 1.94, 95 % CI = 1.01–3.32) or had a partner who drank alcohol (aOR 2.32, 95 % CI = 1.21–4.45). Having a partner who attained tertiary education was protective against IPV (aOR 0.37, 95 % CI = 0.16–0.83). We found no association between HIV status and IPV. IPV is common among women seeking antenatal care at Kisumu District Hospital. Health care providers should be alerted to the possibility of IPV during pregnancy in women who witnessed maternal abuse in childhood, are multiparous, polygamous, have a partner who drinks alcohol or has low level education. Screening for IPV, support and referral is urgently needed to help reduce the burden experienced by pregnant women and their unborn babies.
PMCID: PMC3574621  PMID: 22569943
Intimate partner violence; Pregnancy; Kenya
10.  First Trimester Exposure to Ambient Air Pollution, Pregnancy Complications and Adverse Birth Outcomes in Allegheny County, PA 
Maternal and child health journal  2013;17(3):545-555.
Despite numerous studies of air pollution and adverse birth outcomes, few studies have investigated preeclampsia and gestational hypertension, two pregnancy disorders with serious consequences for both mother and infant. Relying on hospital birth records, we conducted a cohort study identifying 34,705 singleton births delivered at Magee-Women’s Hospital in Pittsburgh, PA between 1997 and 2002. Particle (<10 μm-PM10; <2.5 μm-PM2.5) and ozone (O3) exposure concentrations in the first trimester of pregnancy were estimated using the space–time ordinary Kriging interpolation method. We employed multiple logistic regression estimate associations between first trimester exposures and preeclampsia, gestational hypertension, preterm delivery, and small for gestational age (SGA) infants. PM2.5 and O3 exposures were associated with preeclampsia (adjusted OR = 1.15, 95 % CI = 0.96–1.39 per 4.0 μg/m3 increase in PM2.5; adjusted OR = 1.12, 95 % CI = 0.89–1.42 per 16.8 ppb increase in O3), gestational hypertension (for PM2.5 OR = 1.11, 95 % CI = 1.00–1.23; for O3 OR = 1.12, 95 % CI = 0.97–1.29), and preterm delivery (for PM2.5 ORs = 1.10, 95 % CI = 1.01–1.20; for O3 ORs = 1.23, 95 % CI = 1.01–1.50). Smaller 5–8 % increases in risk were also observed for PM10 with gestational hypertension and SGA, but not preeclampsia. Our data suggest that first trimester exposure to particles, mostly PM2.5, and ozone, may increase the risk of developing preeclampsia and gestational hypertension, as well as preterm delivery and SGA.
PMCID: PMC3636771  PMID: 22544506
Air pollution; Particulate; Preeclampsia; Gestational hypertension; Preterm; Small for gestational; age (SGA)
11.  Predictors of Inadequate Prenatal Care in Methamphetamine-Using Mothers in New Zealand and the United States 
Maternal and child health journal  2013;17(3):566-575.
This study compared patterns of prenatal care among mothers who used methamphetamine (MA) during pregnancy and non-using mothers in the US and New Zealand (NZ), and evaluated associations among maternal drug use, child protective services (CPS) referral, and inadequate prenatal care in both countries. The sample consisted of 182 mothers in the MA-Exposed and 196 in the Comparison groups in the US, and 107 mothers in the MA-Exposed and 112 in the Comparison groups in NZ. Positive toxicology results and/or maternal report of MA use during pregnancy were used to identify MA use. Information about sociodemographics, prenatal care and prenatal substance use was collected by maternal interview. MA-use during pregnancy is associated with lower socio-economic status, single marital status, and CPS referral in both NZ and the US. Compared to their non-using counterparts, MA-using mothers in the US had significantly higher rates of inadequate prenatal care. No association was found between inadequate care and MA-use in NZ. In the US, inadequate prenatal care was associated with CPS referral, but not in NZ. Referral to CPS for drug use only composed 40 % of all referrals in the US, but only 15 % of referrals in NZ. In our study population, prenatal MA-use and CPS referral eclipse maternal sociodemographics in explanatory power for inadequate prenatal care. The predominant effect of CPS referral in the US is especially interesting, and should encourage further research on whether the US policy of mandatory reporting discourages drug-using mothers from seeking antenatal care.
