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author:("Mathew, lens")
1.  Lessons learned from the Philadelphia Collaborative Preterm Prevention Project: the prevalence of risk factors and program participation rates among women in the intervention group 
Women who deliver preterm infants are at a much greater risk for repeating a preterm birth (PTB), compared to women without a history of PTB. However, little is known about the prevalence of the risk factors which account for this markedly increased risk. Moreover, little or nothing is known about the feasibility of providing treatments and services to these women, outside of the context of prenatal care, during the inter-conception period, which provides the best opportunity for successful risk-reduction interventions.
The Philadelphia Collaborative Preterm Prevention Project (PCPPP), a large randomized control trial designed to identify and reduce six major risk factors for a repeat preterm birth among women immediately following the delivering of a preterm infant. For the women assigned to the PCPPP treatment group, we calculated the prevalence of the six risk factors in question, the percentages of women who agreed to receive high quality risk-appropriate treatments or services, and the of rates of participation among those who were offered and eligible for these treatments or services.
Urogenital tract infections were identified in 57% of the women, while 59% were found to have periodontal disease. More than 39% were active smokers, and 17% were assessed with clinical depression. Low literacy, and housing instability were identified in, 22 and 83% of the study sample, respectively. Among women eligible for intervention, the percentages who accepted and at least minimally participated in treatment ranged from a low of 28% for smoking, to a high of 85% for urogenital tract infection. Most PCPPP enrollees (57%) had three or more major risk factors. Participation rates associated with the PCPPP treatments or services varied markedly, and were quite low in some cases, despite considerable efforts to reduce the barriers to receiving care.
The efficacy of individual level risk-reduction efforts designed to prevent preterm/repeat preterm in the pre- or inter-conception period may be limited if participation rates associated with interventions to reduce major risk factors for PTB are low. Achieving adequate participation may require identifying, better understanding, and eliminating barriers to access, beyond those associated with cost, transportation, childcare, and service location or hours of operation.
Trial registration (NCT01117922)
PMCID: PMC4230507  PMID: 25361563
Prematurity; Preterm birth; Pregnancy; Perinatal periods of risk; Health care participation; Infant mortality; Preventive care; Access to care; Utilization of care; Preconception care
2.  Parenting Attitudes and Infant Spanking: The Influence of Childhood Experiences 
Pediatrics  2009;124(2):e278-e286.
To assess associations among maternal childhood experiences and subsequent parenting attitudes and use of infant spanking (IS), and determine if attitudes mediate the association between physical abuse exposure and IS.
We performed a prospective study of women who received prenatal care at community health centers in Philadelphia, Pennsylvania. Sociodemographic characteristics, adverse childhood experiences (ACEs), attitudes toward corporal punishment (CP), and IS use were assessed via face-to-face interviews, conducted at the first prenatal care visit, 3 months postpartum, and 11 months postpartum. Bivariate and multiple logistic regression analyses were conducted.
The sample consisted of 1265 mostly black, low-income women. Nineteen percent of the participants valued CP as a means of discipline, and 14% reported IS use. Mothers exposed to childhood physical abuse and verbal hostility were more likely to report IS use than those not exposed (16% vs 10%, P = .002; 17% vs 12%, P = .02, respectively). In the adjusted analyses, maternal exposure to physical abuse, other ACEs, and valuing CP were independently associated with IS use. Attitudes that value CP did not mediate these associations.
Mothers who had childhood experiences of violence were more likely to use IS than mothers without such experiences. Intergenerational transmission of CP was evident. Mothers who had experienced physical abuse as a child, when compared to those who had not, were 1.5 times more likely to use IS. Child discipline attitudes and maternal childhood experiences should be discussed early in parenting in order to prevent IS use, particularly among at-risk mothers.
PMCID: PMC3760718  PMID: 19620204
physical punishment; adverse childhood experiences; positive influences in childhood; Adult-Adolescent Parenting Inventory
3.  Pregnancy Intention and Contraceptive Use at Six Months Postpartum Among Women With Recent Preterm Delivery 
To describe pregnancy intention and contraceptive use among women with a recent delivery that occurred at 35 weeks gestation or fewer and who were enrolled in a large-scale randomized control trial.
In this descriptive study we used data from assessments conducted at 6 months postpartum as part of a randomized controlled clinical trial, the Philadelphia Collaborative Preterm Prevention Project (PCPPP).
