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Objectives: To evaluate the relationship between hypertensive (HTN) disorders and severe maternal morbidity (SMM). To understand whether there is differential prevalence of HTN disorders by race and whether the relationship between HTN disorders and SMM is modified by race and ethnicity. Methods: We performed a retrospective cohort study using patient-level rates of SMM for pregnancies at all 61 non-military hospitals in Washington State from 10/2015 to 9/2016. Data were obtained from the Washington State Comprehensive Hospital Abstract Reporting System. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated to evaluate the association of HTN disorders and SMM (with and without transfusion) overall and by race. The population-attributable fraction of HTN disorders on SMM within each racial/ethnic group was calculated. Results: Of 76,965 deliveries, 864 (1.1%) had any SMM diagnosis or procedure. All racial and ethnic minorities, except white and Asian, were disproportionally affected by preeclampsia with severe features (SF) and SMM. Overall, and within each racial/ethnic group, the SMM rate was higher among pregnancies with any HTN disorder compared to no HTN disorder (2.8 vs. 0.9%, OR 3.1, 95% CI 2.7–3.6). Race and ethnicity significantly modified the association. Overall and within each racial/ethnic group, there was a dose-response relationship between the type of HTN disorder and SMM, with more severe HTN disorders leading to a greater risk of SMM. The population-attributable fraction of HTN disorders on SMM was 20.6% for Black individuals versus 17.5% overall. The findings were similar when reclassifying transfusion-only SMM as no SMM. Conclusions: In Washington, HTN disorders are associated with SMM in a dose-dependent fashion with the greatest impact among Black individuals. Significance: What is already known on this subject?: Hypertensive disorders are a risk factor for SMM and hypertensive disorders and SMM occur disproportionately among marginalized populations. What does this study add to what is already known?: This study highlights that severe hypertensive disorders, especially preeclampsia with SF, disproportionately affect marginalized groups, and SMM appears to be disproportionately attributable to hypertensive disorders among people who identify as Black. [ABSTRACT FROM AUTHOR]

Objective: In-hospital formula supplementation places infants at risk for early breastfeeding cessation. The study's aim was to identify predictive and protective factors for in-hospital formula supplementation in individuals documented as wanting to exclusively breastfeed and residing in a geographic region with adverse social determinants of health and low breastfeeding rates. Additionally, we wished to determine if lactation consultation served as a protective factor against supplementation. Methods: In this cross-sectional study, we retrospectively reviewed 500 randomly selected charts of newborns born in a 12 month period at a regional tertiary care hospital. We included healthy, full-term neonates having a recorded maternal decision to exclusively breastfeed. Maternal-newborn dyad characteristics were compared between those exclusively breastfeeding and those with in-hospital formula supplementation. Results: Of the 500 charts, 70% of individuals desired to exclusively breastfeed. Overall, 41% of breastfed newborns were supplemented with formula before discharge, and 32% of women met with lactation consultants prior to supplementation. No statistically significant association was present between exclusive breastfeeding at discharge and meeting with a hospital lactation consultant (p = 0.55). When controlling for the confounders of maternal demographics and lactation consultation, significant associations with formula supplementation included Cesarean delivery (odd ratio: 2.08, 95% confidence interval: 1.04–4.16), primiparity (2.48, 1.27–4.87), and high school level of education (2.78, 1.33–5.78). Conclusions: Maternal characteristics of high school level educational, primiparity, and Caesarean delivery place individuals at risk for in-hospital formula supplementation in individuals wishing to exclusively breastfeed. Addressing barriers to exclusive breastfeeding is essential to enhance maternal and newborn health equity. Significance: What is already known on this subject? Exclusive breastfeeding is recognized as the ideal feeding method for infants. Newborns receiving formula in-hospital are at higher risk for early breastfeeding cessation. Rural residence and/or in the Appalachian region negatively impact breastfeeding rates. What this study adds? Predictors for in-hospital formula supplementation in women desiring to exclusively breastfeed included high school level educational, primiparity, and C-section delivery. Lactation consultation did not associate with decreased initiation of formula supplementation. [ABSTRACT FROM AUTHOR]

Introduction: The Maternal Child Health (MCH) Bureau created MCH Leadership Competencies to support current and future leaders by defining the knowledge and skills necessary to lead in this field. The Michigan-LEND (MILEND) training program developed a 'LIFE. framework', an acronym that stands for Leadership, Interdisciplinary, Family-Professional Partnerships, and Equity, to codify the 12 MCH leadership competencies into an easy to remember and easy to apply structure. This manuscript addresses the question, Does the LIFE framework align with the 12 MCH Leadership Competencies? Our hypothesis is that MI-LEND trainees will demonstrate improvement in their self-assessment of the 12 MCH leadership competencies after completing the MI-LEND program which uses the LIFE framework. Methods: Data were collected from 24 MI-LEND long-term trainees (> 300 hours) who completed a 100-itemleadership self-assessment questionnaire based on the MCH Navigator at the beginning and the end of the training year. Non-parametric sign tests were used to test the median difference, item by item for each of the questions under each competency. Parametric paired-sample t-tests were used to analyze mean difference, competency by competency when the assumption of normality was met. Results: All basic and advanced-level competencies had a statistically significant improvement between the beginning and end of the training year. The greatest changes were seen in Family-Professional Partnerships, Policy, Interdisciplinary Team Building, MCH Knowledge Base and Critical Thinking – all areas emphasized in the L.I.F.E. framework. Discussion: While the LIFE framework may oversimplify MCH Leadership Competencies, it is an effective mnemonic tool to organize and articulate MCH leadership competencies and could foster consistency across MCH programs. [ABSTRACT FROM AUTHOR]

