Ethnic/racial diversity, maternal stress, lactation and very low birthweight infants.

OBJECTIVE: (1) To compare maternal characteristics and psychological stress profile among African-American, Caucasian and Hispanic mothers who delivered very low birthweight infants. (2) To investigate associations between psychosocial factors, frequency of milk expression, skin-to-skin holding (STS), and lactation performance, defined as maternal drive to express milk and milk volume. STUDY DESIGN: Self-reported psychological questionnaires were given every 2 weeks after delivery over 10 weeks. Milk expression frequency, STS, and socioeconomic variables were collected. RESULT: Infant birthweight, education, and milk expression frequency differed between groups. Trait anxiety, depression and parental stress in a neonatal intensive care unit (PSS:NICU) were similar. African-American and Caucasian mothers reported the lowest scores in state anxiety and social desirability, respectively. Maternal drive to express milk, measured by maintenance of milk expression, correlated negatively with parental role alteration (subset of PSS:NICU) and positively with infant birthweight and STS. Milk volume correlated negatively with depression and positively with milk expression frequency and STS. CONCLUSION: Differences between groups were observed for certain psychosocial factors. The response bias to self-reported questionnaires between groups may not provide an accurate profile of maternal psychosocial profile. With different factors correlating with maintenance of milk expression and milk volume, lactation performance can be best enhanced with a multi-faceted intervention program, incorporating parental involvement in infant care, close awareness and management of maternal mental health, and encouragement for frequent milk expression and STS.

Maternal and neonatal outcomes by labor onset type and gestational age.

OBJECTIVE: We sought to determine maternal and neonatal outcomes by labor onset type and gestational age. STUDY DESIGN: We used electronic medical records data from 10 US institutions in the Consortium on Safe Labor on 115,528 deliveries from 2002 through 2008. Deliveries were divided by labor onset type (spontaneous, elective induction, indicated induction, unlabored cesarean). Neonatal and maternal outcomes were calculated by labor onset type and gestational age. RESULTS: Neonatal intensive care unit admissions and sepsis improved with each week of gestational age until 39 weeks (P < .001). After adjusting for complications, elective induction of labor was associated with a lower risk of ventilator use (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.28-0.53), sepsis (OR, 0.36; 95% CI, 0.26-0.49), and neonatal intensive care unit admissions (OR, 0.52; 95% CI, 0.48-0.57) compared to spontaneous labor. The relative risk of hysterectomy at term was 3.21 (95% CI, 1.08-9.54) with elective induction, 1.16 (95% CI, 0.24-5.58) with indicated induction, and 6.57 (95% CI, 1.78-24.30) with cesarean without labor compared to spontaneous labor. CONCLUSION: Some neonatal outcomes improved until 39 weeks. Babies born with elective induction are associated with better neonatal outcomes compared to spontaneous labor. Elective induction may be associated with an increased hysterectomy risk.

Certified nurse midwives effects on catecholamine levels and maternal anxiety during labor

Studies of nurse midwifery care in the last twenty one years have reported excellent birth outcomes (Levy, Wilkenson and Marine, 1971; Platt et al. 1985; Stone et al. 1976). These outcomes are frequently attributed to the special support offered during labor and delivery by nurse midwives. This supportive style is thought to decrease catecholamine levels by reducing maternal anxiety. This prospective observational study evaluated catecholamine levels, anxiety levels, in-hospital costs, obstetrical practices and outcomes between low risk, term, labor and delivery primigravida patients managed by obstetrical residents (n = 55) or by certified nurse-midwives CNM (n = 59). The two groups were similar with regard to obstetrical risk factors present at admission. Each group was selected over the same period of time between March 23, 1994 and November 2, 1994. Specific catecholamines evaluated were epinephrine and norepinephrine. Obstetrical and newborn characteristics were also compared. This study did not prove that there is a decreased level in stress as indicated by lower levels of epinephrine and norepinephrine in nurse-midwife patients compared to obstetrical resident patients after adjusting for the use of epidural anesthesia. There was also no difference found in the perceived anxiety levels between the two groups. This study did confirm that nurse-midwives and obstetrical residents have different practice styles. Nurse-midwife patients had fewer augmented deliveries, fewer operative deliveries, less blood loss, fewer episiotomies and fewer third and fourth degree lacerations. The physician's choice to utilize more interventions such as continuous fetal monitoring and epidural anesthesia did not improve outcomes. The hospital cost of the nurse-midwife patients in this study was 35 percent lower than the physician patients. ^

