Sequential screening for psychosocial and behavioural risk during pregnancy in a population of urban African Americans

Objective: Screening for psychosocial and behavioral risks, such as depression, intimate partner violence and smoking, during pregnancy is considered state-of-the-art in prenatal care (PNC). This prospective longitudinal analysis examines the added benefit of repeated screening over a one-time screen in identifying such risks during pregnancy. Design: Data were collected as part of a randomized controlled trial to address intimate partner violence (IPV), depression, smoking and environmental tobacco smoke exposure (ETSE) in African-Americans women. Setting: PNC sites in the District of Columbia serving mainly minority women Population: 1044 African-American pregnant women in the District of Columbia Methods: Mothers were classified by their initial response (acknowledgement of risks) and updated during pregnancy. Risks were considered new if they were not previously reported. Standard hypothesis tests and logistic regression were used to predict acknowledgment of any new risk(s) during pregnancy. Main Outcome Measures: New risks; psychosocial variables to understand what factors might help identify acknowledgement of additional risk(s). Results: Repeated screening identified more mothers acknowledging risk over time. Reported smoking increased by 11%, ETSE by 19%, IPV by 9%, and depression by 20%. The psychosocial variables collected at the baseline that were entered into the logistic regression model included relationship status, education, Medicaid, illicit drug use, and alcohol use during pregnancy. Among these, only education less than high school was associated in acknowledgement of new risk in the bivariate analyses and significantly predicted identification of new risks (OR=1.39, 95%CI, 1.01-1.90). Conclusions: It is difficult early on to predict who will acknowledge new risks over the course of pregnancy, thus all women should be screened repeatedly to allow identification and intervention during PNC

Very Preterm Birth is Reduced in Women Receiving an Integrated Behavioral Intervention: A Randomized Controlled Trial

Background This study examines whether an integrated behavioral intervention with proven efficacy in reducing psycho-behavioral risks (smoking, environmental tobacco smoke exposure (ETSE), depression, and intimate partner violence (IPV)) in African-Americans is associated with improved pregnancy outcomes Methods A randomized controlled trial targeting risks during pregnancy was conducted in the District of Columbia. African-American women were recruited if reporting at least one of the risks mentioned above. Randomization to intervention or usual care was site and risk specific. Sociodemographic, health risk and pregnancy outcome data were collected. Data on 819 women, and their singleton live born infants were analyzed using an intent-to-treat approach. Bivariate analyses preceded a reduced logistical model approach to elucidate the effect of the intervention on the reduction of prematurity and low birth weight. Results The incidence of low birthweight LBW was 12% and very low birthweight VLBW was 1.6%. Multivariate logistic regression results showed that depression was associated with LBW (OR=1.71, 95%CI=1.12-2.62). IPV was associated with PTB and VPTB (OR 1.64, 95%CI=1.07-2.51, OR=2.94, 95%CI=1.40-6.16, respectively). The occurrence of VPTB was significantly reduced in the intervention compared to the usual care group (OR=0.42, 95%CI=0.19-0.93). Conclusions Our study confirms the significant associations between multiple psycho-behavioral risks and poor pregnancy outcomes, including LBW and PTB. Our behavioral intervention with demonstrated efficacy in addressing multiple risk factors simultaneously reduced VPTB within an urban minority population

Low-income minority mothers’ reports of infant health care utilisation compared with medical records