Participants and Setting
Participants were recruited following a preterm birth (PTB) in one of the 12 urban birth hospitals. All women enrolled in PCPPP, who completed their 6-month postpartum assessment, and who were sexually active at the time of that assessment (n = 566), were included in the analysis.
Data were collected during face-to-face interviews. Study questionnaires included questions about participants' plans for the timing of subsequent pregnancies, contraceptive behaviors, and other health variables.
Nearly all of the participants (90.1%, n = 509) reported they did not want to get pregnant within one year of the index PTB. However, more than one half of these women (54.6%) reported contraceptive practices of low or moderate effectiveness. Most predictive of intending another pregnancy within the year was the death of the index PTB infant (odds ratio [OR]= 18.2,95% confidence interval [CI] [8.9, 37.0]).
Discordant pregnancy intention and contraceptive use were reported among this group of mothers of PTB infants who are at particularly high risk for a poor outcome of any subsequent pregnancy. The findings highlight the need for further investigation of the causes, correlates, and consequences of discordant pregnancy intentions and contraceptive practices.
PMCID: PMC3409429  PMID: 22834885
preterm prevention; postpartum; prematurity risks; pregnancy intention; Philadelphia Collaborative; Preterm Prevention; Project; interconception care; unintended pregnancies; contraceptive use
4.  Perceived Discrimination and Depressive Symptoms, Smoking, and Recent Alcohol Use in Pregnancy 
Birth (Berkeley, Calif.)  2010;37(2):90-97.
Perceived discrimination is associated with poor mental health and health-compromising behaviors in a range of vulnerable populations, but this link has not been assessed among pregnant women. We aimed to determine whether perceived discrimination was associated with these important targets of maternal health care among low-income pregnant women.
Face-to-face interviews were conducted in English or Spanish with 4,454 multi-ethnic, low-income, inner-city women at their first prenatal visit at public health centers in Philadelphia, Pennsylvania, USA, from 1999 to 2004. Perceived chronic everyday discrimination (moderate and high levels) in addition to experiences of major discrimination, depressive symptomatology (CES-D ≥23), smoking in pregnancy (current), and recent alcohol use (12 months before pregnancy) were assessed by patient self-report.
Moderate everyday discrimination was reported by 873 (20%) women, high everyday discrimination by 238 (5%) women, and an experience of major discrimination by 789 (18%) women. Everyday discrimination was independently associated with depressive symptomatology (moderate = PR 1.58, 95% confidence interval (CI) 1.38-1.79, high = PR 1.82, 95% CI 1.49-2.21); smoking (moderate = PR 1.19, 95% CI 1.05-1.36, high = PR 1.41, 95% CI 1.15-1.74); and recent alcohol use (moderate = PR 1.23, 95% CI 1.12-1.36). However, major discrimination was not independently associated with these outcomes.
This study demonstrated that perceived chronic everyday discrimination, but not major discrimination, was associated with depressive symptoms and health-compromising behaviors independent of potential confounders, including race and ethnicity, among pregnant low-income women. (BIRTH 37:2 June 2010)
PMCID: PMC3627361  PMID: 20557531
alcohol drinking; depression; discrimination (psychology); health behavior; pregnant women; prenatal care; smoking
5.  Subjective Social Status and Maternal Health in a Low Income Urban Population 
Maternal and child health journal  2012;16(4):834-843.
Appropriate measurement of socioeconomic status (SES) in health research can be problematic. Conventional SES measures based on ‘objective’ indicators such as income, education, or occupation may have questionable validity in certain populations. The objective of this investigation was to determine if a relatively new measurement of SES, subjective social status (SSS), was more consistently and strongly associated with multiple health outcomes for low income mothers. Data available from a large scale community-based study examining maternal and infant health for a low income urban population were used to examine relationships between SSS and a wide range of postpartum physical and emotional health outcomes. Crosstabulations and multivariate analyses focused on the breadth and depth of these relationships; in addition, the relative strength of the relationships between SSS and the health outcomes was compared to that of conventional measures of SES, including both income and education. SSS was significantly related to all physical and emotional health outcomes examined. The overall pattern of findings indicated that these relationships were independent of, as well as more consistent and stronger than, those between conventional measures of SES and postpartum health outcomes. SSS represents an important dimension of the relationship between SES and postpartum physical and emotional health. In low income populations the failure to account for this dimension likely underestimates the influence of SES on postpartum health. This has important implications for the interpretation of findings in empirical studies which seek to control for the effects of SES on maternal health outcomes.