Content of prenatal care and spontaneous preterm birth: Findings from the 1988 National Maternal and Infant Health Survey

The purposes of this study were to examine (1) the relationship between selected components of the content of prenatal care and spontaneous preterm birth; and (2) the degree of comparability between maternal and caregivers' responses regarding the number of prenatal care visits, selected components of the content of prenatal care, and gestational age, based on analyses of the 1988 National Maternal and Infant Health Survey conducted by the National Centers for Health Statistics. Spontaneous preterm birth was subcategorized into very preterm and moderately preterm births, with term birth as the controls. The study population was limited to non-Hispanic Anglo- and African-American mothers. The racial differences in terms of birth outcomes were also compared.^ This study concluded that: (1) there was not a high degree of comparability (less than 80%) between maternal and prenatal care provider's responses regarding the number of prenatal care visits and the content of prenatal care; (2) there was a low degree of comparability (less than 50%) between maternal and infant's hospital of delivery responses regarding gestational age at birth; (3) there were differences in selected components of the content of prenatal care between the cases and controls, overall and stratified by ethnicity (i.e., hemoglobin/hematocrit test, weight measurement, and breast-feeding counseling), but they were confounded with missing values and associated preterm delivery bias; (4) there were differences in selected components of the content of prenatal care between Anglo- and African-American cases (i.e., vitamin/mineral supplement advice, weight measurement, smoking cessation and drug abuse counseling), but they, too, were difficult to interpret definitively due to item nonresponse and preterm delivery biases; (5) no significant predictive association between selected components of the content of prenatal care and spontaneous preterm birth was found; and (6) inadequate/intermediate prenatal care and birth out of wedlock were found to be associated with moderately preterm birth.^ Future research is needed to examine the validity of maternal and prenatal care providers' responses and identify the sources of disagreement between their responses. In addition, further studies are needed to examine the relationship between the quality of prenatal care and preterm birth. Finally, the completeness and quality of patient and provider data on the utilization and content of prenatal care needs to be strengthened in subsequent studies. ^

The door of the tomb is open: Participatory action research to assess the impact of strengthened community capacity on maternal health care in rural Mali

This participatory action-research project addressed the hypothesis that strengthened community and women's capacity for self-development will lead to action to address maternal health problems and the prevention of maternal morbidity and mortality in Mali. Research objectives were: (1) to undertake a comparative cross-sectional study of the association of community capacity with improved maternal health in rural areas of Sanando, Mali, where capacity building interventions have taken place in some villages but not in others. (2) to describe women's maternal health status, access to and use of maternal health services given their residence in program or comparison communities.^ The participatory action research project was an integrated qualitative and quantitative study using participatory rural appraisal exercises, semi-structured group interviews and a cross-sectional survey.^ Factors related to community capacity for self-development were identified: community harmony; an understanding of the benefits of self-development; dynamic leadership; and a structure to implement collective activities.^ A distinct difference between the program and comparison villages was the commitment to train and support traditional birth attendants (TBAs). The TBAs in the program villages work in the context of the wider, integrated self-development program and, 10 years after their initial training, the TBAs continue to practice.^ Many women experience labor and childbirth alone or are attended by an untrained relative in both program and comparison villages. Nevertheless a significant change is apparent, with more women in program villages than in comparison villages being assisted by the TBAs. The delivery practices of the TBAs reveal the positive impact of their training in the "three cleans" (clean hands of the assistant, clean delivery surface and clean cord-cutting). The findings of this study indicate a significant level of unmet need for child spacing methods in all villages.^ The training and support of TBAs in the program villages yielded significant improvements in their delivery practices, and resulting outcomes for women and infants. However, potential exists for further community action. Capacities for self-development have not yet been directed toward an action plan encompassing other Safe Motherhood interventions, including access to family planning services and emergency obstetric care services. ^