This study aimed to investigate mothers’ reporting of the nature, location, frequency and content of health care visits for their infants, as compared with data abstracted from the infants’ medical records. It was part of a community-based parenting intervention designed to improve preventive health care utilisation among minority mothers in Washington, DC. Mothers 18 years old with newborn infants and with poor or no prenatal care were enrolled in the study. A total of 160 mother–infant dyads completed the 12-month study. Mothers were interviewed when the infants were 4, 8 and 12 months old, and were asked to recall infant visits to all health care providers. Medical records from identified providers were used for verification. The number and type of immunisations given, types of providers visited, and reason for the visits were compared. Only about a quarter of mothers agreed with their infants’ medical records on the number of specific immunisations received. The mothers reported fewer polio (1.8 vs. 2.1, P = 0.006), diphtheria and tetanus toxoids and pertussis (DTP) (1.8 vs. 2.2, P = 0.002), and Haemophilus influenzae type b (HiB) (1.3 vs. 2.1, P \u3c 0.0001) immunisations than were recorded. Similarly, about a quarter of the mothers were unaware of any polio, DTP or hepatitis B immunisations given, as documented in the medical records, and 38% did not know that their infant was immunised for HiB. Nearly half of the mothers recalled more infant doctors’ visits than were recorded in the medical records (4.1 vs. 3.6 visits, P = 0.017). The mothers generally disagreed with the providers about the reason for a particular visit and reported fewer sick-baby visits (1.5 vs. 3.3, P \u3c 0.0001) than the providers recorded. Mothers’ reports and medical records matched in only 19% of the cases. In 47%, mothers under-reported and in 34% overreported the total number of visits. The strongest agreement between mothers’ reports and medical records was in the case of emergency room visits (63%). In conclusion, in this population, mothers’ reporting did not match that of providers with respect to specific information: the number of immunisations, the location where services were provided, and the classification of sick- vs. well-baby visits. Future studies that evaluate health care utilization data should take these discrepancies into consideration in their selection of information source, and in their interpretation of the data

Infant Mortality in American Indians and Alaska Natives 1995–1999 and 2000–2004

Objectives. (1) To determine the infant mortality rate (IMR) in American Indians/ Alaska Natives (AI/AN) and Whites between 1995–1999 and 2000–2004. (2) To compare the leading causes of infant mortality in AI/AN and Whites. (3) To examine differences in neonatal vs. postneonatal causes of death in Whites and AI/AN. Methods. Using the 1995–99 and 2000–04 Centers for Disease Control and Prevention’s National Center for Health Statistics national linked birth/infant death data, we examined neonatal and postneonatal IMR among AI/AN and Whites. Results. AI/AN experienced significantly greater overall IMR in 1995–1999 and 2000–2004 than Whites. While the reduction in the IMR between these time periods was statistically significant for Whites, the reduction among AI/AN was not. We found that AI/AN had an IMR 1.5 times as high as that of Whites. Conclusions. While the overall IMR has decreased in AI/AN, disparities in postneonatal IMR persist between AI/AN and Whites

An Intervention to Reduce Environmental Tobacco Smoke Exposure Improves Pregnancy Outcomes

Objective—We tested the efficacy of a cognitive-behavioral intervention in reducing environmental tobacco smoke exposure (ETSE) and improving pregnancy outcomes among African-American women. Methods—We recruited 1,044 women to a randomized controlled trial during 2001-2004 in Washington, DC. Data on 691 women with self-reported ETSE were analyzed. A subset of 520 ETSE women and salivary cotinine levels (SCLs)/ml was also analyzed. Individually tailored counseling sessions adapted from evidence-based interventions for ETSE and other risks, were delivered to the intervention group. The usual care group received routine prenatal care as determined by their provider. Logistic regression models were used to predict ETSE before delivery and adverse pregnancy outcomes. Results—Women in the intervention were less likely to self-report ETSE before delivery when controlling for other covariates (OR=0.50, 95%CI=0.35-0.71). Medicaid recipients were more likely to have ETSE (OR=1.97, 95%CI=1.31-2.96). With advancing maternal age, the likelihood of ETSE was less (OR=0.96, 95%CI=0.93-0.99). For women in the intervention the rates of very low birth weight (VLBW) and very preterm birth (VPTB) were significantly improved (OR=0.11, 95%CI=0.01-0.86; OR=0.22, 95%CI=0.07-0.68, respectively). For women with SCL/ml, maternal age was not significant. Intimate partner violence at baseline significantly increased the chances of VLBW and VPTB (OR=3.75, 95%CI=1.02-13.81; OR=2.71, 95%CI=1.11-6.62, respectively). These results were true for mothers who reported ETSE overall and for those with SCL/ml. Conclusions—This is the first randomized clinical trial demonstrating efficacy of a cognitivebehavioral intervention targeting ETSE in pregnancy. We significantly reduced ETSE as well as VPTB and VLBW, leading causes of neonatal mortality and morbidity in minority populations. This intervention may reduce health disparities seen in reproductive outcomes

