MOSAIC (MOthers' Advocates In the Community): protocol and sample description of a cluster randomised trial of mentor mother support to reduce intimate partner violence among pregnant or recent mothers

Background : Intimate partner violence (IPV) is prevalent globally, experienced by a significant minority of women in the early childbearing years and is harmful to the mental and physical health of women and children. There are very few studies with rigorous designs which have tested the effectiveness of IPV interventions to improve the health and wellbeing of abused women. Evidence for the separate benefit to victims of social support, advocacy and non-professional mentoring suggested that a combined model may reduce the levels of violence, the associated mental health damage and may increase a woman's health, safety and connection with her children. This paper describes the development, design and implementation of a trial of mentor mother support set in primary care, including baseline characteristics of participating women.

Methods/Design : MOSAIC (MOtherS' Advocates In the Community) was a cluster randomised trial embedded in general practice and maternal and child health (MCH) nursing services in disadvantaged suburbs of Melbourne, Australia. Women who were pregnant or with infants, identified as abused or symptomatic of abuse, were referred by IPV-trained GPs and MCH nurses from 24 general practices and eight nurse teams from January 2006 to December 2007. Women in the intervention arm received up to 12 months support from trained and supported non-professional mentor mothers. Vietnamese health professionals also referred Vietnamese women to bilingual mentors in a sub-study. Baseline and follow-up surveys at 12 months measured IPV (CAS), depression (EPDS), general health (SF-36), social support (MOS-SF) and attachment to children (PSI-SF). Significant development and piloting occurred prior to trial commencement. Implementation interviews with MCH nurses, GPs and mentors assisted further refinement of the intervention. In-depth interviews with participants and mentors, and follow-up surveys of MCH nurses and GPs at trial conclusion will shed further light on MOSAIC's impact.

Discussion : Despite significant challenges, MOSAIC will make an important contribution to the need for evidence of effective partner violence interventions, the role of non-professional mentors in partner violence support services and the need for more evaluation of effective health professional training and support in caring for abused women and children among their populations.

Intersection of autonomy and social control : negotiating teenage motherhood

Contrary to popular belief, teenage mothers are a declining proportion of birthing women; however they receive much negative public attention. Of particular public concern is the high cost of supporting teenage mothers, in terms of financial, health and welfare resources. Historically, the typical founding mother of white Australia was single, but post-war changes in the family structure incorporated the expectation that children be born into two-parent households with the male as the breadwinner. Policy changes in the seventies saw the introduction of the Sole Parents Pension which meant that many birthing teenage women could choose to keep their infants rather than have a clandestine adoption or an enforced marriage. The parenting practices of teenage mothers have been criticised for being less than optimal, and mother and child are reported as being disadvantaged cognitively, psychosocially, and educationally. One widespread nursing service which provides support for new mothers in Victoria is the Maternal and Child Health Service; however, teenage mothers appear reluctant to use such services. Why this should be so became an important question for this research, since little is known about the parenting practices of teenage mothers. This study therefore sought to explore mothering from the perspective of five sole supporting teenage mothers each of whom had a child over six months of age. The research methodology took an interpretive ethnographic approach and was guided by feminist principles. The data were collected through repeated interviewing, participant observation, informal discussions with key informants, field notes and journalling. Data analysis was aided by the use of the software, program NUD-IST. It was found that the young women in this study each chose to give birth with full realisation that their existence was dependent on the Welfare State. Unanticipated, however, were the many structural barriers which made their lives cataclysmic, but these reinforced their determination to prove themselves worthy and capable mothers. The young women negotiated motherhood through a range of social supports and through maternal practice. Unquestionably, their social dependency on the welfare system forced them into marginal citizen status. Moreover, absolute and intrinsic poverty levels were experienced, brought about by inadequate welfare payments. Formal support agencies, such as the Maternal and Child Health nurses were rarely approached to provide childrearing support beyond the initial months following birthing, since the teenagers' basic needs such as shelter, food and clothing took precedence over their parenting needs. Additionally, some nurses were perceived to hold judgmental attitudes towards teenage mothers. It was far easier to forestall confrontation with nurses and the other 'older' women clientele by avoiding them. Thus XI they turned to charitable agencies who provided a safety net in the form of emergency supplies of money, food, or equipment. Informal networks of friends provided alternative modes of support when family help failed to materialise. The children, however, provided the young women with an opportunity to transform their lives by breaking free of the past, and by creating a new, mature existence for themselves. Despite being abandoned by family, friends, lovers and society, in the privacy and isolation of their own homes, they attempted to provide a more nurturing environment for their children than they themselves had received. Each bestowed unconditional maternal love on the child and were rewarded through the pleasures of watching their children grow and develop into worthwhile individuals. The children became the focus of their attention and their reason for living. In the course of their welfare dependency, the young women became public property, targets of surveillance, and were subjected to stigmatising and condescending public attitudes wherever they went. In this way, it was evident that they were an oppressed group, but each found ways of resisting. Rather than focussing on their oppressive or disabling lives, or dwelling on their disadvantaged status, the young women sought their identities as mature women through motherhood and by demonstrating that they could do this important job well. Through motherhood their lives had meaning and a sense of purpose. The thesis concludes that motherhood in the teenage years is difficult. However, if appropriate supports are made available, teenage mothers need be no different from non-teenage mothers. But with state resources shrinking, and their own resources limited, teenage mothers are disadvantaged. In some ways, this study showed that all levels of support were inadequate, although those provided through the charitable organizations were seen to be the most appropriate. This reflects the current policy of economic rationalism adopted by most Western liberal democracies in the 1980s and 1990s and no less by the former Keating Labor Government in Australia.