The relationship of maternal low birthweight and infant low birthweight among African-American women at term delivery: Findings from the 1988 National Maternal and Infant Health Survey

A cohort study study design was used to study the relationship of maternal low birthweight and infant low birthweight among African American women delivering full term infants. The cohort consisted of 3,157 mother-infant pairs drawn from the 1988 National Maternal and Infant Health Survey conducted by the National Center for Health Statistics. The objectives of the study were (1) to determine if low birthweight, African American mothers delivering term infants experienced higher rates of infant low birthweight and (2) to examine the role of selected contributory variables in the relationship of maternal low birthweight and infant low birthweight. Contributory risk factors examined included maternal marital status, maternal age, maternal education, maternal height, maternal prepregnant weight, birth order, history of a prior low birthweight delivery, timing of prenatal care, number of prenatal visits, gestational length, infant gender, and behavioral factors of smoking, alcohol, and illicit drug use during pregnancy.^ Using logistic regression analysis, risk of infant low birthweight among maternal low birthweight mothers increased after controlling for less than a high school education, less than 20 years of age, prepregnant weight less than 100 lbs, history of a prior low birthweight delivery, birth order, smoking during pregnancy, and use of alcohol and illicit drugs during pregnancy, but was not statistically significant. Loss of statistical significance was attributed to a large reduction in cases available for analysis after including illicit drug use in the model.^ This study demonstrated a consistent pattern of increased rates of infant low birthweight among low birthweight mothers. The force of history remains, hence women with this trait should be carefully monitored and advised during pregnancy to decrease risk of a low birthweight infant, in order to decrease the chain of events leading to future generations of low birthweight mothers. ^

Case-control study of association of maternal recall of diarrhea or use of antimicrobials in the periconceptional period and neural tube defects

In June 1995 a case-control study was initiated by the Texas Department of Health among Mexican American women residing in the fourteen counties of the Texas-Mexico border. Case-women had carried infants with neural tube defect. Control-women had given birth to infants without neural tube defects. The case-control protocol included a general questionnaire which elicited information regarding illnesses experienced and antibiotics taken from three months prior to conception to three months after conception. An assessment of the associations between periconceptional diarrhea and the risk of neural tube defects indicated that the unadjusted association of diarrhea and risk of neural tube defect was significant (OR = 3.3, CI = 1.4–7.6). The unadjusted association of use of oral antimicrobials and risk of neural tube defect was also significant (OR = 3.4, CI = 1.6–7.3). These associations persisted among women who had no fever during the periconceptional period and were present irrespective of folate intake. Diarrhea was associated with an increased risk of NTD independent of use of antimicrobials. The converse was also true; antimicrobials were associated with an increased risk of NTD independent of diarrhea. Further research regarding these potentially modifiable risk factors is warranted. Replication of these findings could result in interventions in addition to folate supplementation. ^

Case control study identifying the maternal risk factors for congenital syphilis in Texas: 1998--2001