Prediction of Birth Weight By Cotinine Levels During Pregnancy in a Population of African American Smokers

Objective—The goal was to investigate the association between maternal salivary cotinine levels (SCLs) and pregnancy outcome among African Americans smokers Methods—In a randomized controlled trial conducted in 2001-2004 in Washington, D.C. 714 women (126 active smokers (18%)) were tested for SCLs at the time of recruitment and later in pregnancy. Sociodemographic health risks and pregnancy outcomes were recorded. Results—Birth weights were significantly lower for infants born to mothers with baseline SCLs of ≥20 ng/ml compared to/ml (p=0.024), ≥50 ng/ml compared to/ml (p=0.002), ≥100 ng/ml compared to/ml (p=0.002), in bivariate analyses. In linear regression analyses adjusting for sociodemographic and medical factors, SCLs of ≥20 ng/ml were associated with a reduction in birth weight of 88 grams when SCLs were measured at baseline (p=0.042) and 205 grams when SCLs were measured immediately before delivery (p Conclusions—Elevated SCLs early in pregnancy or before delivery were associated with reductions in birth weight. At any cutoff level, birth weight reduction was more significant for the same SCL measured late in pregnancy. Maintaining lower levels of smoking for women who are unable to quit may be beneficial

Smoking Cessation and Relapse Among Pregnant African-American Smokers in Washington, DC

Smoking is the single most preventable cause of perinatal morbidity. This study examines smoking behaviors during pregnancy in a high risk population of African Americans. The study also examines risk factors associated with smoking behaviors and cessation in response to a cognitive behavioral therapy (CBT) intervention. This study is a secondary analysis of data from a randomized controlled trial addressing multiple risks during pregnancy. Five hundred African-American Washington, DC residents who reported smoking in the 6 months preceding pregnancy were randomized to a CBT intervention. Psycho-social and behavioral data were collected. Self-reported smoking and salivary cotinine levels were measured prenatally and postpartum to assess changes in smoking behavior. Comparisons were made between active smokers and those abstaining at baseline and follow-up in pregnancy and postpartum. Sixty percent of participants reported quitting spontaneously during pregnancy. In regression models, smoking at baseline was associated with older age,\a high school education and illicit drug use. At follow-up closest to delivery, smoking was associated with lower education, smoking and cotinine level at baseline and depression. At postpartum, there was a relapse of 34%. Smokers postpartum were significantly more likely to smoke at baseline and use illicit drugs in pregnancy. Mothers in the CBT intervention were less likely to relapse. African-American women had a high spontaneous quit rate and no response to a CBT intervention during pregnancy. Postpartum mothers’ resolve to maintain a quit status seems to wane despite their prolonged period of cessation. CBT reduced postpartum relapse rates

An integrated intervention to reduce intimate partner violence in pregnancy: a randomized trial