PMCID: PMC3717345  PMID: 22588827
Methamphetamine; Adequate prenatal care; New Zealand; Kessner Index; Child protective services
12.  The Effect of Time in the U.S. on the Duration of Breastfeeding in Women of Mexican Descent 
Maternal and child health journal  2007;11(2):119-125.
Although women of Mexican decent have high rates of breastfeeding, these rates may vary considerably by acculturation level. This study investigated whether increased years of residence in the U.S. is associated with poorer breastfeeding practices, including shorter duration of any and exclusive breastfeeding, in a population of low-income mothers of Mexican descent.
Pregnant women (n=490) were recruited from prenatal clinics serving a predominantly Mexican-origin population in an agricultural region of California. Women were interviewed during pregnancy, shortly postpartum, and when their child was 6 months, 1 year, 2 years, and 3.5 years of age.
Increased years of residence in the U.S. was associated with decreased likelihood of initiating breastfeeding and shorter duration of exclusive and any breastfeeding. Median duration of exclusive breastfeeding was 2 months for women living in the U.S. for 5 years or less, 1 month for women living in the U.S. for 6 to 10 years, and less than one week for women living in the U.S. for 11 years or more, or for their entire lives (lifetime residents). After controlling for maternal age, education, marital status and work status, lifetime residents of the U.S. were 2.4 times more likely to stop breastfeeding, and 1.5 times more likely to stop exclusive breastfeeding, than immigrants who had lived in the U.S. for 5 years or less.
Efforts are needed to encourage and support Mexican-origin women to maintain their cultural tradition of breastfeeding as they become more acculturated in the U.S.
PMCID: PMC3957412  PMID: 17279324
Breastfeeding; acculturation; Mexican Americans; Mexican immigrants; immigration
13.  Effects of Prenatal Care on Child Health at Age 5 
Maternal and child health journal  2013;17(2):189-199.
The broad goal of contemporary prenatal care is to promote the health of the mother, child, and family through the pregnancy, delivery, and the child’s development. Although the vast majority of mothers giving birth in developed countries receive prenatal care, past research has not found compelling evidence that early or adequate prenatal care has favorable effects on birth outcomes. It is possible that prenatal care confers health benefits to the child that do not become apparent until after the perinatal period.
Using data from a national urban birth cohort study in the U.S., we estimate the effects of prenatal care on four markers of child health at age 5—maternal-reported health status, asthma diagnosis, overweight, and height. We implement a number of different strategies to address the issue of potential omitted variables bias as well as a large number of specification checks to validate the findings.
Results and Conclusions
Prenatal care, defined a number of different ways, does not appear to have any effect on the outcomes examined. The findings are robust and suggest that routine health care encounters during the prenatal period could potentially be used more effectively to enhance children’s health trajectories. However, future research is needed to explore the effects of prenatal care on additional child health and developmental outcomes as well as the effects of preconceptional and maternal lifetime helathcare on child health.
PMCID: PMC3391357  PMID: 22374319
prenatal care timing; prenatal care adequacy; child health outcomes
14.  Quality Disparities in Child Care for At-Risk Children: Comparing Head Start and Non-Head Start Settings 
Maternal and child health journal  2013;17(1):180-188.
The study objectives are to describe child care type and quality experienced by developmentally at-risk children, examine quality differences between Head Start and non-Head Start settings, and identify factors associated with receiving higher-quality child care. Data are analyzed from the Early Childhood Longitudinal Survey, Birth Cohort, a prospective study of a nationally representative sample of US children born in 2001. The sample consisted of 7,500 children who were assessed at 48 months of age. The outcome of interest is child care quality, measured by the Early Childhood Environmental Rating Scale (center care) and the Family Day Care Rating Scale (family day care). Results of descriptive and multivariate regression analyses are presented. Less than one-third of poor children were in Head Start. Child care quality was higher in Head Start centers than other centers, particularly among poor children (4.75 vs. 4.28, p < 0.001), Hispanics (4.90 vs. 4.45, p < 0.001), and whites (4.89 vs. 4.51, p < 0.001). African Americans experienced the lowest quality care in both Head Start and non-Head Start centers. Quality disadvantage was associated with Head Start family care settings, especially for low birthweight children (2.04 in Head Start vs. 3.58 in non-Head Start, p < 0.001). Lower family day care quality was associated with less maternal education and African American and Hispanic ethnicity. Center-based Head Start provides higher quality child care for at-risk children, and expansion of these services will likely facilitate school readiness in these populations. Quality disadvantages in Head Start family day care settings are worrisome and warrant investigation.