Background. Congenital syphilis (CS) is the oldest recognized congenital infection in the world. CS infection can affect multiple organs and can even cause neonatal death. CS is largely preventable when maternal syphilis is treated in an adequate and timely manner. During the decade of the nineties, rates of CS in Texas have often exceeded the overall US rate. Few studies, with adequate sample sizes, have been conducted to determine the risk factors associated with CS while controlling for factors associated with adult (maternal) syphilis infection. Objective. To determine the current maternal risk factors for CS infection in Texas from 1998–2001. Methods. A total of 1083 women with positive serological tests for syphilis during pregnancy or at delivery were reported to, and assessed by, health department surveillance staff. Mothers delivering infants in Texas between January 1, 1998 and June 30, 2001 comprised the study population. Mothers of infants diagnosed with confirmed or presumptive CS (N = 291) were compared to mothers of infants diagnosed as non-cases (N = 792) to determine the risk factors for vertical transmission (while controlling for risk factors of horizontal transmission). Logistic regression analyses were conducted to determine the associated odds between selected maternal variables and the outcome of CS. Results. Among 291 case infants, 5 (1.7%), 12 (4.1%), 274 (94.2%) were classified as confirmed cases, syphilitic stillbirths, and presumptive cases, respectively. Lack of maternal syphilis treatment was the strongest predictor of CS: odds ratio (OR) = 199.57 (95% CI 83.45–477.25) compared to those receiving treatment before pregnancy, while women treated during their pregnancies were also at increased risk (OR = 6.67, 95% CI 4.01–11.08). Women receiving no prenatal care were more likely (OR = 2.77, 95% CI 1.60–4.79) to have CS infants than those receiving prenatal care. Single women had higher odds (OR = 1.90, 95% CI 1.10–3.26) than ever-married women. African-Americans (OR 0.91, 95% CI 0.37–2.23) and Hispanics (OR = 1.66, 95% CI 0.68–4.05) may be more likely to have a CS infant than non-Hispanic Whites. Conclusions. The burden of CS in Texas can be alleviated through the provision of quality health care services, particularly prenatal care and treatment for sexually transmitted diseases. ^

Effect of maternal weight status on the relationship between prenatal smoking and infant birth weight

The purpose of this study was to assess the effect of maternal pre-pregnancy weight status on the relationship between prenatal smoking and infant birth weight (IBW). Prenatal cigarette smoking and maternal weight exert opposing effects on IBW; smoking decreases birth weight while maternal pre-pregnancy weight is positively correlated with birth weight. As such, mutual effect modification may be sufficiently significant to alter the independent effects of these two birth weight correlates. Finding of such an effect has implications of prenatal smoking cessation education. Perception of risk is an important determinant of smoking cessation, and reduced or low birth weight (LBW) as a smoking-associated risk predominates prenatal smoking counseling and education. In a population such as the US, where obesity is becoming epidemic, particularly among minority and low-income groups, perception of risk may be lowered should increased maternal size attenuate the effect of smoking. Previous studies have not found a significant interaction effect of prenatal smoking and maternal pre-pregnancy weight on IBW; however, use of self-reported smoking status may have biased findings. Reliability of self-reported smoking status reported in the literature is variable, with deception rates ranging from a low of 5% to as high as 16%. This study, using data from a prenatal smoking cessation project, in which smoking status was validated by saliva cotinine, was an opportunity to assess effect modification of smoking and maternal weight using biochemically determined smoking status in lieu of self report. Stratified by saliva cotinine, 151 women from a prenatal smoking cessation cohort, who were 18 years and older and had full-term, singleton births, were included in this study. The effect of smoking in terms of mean birth weight across three levels of maternal pre-pregnancy weight was assessed by general linear modeling procedures, adjusting for other known correlates of IBW. Effect modification was marginally significant, p = .104, but only with control for differential effects among racial/ethnic groups. A smaller than planned sample of nonsmokers, or women who quit smoking during the pregnancy, prohibited rejection of the null hypothesis of no difference in the effect of smoking across levels of pre-pregnancy weight. ^

An examination of the relationship between maternal and neighborhood-level characteristics and intrauterine growth retardation in Harris County, Texas, 1999--2001