Healthy eating and obesity prevention for preschoolers : a randomised controlled trial

Background
Developing effective prevention and intervention programs for the formative preschool years is seen as an essential step in combating the obesity epidemic across the lifespan. The overall goal of the current project is to measure the effectiveness of a healthy eating and childhood obesity prevention intervention, the MEND (Mind Exercise Nutrition Do It!) program that is delivered to parents of children aged 2-4 years.

Methods/Design
This randomised controlled trial will be conducted with 200 parents and their 2-4 year old children who attend the MEND 2-4 program in metropolitan and regional Victoria. Parent-child dyads will attend ten 90-minute group workshops. These workshops focus on general nutrition, as well as physical activity and behaviours. They are typically held at community or maternal and child health centres and run by a MEND 2-4 trained program leader. Child eating habits, physical activity levels and parental behaviours and cognitions pertaining to nutrition and physical activity will be assessed at baseline, the end of the intervention, and at 6 and 12 months post the intervention. Informed consent will be obtained from all parents, who will then be randomly allocated to the intervention or wait-list control group.

Discussion
Our study is the first RCT of a healthy eating and childhood obesity prevention intervention targeted specifically to Australian parents and their preschool children aged 2-4 years. It responds to the call by experts in the area of childhood obesity and child health that prevention of overweight in the formative preschool years should focus on parents, given that parental beliefs, attitudes, perceptions and behaviours appear to impact significantly on the development of early overweight. This is 'solution-oriented' rather than 'problem-oriented' research, with its focus being on prevention rather than intervention. If this is a positive trial, the MEND2-4 program can be implemented as a national program.

Trial Registration
Australian New Zealand Clinical Trials Registry ACTRN12610000200088

Mothers' AdvocateS In the Community (MOSAIC)- non-professional mentor support to reduce intimate partner violence and depression in mothers: a cluster randomised trial in primary care

Background : Effective interventions to increase safety and wellbeing of mothers experiencing intimate partner violence (IPV) are scarce. As much attention is focussed on professional intervention, this study aimed to determine the effectiveness of non-professional mentor support in reducing IPV and depression among pregnant and recent mothers experiencing, or at risk of IPV.

Methods : MOSAIC was a cluster randomised trial in 106 primary care (maternal and child health nurse and general practitioner) clinics in Melbourne, Australia. 63/106 clinics referred 215 eligible culturally and linguistically diverse women between January 2006 and December 2007. 167 in the intervention (I) arm, and 91 in the comparison (C) arm. 174 (80.9%) were recruited. 133 (76.4%) women (90 I and 43 C) completed follow-up at 12 months.

Intervention: 12 months of weekly home visiting from trained and supervised local mothers, (English & Vietnamese speaking) offering non-professional befriending, advocacy, parenting support and referrals.

Main outcome measures: Primary outcomes; IPV (Composite Abuse Scale CAS) and depression (Edinburgh Postnatal Depression Scale EPDS); secondary measures included wellbeing (SF-36), parenting stress (PSI-SF) and social support (MOS-SF) at baseline and follow-up.