PMCID: PMC3407821  PMID: 22392601
Child care; Head Start program; Low income population; Preschool child; Low birthweight; Poverty
15.  Maternal pre-pregnancy weight and gestational weight gain and their association with birthweight with a focus on racial differences 
To examine the interaction between maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) and their association with birthweight, with a focus on racial differences.
We used birth certificate data from live singleton births of South Carolina resident mothers, who self-reported their race as non-Hispanic white (NHW, n=140,128) or non-Hispanic black (NHB, n=82,492) and who delivered at 34–44 weeks of gestation between 2004–2008 to conduct a cross-sectional study. Linear regression was used to examine the relationship between our exposures (i.e., race, BMI and GWG) and our outcome birthweight.
Based on 2009 Institute of Medicine guidelines, the prevalence of adequate, inadequate and excessive GWG was 27.1%, 24.2% and 48.7%, respectively, in NHW women and 24.2%, 34.8% and 41.0%, respectively, in NHB women. Adjusting for infant sex, gestational age, maternal age, tobacco use, education, prenatal care, and Medicaid, the difference in birthweight between excessive and adequate GWG at a maternal BMI of 30 kg/m2 was 118g (95% CI: 109, 127) in NHW women and 101g (95% CI: 91, 111) in NHB women. Moreover, excessive versus adequate GWG conveyed similar protection from having a small for gestational age infant in NHW [OR=0.64 (95% CI 0.61, 0.67)] and NHB women [OR=0.68 (95% CI: 0.65, 0.72)].
We report a strong association between excessive GWG and higher infant birthweight across maternal BMI classes in NHW and NHB women. Given the high prevalence of excessive GWG even a small increase in birthweight may have considerable implications at the population level.
PMCID: PMC3677820  PMID: 22322428
Gestational weight gain; racial/ethnic health differences; obesity; birthweight
16.  Regional Variation in Late Preterm Births in North Carolina 
Late preterm (LPT) neonates (34 0/7th to 36 6/7th weeks' gestation) account for 70% of all premature births in the United States. LPT neonates have a higher morbidity and mortality risk than term neonates. LPT birth rates vary across geographic regions. Unwarranted variation is variation in medical care that cannot be explained by sociodemographic or medical risk factors; it represents differences in health system performance, including provider practice variation. The purpose of this study is to identify regional variation in LPT births in North Carolina that cannot be explained by sociodemographic or medical/obstetric risk factors.
We searched the NC State Center for Health Statistics linked birth-death certificate database for all singleton term and LPT neonates born between 1999 and 2006. We used multivariable logistic regression analysis to control for socio-demographic and medical/obstetric risk factors. The main outcome was the percent of late preterm birth in each of the six perinatal regions in North Carolina.
We identified 884,304 neonates; 66,218 (7.5%) were LPT. After multivariable logistic regression, regions 2 (7.0%) and 6 (6.6%) had the highest adjusted percent of LPT birth.
Analysis of a statewide birth cohort demonstrates regional variation in the incidence of LPT births among NC's perinatal regions after adjustment for sociodemographic and medical risk factors. We speculate that provider practice variation might explain some of the remaining difference. This is an area where policy changes and quality improvement efforts can help reduce variation, and potentially decrease LPT births.
PMCID: PMC3725330  PMID: 22350629
late preterm; preterm birth; unwarranted variation; practice variation
17.  Biases in studying gestational weight gain and infant mortality in U.S. birth certificates 
Maternal and child health journal  2012;16(4):10.1007/s10995-012-0987-x.
PMCID: PMC3853097  PMID: 22453329
18.  Early predictors of obesity and cardiovascular risk among American Indian children 
Maternal and child health journal  2012;16(9):1879-1886.