The persistence of low birth weight and intrauterine growth retardation (IUGR) in the United States has puzzled researchers for decades. Much of the work that has been conducted on adverse birth outcomes has focused on low birth weight in general and not on IUGR. Studies that have examined IUGR specifically thus far have focused primarily on individual-level maternal risk factors. These risk factors have only been able to explain a small portion of the variance in IUGR. Therefore, recent work has begun to focus on community-level risk factors in addition to the individual-level maternal characteristics. This study uses Social Ecology to examine the relationship of individual and community-level risk factors and IUGR. Logistic regression was used to establish an individual-level model based on 155, 856 births recorded in Harris County, TX during 1999-2001. IUGR was characterized using a fetal growth ratio method with race/ethnic and sex specific mean birth weights calculated from national vital records. The spatial distributions of 114,460 birth records spatially located within the City of Houston were examined using choropleth, probability and density maps. Census tracts with higher than expected rates of IUGR and high levels of neighborhood disadvantage were highlighted. Neighborhood disadvantage was constructed using socioeconomic variables from the 2000 U.S. Census. Factor analysis was used to create a unified single measure. Lastly, a random coefficients model was used to examine the relationship between varying levels of community disadvantage, given the set of individual-level risk factors for 152,997 birth records spatially located within Harris County, TX. Neighborhood disadvantage was measured using three different indices adapted from previous work. The findings show that pregnancy-induced hypertension, previous preterm infant, tobacco use and insufficient weight gain have the highest association with IUGR. Neighborhood disadvantage only slightly further increases the risk of IUGR (OR 1.12 to 1.23). Although community level disadvantage only helped to explain a small proportion of the variance of IUGR, it did have a significant impact. This finding suggests that community level risk factors should be included in future work with IUGR and that more work needs to be conducted. ^

Maternal ingestion of radon-222 in drinking water and the absorbed radiation dose to the embryo

Maternal ingestion of high concentrations of radon-222 (Rn-222) in drinking during pregnancy may pose a significant radiation hazard to the developing embryo. The effects of ionizing radiation to the embryo and fetus have been the subject of research, analyses, and the development of a number of radiation dosimetric models for a variety of radionuclides. Currently, essentially all of the biokinetic and dosimetric models that have been developed by national and international radiation protection agencies and organizations recommend calculating the dose to the mother's uterus as a surrogate for estimating the dose to the embryo. Heretofore, the traditional radiation dosimetry models have neither considered the embryo a distinct and rapidly developing entity, the fact that it is implanted in the endometrial layer of the uterus, nor the physiological interchanges that take place between maternal and embryonic cells following the implantation of the blastocyst in the endometrium. The purpose of this research was to propose a new approach and mathematical model for calculating the absorbed radiation dose to the embryo by utilizing a semiclassical treatment of alpha particle decay and subsequent scattering of energy deposition in uterine and embryonic tissue. The new approach and model were compared and contrasted with the currently recommended biokinetic and dosimetric models for estimating the radiation dose to the embryo. The results obtained in this research demonstrate that the estimated absorbed dose for an embryo implanted in the endometrial layer of the uterus during the fifth week of embryonic development is greater than the estimated absorbed dose for an embryo implanted in the uterine muscle on the last day of the eighth week of gestation. This research provides compelling evidence that the recommended methodologies and dosimetric models of the Nuclear Regulatory Commission and International Commission on Radiological Protection employed for calculating the radiation dose to the embryo from maternal intakes of radionuclides, including maternal ingestion of Rn-222 in drinking water would result in an underestimation of dose. ^

Analyses of maternal and child mortality rates of five West African countries: Cote d'Ivoire, Guinea, Liberia, Senegal, Sierra Leone