Analysis: Intention-to-treat using multivariable logistic regression and propensity scoring.

Results : There was evidence of a true difference in mean abuse scores at follow-up in the intervention compared with the comparison arm (15.9 vs 21.8, AdjDiff -8.67, CI -16.2 to -1.15). There was weak evidence for other outcomes, but a trend was evident favouring the intervention: proportions of women with CAS scores ≥7, 51/88 (58.4%) vs 27/42 (64.3%) AdjOR 0.47, CI 0.21 to 1.05); depression (EPDS score ≥13) (19/85, 22% (I) vs 14/43, 33% (C); AdjOR 0.42, CI 0.17 to 1.06); physical wellbeing mean scores (PCS-SF36: AdjDiff 2.79; CI -0.40 to 5.99); mental wellbeing mean scores (MCS-SF36: AdjDiff 2.26; CI -1.48 to 6.00). There was no observed effect on parenting stress. 82% of women mentored would recommend mentors to friends in similar situations.

Conclusion : Non-professional mentor mother support appears promising for improving safety and enhancing physical and mental wellbeing among mothers experiencing intimate partner violence referred from primary care.

Outcomes of population based language promotion for slow to talk toddlers at ages 2 and 3 years: let’s learn language cluster randomised controlled trial

Objective To determine the benefits of a low intensity parent-toddler language promotion programme delivered to toddlers identified as slow to talk on screening in universal services.
Design Cluster randomised trial nested in a population based survey.
Setting Three local government areas in Melbourne, Australia.
Participants Parents attending 12 month well child checks over a six month period completed a baseline questionnaire. At 18 months, children at or below the 20th centile on an expressive vocabulary checklist entered the trial.
Intervention Maternal and child health centres (clusters) were randomly allocated to intervention (modified “You Make the Difference” programme over six weekly sessions) or control (“usual care”) arms.
Main outcome measures The primary outcome was expressive language (Preschool Language Scale-4) at 2 and 3 years; secondary outcomes were receptive language at 2 and 3 years, vocabulary checklist raw score at 2 and 3 years, Expressive Vocabulary Test at 3 years, and Child Behavior Checklist/1.5-5 raw score at 2 and 3 years.
Results 1217 parents completed the baseline survey; 1138 (93.5%) completed the 18 month checklist, when 301 (26.4%) children had vocabulary scores at or below the 20th centile and were randomised (158 intervention, 143 control). 115 (73%) intervention parents attended at least one session (mean 4.5 sessions), and most reported high satisfaction with the programme. Interim outcomes at age 2 years were similar in the two groups. Similarly, at age 3 years, adjusted mean differences (intervention−control) were −2.4 (95% confidence interval −6.2 to 1.4; P=0.21) for expressive language; −0.3 (−4.2 to 3.7; P=0.90) for receptive language; 4.1 (−2.3 to 10.6; P=0.21) for vocabulary checklist; −0.5 (−4.4 to 3.4; P=0.80) for Expressive Vocabulary Test; −0.1 (−1.6 to 1.4; P=0.86) for externalising behaviour problems; and −0.1 (−1.3 to 1.2; P=0. 92) for internalising behaviour problems.
Conclusion This community based programme targeting slow to talk toddlers was feasible and acceptable, but little evidence was found that it improved language or behaviour either immediately or at age 3 years.

Opportunities for primary and secondary prevention of excess gestational weight gain : General Practitioners’ perspectives

Background

The impact of excess gestational weight gain (GWG) on maternal and child health outcomes is well documented. Understanding how health care providers view and manage GWG may assist with influencing healthy gestational weight outcomes. This study aimed to assess General Practitioner's (GPs) perspectives regarding the management and assessment of GWG and to understand how GPs can be best supported to provide healthy GWG advice to pregnant women.
Methods

Descriptive qualitative research methods utilising semi - structured interview questions to assess GPs perspectives and management of GWG. GPs participating in shared antenatal care in Geelong, Victoria and Sydney, New South Wales were invited to participate in semi - structured, individual interviews via telephone or in person. Interviews were digitally recorded and transcribed verbatim. Data was analysed utilising thematic analysis for common emerging themes.
Results