American Indian (AI) children have the highest rates of obesity among ethnic groups in the United States, and rates continue to increase. This study was designed to examine the effects of prenatal and early postnatal factors on AI children’s body mass index (BMI) trajectories, adiposity, and cardiovascular risk markers during early childhood. We screened 471 AI children (ages 5–8) from three Wisconsin tribes. Screenings included anthropometric and body fat measures and non-fasting lipid and glucose via fingerstick blood samples. Tribal records from Women Infants and Children (WIC) programs and clinic charts provided data on children’s BMI trajectories, maternal prenatal factors, and the early postnatal feeding environment. Forty-seven percent of children were overweight or obese. Analysis of growth trajectories showed that children’s BMI category was largely determined within the first year of life. Significant predictors of children's BMI category at age 1 included macrosomia (OR: 4.38), excess gestational weight gain (OR: 1.64) and early termination of breastfeeding (OR: 1.66). Children who were overweight/obese at age 1 had greater odds of being overweight (OR: 3.42) or obese (OR: 3.36), and having unhealthy levels of body fat (OR: 2.95) and LDL cholesterol (OR: 1.64) at ages 5–8. Children’s BMI category is determined in the early post-natal environment, within the first year of life, by factors including excess gestational weight gain and early termination of breastfeeding. In turn, children’s BMI category at age 1 predicts the emergence of cardiovascular risk markers in early childhood.
PMCID: PMC3438386  PMID: 22527771
American Indian; Breastfeeding; Gestational Weight gain; Growth trajectories; Macrosomia
19.  Perceptions of low-income African-American mothers about excessive gestational weight gain 
Maternal and child health journal  2012;16(9):10.1007/s10995-011-0930-6.
A rising number of low-income African-American mothers gain more weight in pregnancy than is recommended, placing them at risk for poor maternal and fetal health outcomes. Little is known about the perceptions of mothers in this population that may influence excessive gestational weight gain.
In 2010–2011, we conducted 4 focus groups with 31 low-income, pregnant African-Americans in Philadelphia. Two readers independently coded the focus group transcripts to identify recurrent themes.
We identified 9 themes around perceptions that encouraged or discouraged high gestational weight gain. Mothers attributed high weight gain to eating more in pregnancy, which was the result of being hungrier and the belief that consuming more calories while pregnant was essential for babies’ health. Family members, especially participants own mothers, strongly reinforced the need to “eat for two” to make a healthy baby. Mothers and their families recognized the link between poor fetal outcomes and low weight gains but not higher gains, and thus, most had a greater pre-occupation with too little food intake and weight gain rather than too much. Having physical symptoms from overeating and weight retention after previous pregnancies were factors that discouraged higher gains.
Low-income African American mothers had more perceptions encouraging high gestational weight gain than discouraging it. Interventions to prevent excessive weight gain need to be sensitive to these perceptions. Messages that link guideline recommended weight gain to optimal infant outcomes and mothers’ physical symptoms may be most effective for weight control.
PMCID: PMC3835695  PMID: 22160656
Pregnancy; Weight gain; African-American; Obesity; Diet
20.  Patterns of body composition among HIV-infected, pregnant Malawians and the effects of famine season1 
Maternal and child health journal  2013;17(2):10.1007/s10995-012-0970-6.
We describe change in weight, midupper arm circumference (MUAC), arm muscle area (AMA) and arm fat area (AFA) in 1130 pregnant HIV-infected women with CD4 counts > 200 as part of the BAN Study (, a randomized, controlled clinical trialto evaluate antiretroviral and nutrition interventions to reducemother-to-child transmission of HIV during breast feeding. In a longitudinal analysis, we found a linear increase in weight with a mean rate of weight gain of 0.27 kgs/wk, from baseline (12 to 30 wks gestation) until the last follow-up visit (32 to 38 wks). Analysis of weight gain showed that 17.1% of the intervals between visits resulted in a weight loss. In unadjusted models, MUAC and AMA increased and AFA declined during late pregnancy. Based on multivariable regression analysis, exposure to the famine season resulted in larger losses in AMA [−0.08, 95%CI: −0.14, −0.02; p=0.01] while AFA losses occurred irrespective of season [−0.55, 95%: −0.95, −0.14, p=0.01]. CD4 was associated with AFA [0.21, 95%CI: 0.01, 0.41, p=.04]. Age was positively associated with MUAC and AMA. Wealth index was positively associated with MUAC, AFA, and weight. While patterns of anthropometric measures among HIV-infected, pregnant women were found to be similar to those reported for uninfected women in sub-Saharan Africa, effects of the famine season among undernourished, Malawian women are of concern. Strategies to optimize nutrition during pregnancy for these women appear warranted.