PMCID: PMC3421457  PMID: 21487843
Subjective social status; Socioeconomic status; Maternal health outcomes; Postpartum health; Low-income mothers
6.  Small-for-Gestational-Age Births in Pregnant Women with HIV, due to Severity of HIV Disease, Not Antiretroviral Therapy 
Objectives. To determine rate and factors associated with small-for-gestational-age (SGA) births to women with HIV. Methods. Prospective data were collected from 183 pregnant women with HIV in an urban HIV prenatal clinic, 2000–2011. An SGA birth was defined as less than the 10th or 3rd percentile of birth weight distribution based upon cut points developed using national vital record data. Bivariate analysis utilized chi-squared and t-tests, and multiple logistic regression analyses were used. Results. The prevalence of SGA was 31.2% at the 10th and 12.6% at the 3rd percentile. SGA at the 10th (OR 2.77; 95% CI, 1.28–5.97) and 3rd (OR 3.64; 95% CI, 1.12–11.76) percentiles was associated with cigarette smoking. Women with CD4 count >200 cells/mm3 at the first prenatal visit were less likely to have an SGA birth at the 3rd percentile (OR 0.29; 95% CI, 0.10–0.86). Women taking NNRTI were less likely to have an SGA infant at the 10th (OR 0.28; 95% CI, 0.10–0.75) and 3rd (OR 0.16; 95% CI, 0.03–0.91) percentiles compared to those women on PIs. Conclusions. In this cohort with high rates of SGA, severity of HIV disease, not ART, was associated with SGA births after adjusting for sociodemographic, medication, and disease severity.
PMCID: PMC3388287  PMID: 22778533
7.  Incident Smoking During Pregnancy and the Postpartum Period in a Low-Income Urban Population 
Public Health Reports  2011;126(1):50-59.
We determined the prevalence of first lifetime use of cigarettes during pregnancy or in the early postpartum period (incident smoking) and identified sociodemographic and health-related characteristics of incident smokers.
We used statistics based on data from a longitudinal study of a large cohort of pregnant, low-income, urban women (n=1,676) to describe the timing of first-time use and to compare incident smokers with those who had never smoked and those who had already smoked prior to pregnancy.
About one in 10 (10.2%) women who had not previously smoked initiated cigarette smoking during pregnancy or in the early postpartum period. Compared with those who had never smoked, incident smokers were more likely to report high levels of stress and to have elevated levels of depressive symptomatology, which may be rooted in relatively poor social and economic conditions.
A significant number of women may be initiating smoking during pregnancy or in the early postpartum period. These women have characteristics that are consistent with the risk factors associated with smoking. Further research is warranted to determine prevalence in other populations, identify the risk factors for incident smoking, and assess the potential for primary prevention efforts designed to help women who had previously avoided cigarette use to remain smoke-free throughout pregnancy and in the postpartum period.
PMCID: PMC3001823  PMID: 21337931
8.  Risky Health Behaviors among Mothers-to-Be: The Impact of Adverse Childhood Experiences 
Academic pediatrics  2010;10(4):245-251.
Adverse childhood experiences (ACEs) are risk factors for health problems later in life. This study aims to 1) assess the influence of ACEs on risky health behaviors among mothers-to-be, and 2) determine whether a dose response occurs between ACEs and risky behaviors.
Prospective survey of women attending health centers conducted at the first prenatal care visit, and 3 and 11 months postpartum. Surveys obtained information on maternal sociodemographic and health characteristics, and 7 ACEs prior to age 16. Risky behaviors included smoking, alcohol use, marijuana use and other illicit drug use during pregnancy.
Our sample (n=1,476) consisted of low-income (mean annual personal income: $8272), young (mean age: 24 yrs), African American (71%), single (75%) women.
Twenty-three percent of women reported smoking even after finding out they were pregnant, 7% reported alcohol use, and 7% reported illicit drug use during pregnancy. Nearly three-fourths (71%) had one or more ACE(s). There was a higher prevalence of each risky behavior among those exposed to each ACE than among those unexposed. The exception was alcohol use during pregnancy where there was not an increased risk among those exposed when compared to those unexposed to witnessing a shooting or having a guardian in trouble with the law or in jail. The adjusted odds ratio for each risky behavior was greater than 2.5 for those with ≥ 3 ACEs when compared to those without.