OBJECTIVE: We estimated the efficacy of a psycho-behavioral intervention in reducing intimate partner violence (IPV) recurrence during pregnancy and postpartum, and in improving birth outcomes in African-American women METHODS: We conducted a randomized controlled trial in which 1,044 women were recruited. Individually-tailored counseling sessions were adapted from evidence-based interventions for IPV and other risks. Logistic regression was used to model IPV victimization recurrence, to predict minor, severe, physical and sexual IPV. RESULTS: Women randomized to the intervention were less likely to have recurrent episodes of IPV victimization (OR=0.48, 95%CI=0.29-0.80). Women with minor IPV were significantly less likely to experience further episodes during pregnancy (OR=0.48, 95%CI=0.26-0.86, OR=0.53, 95%CI=0.28-0.99) and postpartum (OR=0.56, 95%CI=0.34-0.93). Numbers needed to treat were 17, 12, and 22, respectively as compared to the usual care Women with severe IPV showed significantly reduced episodes at postpartum (OR=0.39, 95%CI=0.18-0.82) and number needed to treat is 27. Women who experienced physical IPV showed significant reduction at the first follow-up (OR=0.49, 95%CI=0.27-0.91) and postpartum (OR=0.47, 95%CI=0.27-0.82) and number needed to treat is 18 and 20, respectively. Intervention women had significantly fewer very preterm infants (p=0.03) and an increased mean gestational age (p=0.016). CONCLUSION: A relatively brief intervention during pregnancy had discernable effects on IPV and pregnancy outcomes. Screening for IPV as well as other psychosocial and behavioral risks and incorporating similar interventions in prenatal care is strongly recommended

Health Beliefs and Parenting Attitudes Influence Breastfeeding Patterns Among Low-income African-American women

OBJECTIVE: To describe breastfeeding initiation among 210 urban African-American mothers with inadequate prenatal care. METHODS: This study is a case–control study of postpartum mothers recruited from four large urban hospitals. RESULTS: Mothers who chose to breastfeed were more educated, employed before birth, married, and using contraception postnatally. Regression model analysis controlling for demographic differences revealed that breastfeeding was significantly associated with a higher perception of severity of illness and higher confidence in the ability of health care to prevent illness. Breastfeeding mothers were less likely to reverse parent– child roles and had a lower perception of hassle from their infant’s behavior. When comparing mothers who breastfed longer than 8 weeks to those who did not breastfeed, breastfeeding mothers had high scores related to empathy toward infants on the Adult–Adolescent Parenting Inventory as well as a low perception of hassle on the Parenting Daily Hassle. The perception of existing formal or informal social support did not influence breastfeeding behavior. CONCLUSION: Personal attributes of low-income urban mothers such as health beliefs and parental attitudes may play a role in the initiation and duration of breastfeeding. Low-income African-American mothers may be influenced in their choice to breastfeed by supportive messages from physicians and nurses delivering care to mothers and their newborns. Emphasis should be placed on the role breastfeeding can play in preventing childhood illnesses

Environmental Tobacco Smoke Avoidance Among Pregnant African-American Nonsmokers

Background—Environmental tobacco smoke (ETS) exposure during pregnancy contributes to adverse infant health outcomes. Limited previous research has focused on identifying correlates of ETS avoidance. This study sought to identify proximal and more distal correlates of ETS avoidance early in pregnancy among African-American women. Methods—From a sample of low-income, black women (n=1044) recruited in six urban, prenatal care clinics (July 2001–October 2003), cotinine-confirmed nonsmokers with partners, household/ family members, or friends who smoked (n=450) were identified and divided into two groups: any past-7-day ETS exposure and cotinine-confirmed ETS avoidance. Bivariate and multivariate logistic regression analyses identified factors associated with ETS avoidance. Data were initially analyzed in 2004. Final models were reviewed and revised in 2007 and 2008. Results—Twenty-seven percent of pregnant nonsmokers were confirmed as ETS avoiders. In multivariate logistic regression analysis, the odds of ETS avoidance were increased among women who reported household smoking bans (OR=2.96; 95% CI=1.83, 4.77; p Conclusions—Social contextual factors were the strongest determinants of ETS avoidance during pregnancy. Results highlight the importance of prenatal screening to identify pregnant nonsmokers at risk, encouraging household smoking bans, gaining support from significant others, and fully understanding the interpersonal context of a woman’s pregnancy before providing behavioral counseling and advice to prevent ETS exposure