Twenty eight GPs participated, 14 from each state. Common themes emerged relating to awareness of the implications of excess GWG, advice regarding weight gain, regularity of gestational weighing by GPs, options for GPs to seek support to provide healthy lifestyle behaviour advice and barriers to engaging pregnant women about their weight. GPs perspectives concerning excess GWG were varied. They frequently acknowledged maternal and child health complications resulting from excess GWG yet weighing practices and GWG advice appeared to be inconsistent. The preferred support option to promote healthy weight was referral to allied health practitioners yet GPs noted that cost and limited access were barriers to achieving this.
Conclusions

GPs were aware of the importance of healthy GWG yet routine weighing was not standard practice for diverse reasons. Management of GWG and perspectives of the issue varied widely. Time efficient and cost effective interventions may assist GPs in ensuring women are supported in achieving healthy GWG to provide optimal maternal and infant health outcomes.

Precursors and correlates of anxiety trajectories from late childhood to late adolescence

The present research employed a prospective, multi-informant design to examine precursors and correlates of differing anxiety profiles from late childhood to late adolescence. The sample consisted of 626 boys and 667 girls who are participants in the Australian Temperament Project, a large, longitudinal, community-based study that has followed young people's psychosocial adjustment from infancy to adulthood. The present research analyzes data collected from the first 12 waves of data, from 4–8 months to 17 years. Parents, primary school teachers, maternal and child health nurses, and from the age of 11 onward, the young people themselves have provided survey data. Trajectory analyses revealed three distinct patterns of self-reported anxiety from late childhood to late adolescence, comprising low, moderate, and high (increasing) trajectories, which differed somewhat between boys and girls. A range of parent- and teacher-reported factors was found to be associated with these trajectories, including temperament style, behavior problems, social skills, parenting, negative family events, and peer relationships. Compared with male trajectories, female trajectories were associated with a greater variety of psychosocial variables (including parenting and externalizing problems), which may partially account for the higher prevalence of anxiety in adolescent girls compared with boys. Findings shed light on gender-specific pathways to anxiety and the need for comprehensive, integrative approaches to intervention and prevention programs.

The importance of first-time parent groups for new parents

First-time parent groups are offered to all new parents in Victoria, Australia through the Maternal and Child Health Service, which is funded by state and local governments. Parents who join a group attend a series of eight sessions that emphasize parenting skills, relationship development and social support in order to increase confidence and skills in parenting. The present paper highlights the importance of first-time parent groups, claiming that these groups serve an important social support and health function amid a climate of early discharge policies and changing family structures. Although there are a number of challenges to the successful running of groups, it is argued that first-time parents benefit from participating in these groups in a number of ways: by developing social networks, gaining self confidence, and through access to relevant information on child health and parenting. Research indicates that first-time parent groups provide lasting benefits not only for families, but also for society as a whole. Maternal and child health nurses play a key role in facilitating groups for first-time parents.

Family food environments as determinants of children's eating : implications for obesity prevention