PMCID: PMC3837416  PMID: 22395817
21.  Maternal Visceral Adiposity by Consistency of Lactation 
Maternal and child health journal  2012;16(2):10.1007/s10995-011-0758-0.
The purpose of this study was to examine the assocation between lactation and maternal visceral adiposity among US women who were on average 7 years postpartum. This cross-sectional analysis included 89 women who gave birth between 1997 and 2002, who did not have preeclampsia, prepregnancy hypertension or prepregnancy diabetes, and enrolled in The Women and Infant Study of Healthy Hearts (WISH). Computed tomography was used to assess abdominal adiposity. History of lactation was self-reported. Visceral adiposity was greater by 36.96 cm2 (95% CI: 20.92,53.01) among mothers who never breastfed than mothers who breastfed for ≥3 months after every birth, even after adjustment for age, parity, years since last birth, site, socioeconomic, lifestyle, psychological, and family history variables, early adult BMI, and current BMI. Similarly, in fully adjusted models, mothers who breastfed any of their children for less than 3 months had 20.38 cm2 (95% CI: 2.70, 38.06) greater visceral adiposity than mothers who consistently breastfed all their children for 3 or more months. This study found that 7 years postpartum visceral fat depots are significantly greater among mothers who lactated for less than 3 months after the birth of each of their children. These results provide a potential physiologic basis for prior findings that women who do not consistently breastfeed are at an increased risk of diabetes, cardiovascular disease, and the metabolic syndrome.
PMCID: PMC3823370  PMID: 21404071
Lactation; Maternal health; Obesity; Visceral adiposity; Women
22.  Medication Exposure in Pregnancy Risk Evaluation Program: The Prevalence of Asthma Medication Use During Pregnancy 
Maternal and child health journal  2013;17(9):10.1007/s10995-012-1173-x.
Asthma is one of the most common chronic diseases in women of reproductive age, occurring in up to 8% of pregnancies.
Assess the prevalence of asthma medication use during pregnancy in a large diverse cohort.
We identified women aged 15 to 45 years who delivered a live born infant between 2001 and 2007 across 11 U.S. health plans within the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). Using health plans’ administrative and claims data, and birth certificate data, we identified deliveries for which women filled asthma medications from 90 days before pregnancy through delivery. Prevalence (%) was calculated for asthma diagnosis and medication dispensing.
There were 586,276 infants from 575,632 eligible deliveries in the MEPREP cohort. Asthma prevalence among mothers was 6.7%, increasing from 5.5% in 2001 to 7.8% in 2007. A total of 9.7% (n=55,914) of women were dispensed asthma medications during pregnancy. The overall prevalence of maintenance-only medication, rescue-only medication, and combined maintenance and rescue medication was 0.6%, 6.7%, and 2.4% respectively. The prevalence of maintenance-only use doubled during the study period from 0.4% to 0.8%, while rescue-only use decreased from 7.4% to 5.8%.
In this large population-based pregnancy cohort, the prevalence of asthma diagnoses increased over time. The dispensing of maintenance-only medication increased over time, while rescue-only medication dispensing decreased over time.
PMCID: PMC3797257  PMID: 23108737
Asthma; Pregnancy; Medication; Prevalence
23.  Breastfeeding Practices Among First-Time Mothers and Across Multiple Pregnancies 
Maternal and child health journal  2012;16(8):1665-1671.
To investigate maternal characteristics associated with breastfeeding initiation and success. Women enrolled in the Mothers Outcomes After Delivery study reported breastfeeding practices 5–10 years after a first delivery. Women were classified as successful breastfeeding initiators, unsuccessful initiators, or non-initiators. For the first birth, demographic and obstetrical characteristics were compared across these three breastfeeding groups. For multiparous women, agreement in breastfeeding status between births was evaluated. Multivariate regression analysis was used to identify characteristics associated with non-initiation and unsuccessful breastfeeding across all births. Of 812 participants, 740 (91%) mothers tried to breastfeed their first child and 593 (73%) reported breastfeeding successfully. In a multivariate analysis, less educated women were less likely to initiate breastfeeding (odds ratio (OR) for non-initiation 1.97; 95% confidence interval (CI) 1.23, 3.14). There was a notable decrease in breastfeeding initiation with increasing birth order: compared to the first birth, the odds for non-initiation after a second delivery almost doubled (OR 1.83, 95% CI 1.42, 2.35) and the odds for non-initiation after a third delivery were further increased (OR 2.44, 95% CI 1.56, 3.82). Successful breastfeeding in a first pregnancy was a predictor of subsequent breastfeeding initiation and success. Specifically, women who did not attempt breastfeeding or who reported unsuccessful attempts to breastfeed at first birth were unlikely to initiate breastfeeding at later births. Cesarean delivery was not associated with breastfeeding initiation (OR 1.01; 95% CI 0.68, 1.48) or success (OR 1.33; 95% CI 0.92, 1.94). Breastfeeding practices after a first birth are a significant predictor of breastfeeding in subsequent births.