ACEs were associated with risky health behaviors reported by mothers-to-be. Greater efforts should target the prevention of ACEs to lower the risk for adverse health behaviors that have serious consequences for adults and their children.
PMCID: PMC2897837  PMID: 20599179
risky health behaviors; smoking in pregnancy; adverse childhood experiences; childhood adversity
9.  Recruitment and retention of women in a large randomized control trial to reduce repeat preterm births: the Philadelphia Collaborative Preterm Prevention Project 
Recruitment and retention of patients for randomized control trial (RCT) studies can provide formidable challenges, particularly with minority and underserved populations. Data are reported for the Philadelphia Collaborative Preterm Prevention Project (PCPPP), a large RCT targeting risk factors for repeat preterm births among women who previously delivered premature (< 35 weeks gestation) infants.
Design of the PCPPP incorporated strategies to maximize recruitment and retention. These included an advanced database system tracking follow-up status and assessment completion rates; cultural sensitivity training for staff; communication to the community and eligible women of the benefits of participation; financial incentives; assistance with transportation and supervised childcare services; and reminder calls for convenient, flexibly scheduled appointments. Analyses reported here: 1) compare recruitment projections to actual enrollment 2) explore recruitment bias; 3) validate the randomization process 4) document the extent to which contact was maintained and complete assessments achieved 5) determine if follow-up was conditioned upon socio-economic status, race/ethnicity, or other factors.
Of eligible women approached, 1,126 (77.7%) agreed to participate fully. Of the 324 not agreeing, 118 (36.4%) completed a short survey. Consenting women were disproportionately from minority and low SES backgrounds: 71.5% consenting were African American, versus 38.8% not consenting. Consenting women were also more likely to report homelessness during their lifetime (14.6% vs. 0.87%) and to be unmarried at the time of delivery (81.6% versus 47.9%). First one-month postpartum assessment was completed for 83.5% (n = 472) of the intervention group (n = 565) and 76% (426) of the control group. Higher assessment completion rates were observed for the intervention group throughout the follow-up. Second, third, fourth and fifth postpartum assessments were 67.6% vs. 57.5%, 60.0% vs. 48.9%, 54.2% vs. 46.3% and 47.3% vs. 40.8%, for the intervention and control group women, respectively. There were no differences in follow-up rates according to race/ethnicity, SES or other factors. Greater retention of the intervention group may reflect the highly-valued nature of the medical and behavior services constituting the intervention arms of the Project.
Findings challenge beliefs that low income and minority women are averse to enrolling and continuing in clinical trials or community studies.
PMCID: PMC2957387  PMID: 20920265
10.  Distinct Trajectories of Perinatal Depressive Symptomatology: Evidence From Growth Mixture Modeling 
American Journal of Epidemiology  2008;169(1):24-32.
Although heterogeneity in the timing and persistence of maternal depressive symptomatology has implications for screening and treatment as well as associated maternal and child health outcomes, little is known about this variability. A prospective observational study of 1,735 low-income, multiethnic, inner-city women recruited in pregnancy from 2000 to 2002 and followed prospectively until 2004 (1 prenatal and 3 postpartum interviews) was used to determine whether distinct trajectories of depressive symptomatology can be defined from pregnancy through 2 years postpartum. Analysis was carried out through general growth mixture modeling. A model with 5 trajectory classes characterized the heterogeneity seen in the timing and magnitude of depressive symptoms among the study participants from Philadelphia, Pennsylvania. These classes included the following: 1) always or chronic depressive symptomatology (7%); 2) antepartum only (6%); 3) postpartum, which resolves after the first year postpartum (9%); 4) late, present at 25 months postpartum (7%); and 5) never having depressive symptomatology (71%). Women in these trajectory classes differed in demographic (nativity, education, race, parity) health, health behavior, and psychosocial characteristics (ambivalence about pregnancy and high objective stress). This heterogeneity should be considered in maternal depression programs. Additional research is needed to determine the association of these trajectory classes with maternal and child health outcomes.
PMCID: PMC2720701  PMID: 19001135
depression; longitudinal studies; postpartum period; pregnant women

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