The prevalence of childhood obesity is escalating rapidly and it considered to be a major public health problem. Diet is a recognised precursor of fatness, and current evidence supports the premise that in Westernised countries, the dietary intakes of children are likely to be important in obesity genesis. However, we have a relatively poor understanding of the environments in which a child’s eating is learnt and maintained. Much of the existing work in this area is based on small-scale or experimental studies, or has been derived from homogeneous populations within the USA. Despite these limitations, there is evidence that aspects of the child’s family environment are likely to be important in determining obesity risk in children. This thesis examines the impact of the family food environment on a child’s eating through two related studies. The first study, titled the Children and Family Eating (CAFÉ) study comprised three phases. Phase one involved qualitative interviews with 17 parents of 5-6 year-old children to explore parental perceptions regarding those factors in a child’s environment believed to influence the development of their child’s eating habits. These interviews were used to inform the development of quantitative measures of the family food environment. The second phase involved the development of a Food Frequency Questionnaire (FFQ) to assess dietary intake in 5-6 year-olds. The FFQ was informed by analysis of 1995 Australian National Nutrition Survey data. In the final phase the relationships between dietary intakes of 5-6 year-old children, and potential predictors of dietary intake were examined in a cross-sectional study of 560 families. Predictors included measures of: parental perceptions of the adequacy of their child’s diet; food availability and accessibility; child-feeding; the opportunities for parental modelling of food intake; a child’s television exposure; maternal Body Mass Index; and maternal education. Analysis of the CAFÉ data provides unique information regarding the relationships between a child’s family food environment and their food consumption. Models developed for a range of dietary outcomes considered to be predictive of increased risk for obesity, including total energy and fat intakes, vegetable variety, vegetable consumption, and high-energy (non-dairy) fluid consumption, explained between 11 and 20 percent of the variance in dietary intake. Two aspects of the family food environment, parental perception of a child’s dietary adequacy, and the total minutes of television viewed per day, were frequently found to be predictive of dietary outcomes likely to promote fatness in these children. The second study, titled the Parent Education and Support (PEAS) Feeding Intervention Study, was a prospective pre/post non-randomised intervention trial that assessed the impact of a feeding intervention to 240 first-time mothers of one-year-old children. This intervention focused on one aspect of the family food environment, child-feeding, which has been proposed as influential in the development of obesogenic eating behaviours. In this study, Maternal and Child Health Nurses (MCHNs), using a ‘Division of Responsibility’ model of feeding, taught parents to provide nutritious food at regular intervals and to let children decide if to eat and how much to eat. Thus parents were encourages to food their child without exerting pressure, or employing coercion or rewards (controlling behaviours). The aim was to influence parental attitudes and beliefs regarding child-feeding. Through the use of these feeding techniques, this intervention also aimed to increase the variety of fruits and vegetables a child consumed by teaching parents to persist with offering these foods, over the year of the intervention, in non-emotive environments. Fruits and vegetables were chosen in this intervention because they are likely to be protective in the development of obesity. Analysis of the PEAS data suggests that this low-level feeding intervention, delivered through existing Maternal and Child Health services, was modestly effective in changing parental attitudes and beliefs regarding the feeding of young children. Further, the validity of fruits offered to intervention group children increased. This thesis expands the existing knowledge base by providing a comprehensive analysis of the relative impact of aspects of the family environment on dietary intakes of 5-6 year-olds. Further, the analysis of a feeding intervention in first-time parents provides important insights regarding the potential to influence child-feeding and the impact this may have on the promotion of eating behaviours protective against obesity.

The effect of an early childhood obesity intervention on father's obesity risk behaviors: the Melbourne InFANT program

Background
To investigate the effect of an early childhood obesity prevention intervention, incorporating a parent modelling component, on fathers’ obesity risk-related behaviours.

Methods
Cluster randomized-controlled trial in the setting of pre-existing first-time parents groups organised by Maternal and Child Health Nurses in Victoria, Australia. Participants were 460 first-time fathers mean age = 34.2 (s.d.4.90) years. Dietary pattern scores of fathers were derived using principal component analysis, total physical activity and total television viewing time were assessed at baseline (infant aged three to four months) and after 15 months.

Results
No significant beneficial intervention effect was observed on fathers’ dietary pattern scores, total physical activity or total television viewing time.

Conclusion
Despite a strong focus on parent modelling (targeting parents own diet, physical activity and television viewing behaviours), and beneficial impact on mothers’ obesity risk behaviours, this intervention, with mothers as the point of contact, had no effect on fathers’ obesity risk-related behaviours. Based on the established links between children’s obesity risk-related behaviors and that of their fathers, a need exists for research testing the effectiveness of interventions with a stronger engagement of fathers.

Formative evaluation of baby makes 3

Baby Makes 3 was originally developed by Whitehorse Community Health Service and the City of Whitehorse as a program which seeks to prevent violence by promoting respect and equality between couples who have recently become parents for the first time. This is a significant but often stressful event in the life of families and it is not uncommon for couples to adopt ways of relating which reflect gendered norms and foster inequality.
By being offered as a program to all first-time parents by maternal and child health staff, the program in Whitehorse managed to engage with couples at this critical time, many of whom found the program enabled them to adopt greater equality in their relationships. As such, the initial Baby Makes 3 program has been found to be an effective and cost-efficient violence prevention strategy (Flynn, 2011).
The introduction of Baby Makes 3 to the Great South Coast Region is the first time this program has been implemented in a non-metropolitan setting. In addition to the original program aims, a number of additional aims and activities have been added, with the new project being known as Baby Makes 3 Plus.
Programs developed in urban contexts often face different challenges when implemented in rural and regional settings. Likewise, the factors for facilitating success may vary from those in an urban setting (Maidment and Bay, 2012). Hence, this formative evaluation aims to provide feedback on the initial implementation of the original Baby Makes 3 program in the Great South Coast Region with the expectation this will enable problems with implementation and/or opportunities for further enhancement of outcomes to be identified and appropriate action taken.