After traveling to a small country in West Africa last summer, I became interested in learning more about the maternal, infant, and child death rates of that particular region of the continent. For the purposes of this paper I limited the number of countries that would be included in this research to five: Cote d'Ivoire, Guinea, Liberia, Senegal, and Sierra Leone. There are three hypotheses that were considered when conducting the research for this paper. The first was that there is no difference in the under five mortality rates for Cote d'Ivoire, Guinea, Liberia, Senegal, and Sierra Leone. The second hypothesis was that there is no difference in the female literacy rates for Cote d'Ivoire, Guinea, Liberia, Senegal, and Sierra Leone. The final hypothesis was that there is no difference in the male literacy rates for Cote d'Ivoire, Guinea, Liberia, Senegal, and Sierra Leone. The data used were collected from publicly available sources that include the CIA World Factbook, the WHO website, the UNICEF website, the Penn World Data table, and the World Bank website. The p-values that were calculated for all three hypotheses were found to be very significant, and all three of the null hypotheses were rejected. ^

Maternal nutrition and oral health factors in early childhood caries

Background. Early Childhood Caries (ECC) is the most common chronic infectious disease of childhood worldwide. Seven of ten American children have one or more decayed or filled primary teeth by age five. ECC prevalence is especially high in lower socio-economic ethnic populations. Commonly recognized as a diet-induced disease, focal etiological factors include cariogenic bacteria, fermentable carbohydrates, and a susceptible newly erupted tooth. Sequencing of breast and/or bottle feeding and introduction of beikost come at a time when children's defense mechanisms and, perhaps maternal direction of children's dietary patterns, are not yet fully developed or mature. To date, most research has examined biological factors, while maternal factors, especially psychosocial ones, have received scant attention. Objective. To examine the association of psychosocial factors in terms of maternal nutrition and oral health knowledge, attitudes, and beliefs, as well as social support and self-efficacy (KABS2) in a population of socio-economically disadvantaged infants and young children. A secondary aim was to describe ECC prevalence in this population. Methods. This study examined cross-sectionally the relationship between selected maternal psychosocial variables and ECC in a convenience sample of Mexican-American women and very young children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in San Antonio, Texas. Mothers were surveyed by use of a criteria- and content-valid, reliable questionnaire, and dental examinations were conducted on 191 children, aged 5 to 47 months old. Results. Thirty-nine percent of the children had ECC. As assessed on a 30-question scale, women in whose children were diagnosed with ECC were found to demonstrate lower Knowledge ( p=0.03), Attitudes (p=0.02), Beliefs (p=0.04), and Social Support (p<0.01) scores, compared to women whose children were found to be caries-free. No differences in Self-Efficacy scores were found between the groups. Conclusions. These data indicate that current etiological model depicting relevant factors associated with ECC in Mexican-American infants and children of low socio-economic status should be broadened to include consideration of maternal psychosocial factors such as nutrition and oral health knowledge, attitudes, beliefs, and social support, and that these factors should be considered when planning educational approaches to reduce the occurrence of ECC. ^

Maternal health care utilization in rural Jordanian villages: Patterns and predictors

Background. Different individual (demographic) characteristic and health system related characteristics have been identified in the literature to contribute to different rates of maternal health care utilization in developing countries. This study is going to evaluate the individual and quality of health predictors of maternal health care utilization in rural Jordanian villages. ^ Methods. Data from a 2004 survey was used. Individual (predisposing and enabling) variables, quality of health care variables, and maternal care utilization variables were selected for 477 women who had a live birth during the last 5 years. The conceptual framework used in this study will be the Aday-Andersen model for health services utilization. ^ Results. 82.4% of women received at least one antenatal care visit. Individually, village of residence (p=0.036), parity (p=0.048), education (p=0.006), and health insurance (p=0.029) were found to be significant; in addition to respectful treatment (p=0.045) and clean facilities (p=0.001) were the only quality of health care factors found to be significant in predicting antenatal care use. Using logistic regression, living in southern villages (OR=4.7, p=0.01) and availability of transportation (sometimes OR=3.2, p=0.01 and never OR=2.4, p<0.05) were the only two factors to influence maternal care use. ^ Conclusions. Living in the South and transportation are major barriers to maternal care utilization in rural Jordan. Other important cultural factors of interest in some villages should be addressed in future research. Perceptions of women regarding quality of health services should be seriously taken into account. ^