PMCID: PMC3227754  PMID: 21837386
Breastfeeding initiation; Cesarean delivery; Multiparity; Maternal education; Healthy People 2020
24.  The HPV Vaccine: A Comparison of Focus Groups Conducted in South Africa and Ohio Appalachia 
Maternal and child health journal  2013;17(7):1222-1229.
Worldwide, cervical cancer is one of the leading causes of morbidity and mortality among women. Even though women in developing countries account for approximately 85 % of the cervical cancer cases and deaths, disparities in cervical cancer rates are also documented in developed countries like the United States (U.S.). Recently, formative research conducted in the U.S. and developing countries like South Africa have sought to gain a better understanding of the knowledge, beliefs, and attitudes about cervical cancer prevention, HPV, and the acceptance of the HPV vaccine. This study compares findings from two independent focus group studies. One study was conducted in a segregated township in Johannesburg, South Africa (n = 24) and the other study was conducted in Ohio Appalachia (n = 19). The following seven themes emerged during the discussions from both studies: HPV and cervical cancer; health decision making; parent–child communication; healthy children; HPV vaccine costs; sexual abuse; and HPV vaccine education. Findings from both studies indicate the importance of the role of mothers and grandmothers in the health care decision-making process for children and a lack of awareness of HPV and its association with cervical cancer. While there was interest in the HPV vaccine, participants voiced concern about the vaccine’s cost and side effects. Some participants expressed concern that receipt of the HPV vaccine may initiate adolescent sexual behavior. However, other participants suggested that the HPV vaccine may protect young women who may experience sexual abuse. The importance of developing culturally appropriate educational materials and programs about cervical cancer prevention and the HPV vaccine were expressed by participants in both countries.
PMCID: PMC3799762  PMID: 22930347
HPV; HPV vaccine; Cervical cancer prevention; Vulnerable populations
25.  Do Florida Medicaid Providers’ Barriers to HPV Vaccination Vary Based on VFC Program Participation? 
Maternal and child health journal  2013;17(4):609-615.
This study aimed to determine if physicians’ perceived barriers to HPV vaccination were associated with participation in the federal Vaccines for Children (VFC) program.
A sample of 800 Florida Medicaid providers was randomly selected from the Florida Medicaid Master Provider File. A cross-sectional study was conducted using a 27-item survey that included 13 potential barriers to immunizing Medicaid patients against HPV, including concerns about vaccine safety and efficacy, discussing sexuality, vaccinated teens practicing riskier sexual behaviors, cost and reimbursement, ensuring 3-dose series completion, and school attendance requirements associated with HPV vaccination. Pearson Chi-square tests were conducted to investigate differences between each barrier and VFC program participation. Data were analyzed for 449 physicians.
Compared to non-VFC providers, VFC providers were significantly less likely to somewhat or strongly agree that the following were barriers to vaccination: the cost of stocking the HPV vaccine (p = 0.0011), lack of adequate reimbursement for HPV vaccination (p < 0.0001), and lack of timely reimbursement for HPV vaccination (p < 0.0001). After adjusting for provider specialty and number of years since completion of residency training, VFC status remained significantly associated with the barrier regarding lack of adequate reimbursement for vaccination such that non-VFC providers had a 2.6-fold (95% confidence interval, 1.1–5.8) greater odds of somewhat or strongly agreeing that this barrier applied to them.
Increasing participation in the VFC program may decrease physicians’ cost-related barriers, which may increase the number of children vaccinated on time according to the recommended schedule.
PMCID: PMC3795412  PMID: 22569945

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