Home delivery in Southern Lao PDR: challenges to achieving MDG 4 & 5 targets

This study investigated rural Lao PDR village women's views and experiences of recent, or impeding, childbirth to better understand barriers to maternity service usage. Lao PDR has the highest maternal mortality rate (MMR) in the South-East Asian region with very low utilization rates for skilled birth assistance and health sector delivery services. The study site, Sekong, a southern Lao province, was lowest in the country on virtually all indicators of reproductive and maternal health, despite several recent maternal health service interventions. The study's aim was to gain a fuller understanding of barriers to maternity services usage to contribute towards maternity services enhancement, and district and national policy-making for progressing towards 2015 MDG 4 & 5 targets. 

Interview with Luh Putu Lila Wulandari

Luh Putu Lila Wulandari is an Indonesian who studied at the University of New South Wales (UNSW) in 2006-2009. She studied on an Australian Development Scholarship (ADS) and completed a Masters in Public Health, specialising in maternal and child health. She hopes to return to UNSW to complete a PhD. The interview was conducted in English on 8 August 2014 by Dr. Jemma Purdey of Deakin University. This set comprises: an interview recording, a timed summary, and a photograph.

The return of the traditional birth attendant

The World Health Organization has noted much progress towards the realisation of Millennium Development Goals related to maternal and child health. Eighty percent of women in many developing economies now receive at least one visit during pregnancy by a skilled birth attendant (although only 52% had the recommended four visits), and 68% of women across developing regions receive skilled health attendant care (up from 56% in 1990). However, disparities follow regional and urban-rural gaps. Sub-Saharan Africa and Southern Asia lag behind other regions in the provision of antenatal care and skilled attendance at birth (although typically attended by a family member or villager) and over 32 million of the 40 million births not attended by skilled health personnel in 2012 occurred in rural areas. Overall, one-quarter of women in developing nations still birth alone or with a relative to assist them. While increased numbers of medically-trained midwives and health workers or midwife assistants would increase coverage by up to 40%, these are longer-term solutions. In the short term, gross disparities in services in some resource-poor areas have been alleviated by recruiting Traditional Birth Attendants (TBAs) re-trained in emergency obstetric skills to deal with emergency situations and to refer women onto health facilities when necessary. Samoa and Bangladesh are examples. For many women for a range of reasons TBAs are preferable to hospital care. It therefore makes sense to recognise their place within maternity care, to offer basic and ongoing training and to set up registration procedures thus better ensuring the monitoring of outcomes. Incorporating TBAs into the formal healthcare system would meet both physiological and relational components of birth. In terms of the latter, TBAs would act as cultural brokers between Western and traditional cosmologies and provide women with continuity of care from a known carer; in the West a demonstrably simple but effective intervention promoting physiological safety and reducing the need for higher level medical interventions.

Maternal and early postnatal nutrition and mental health of offspring by age 5 years: a prospective cohort study clinical guidance

Objective
Diet quality is related to the risk for depression and anxiety in adults and adolescents; however, the possible impact of maternal and early postnatal nutritional exposures on children’s subsequent mental health is unexplored.

Method
The large prospective Norwegian Mother and Child Cohort Study recruited pregnant women between 1999 and 2008. Data were collected from mothers during pregnancy and when children were 6 months and 1.5, 3, and 5 years of age. Latent growth curve models were used to model linear development in children’s internalizing and externalizing problems from 1.5 to 5 years of age as a function of diet quality during pregnancy and at 1.5 and 3 years. Diet quality was evaluated by dietary pattern extraction and characterized as “healthy” or “unhealthy.” The sample comprised 23,020 eligible women and their children. Adjustments were made for variables including sex of the child, maternal depression, maternal and paternal age, maternal educational attainment, household income, maternal smoking before and during pregnancy, mothers’ parental locus of control, and marital status.

Results
Higher intakes of unhealthy foods during pregnancy predicted externalizing problems among children, independently of other potential confounding factors and childhood diet. Children with a high level of unhealthy diet postnatally had higher levels of both internalizing and externalizing problems. Moreover, children with a low level of postnatal healthy diet also had higher levels of both internalizing and externalizing problems.

Conclusion
Among this large cohort of mothers and children, early nutritional exposures were independently related to the risk for behavioral and emotional problems in children.