Introduction: Women with pre-pregnancy diabetes or pre-pregnancy hypertension have increased risks of complications during pregnancy. Women who obtain prenatal care in the first trimester receive necessary routine testing and disease management tools that aid in controlling such conditions. However, research on the association between pre-pregnancy hypertension and pre-pregnancy diabetes and prenatal care timing among US women is limited. Methods: This study used data from the 2018 National Vital Statistic System (n = 3,618,853). Trained personnel collected information on prenatal care timing, maternal conditions, and demographics. Multivariate logistic regression models evaluated the association between pre-pregnancy hypertension, pre-pregnancy diabetes and prenatal care timing. A stratified analysis was conducted to determine if race/ethnicity modified the associations. Results: After adjustment, women with pre-pregnancy hypertension or pre-pregnancy diabetes had statistically significant increased odds of receiving early prenatal care compared to women without these conditions (OR 1.23; 95% CI: 1.21-1.26 and OR 1.27; 95% CI: 1.24-1.31, respectively). Among non-Hispanic White, non-Hispanic Black, and Hispanic women, those with pre-pregnancy hypertension or pre-pregnancy diabetes had statistically significantly increased odds of receiving early prenatal care compared to women without those pre-existing conditions (P <.001). Discussion: Further research is needed on the transition from preconception care to obstetric care for women with pre-existing diabetes or hypertension. However, these findings suggest that women who have conditions that could cause pregnancy complications are pursuing early prenatal care services to mitigate the development of adverse maternal and infant health conditions. [ABSTRACT FROM AUTHOR]

Background: Maternal perception of child weight status in children with overweight or obesity has received a lot of attention but data on paternal perception of children from presumably healthy cohorts are lacking. Objective: We aimed to investigate paternal and maternal perception of child weight status at the age of 8 years in a cohort of 591 children from 5 European countries. Material and Methods: Included were 8-year-old children and their parents participating in the European Childhood Obesity Project (EU CHOP). Weight and height of children and parents were measured and Body Mass Index (BMI, kg/m2) was calculated. Both parents were asked to assess their perception of child weight status using Eckstein scales and their concern about child overweight. The agreement between mother and father perceptions was assessed by Cohen kappa coefficient and their relationship was analyzed by linear mixed effects models based on ordinal logistic regression, accounting for country, child gender and BMI, parental BMI, level of education, concern and type of feeding during first year of life. Results: Data from children and both parents were available for 432 girls and boys. Mean BMI was comparable in boys and girls (16.7 ± 2.31 vs. 16.9 ± 2.87 kg/m2, P = 0.55). In total, 172 children (29.3%) were overweight or obese. There was a high degree of agreement between mother and father perceptions of their child's weight status (Cohen kappa 0.77). Multivariate modelling showed that perception levels significantly increased with child BMI but were globally lower than assessed. They differed between countries, gender and types of feeding during first year of life, were influenced by education level of the father but were not related to parental BMI and concern about childhood overweight. Conclusions: The study showed no overall differences between mothers and fathers in rating their child's weight status but both parents had a propensity to underestimate their child's actual weight, particularly in boys. The EU CHOP trial registered at clinicaltrials.gov as NCT00338689. [ABSTRACT FROM AUTHOR]

Objectives: Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. Methods: A 36-month time series data set (2014–2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. Results: There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202–234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). Conclusions for Practice: Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about provider attitudes regarding safety of selected hormonal contraceptives among breastfeeding women. Methods: Using a nationwide survey, associations were analyzed between provider characteristics and perception of safety of combined oral contraceptives (COCs) in breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors and depot medroxyprogesterone acetate (DMPA) in breastfeeding women < 1 month postpartum and ≥ 1 month postpartum. Results: Approximately 68% of public-sector providers considered COCs safe for breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors, with lower odds among non-physicians versus physicians (adjusted odds ratios [aOR] range 0.34–0.51) and those with a focus on adolescent health/pediatrics versus reproductive health (aOR 0.68, 95% confidence interval [CI] 0.47–0.99). Most public-sector providers considered DMPA safe for breastfeeding women during any time postpartum, with lower odds among non-physicians versus physicians (aOR range 0.20–0.54) and those with primary clinical focus other than reproductive health (aOR range 0.26–0.65). The majority of office-based physicians considered COCs safe for breastfeeding women ≥ 1 month postpartum without other venous thrombosis risk factors, with lower odds among those who did not use, versus those who used, CDC's contraceptive guidance (aOR 0.40, 95% CI 0.21–0.77). Most office-based physicians also considered DMPA safe for breastfeeding women during any time postpartum. Conclusions for Practice: A high proportion of providers considered use of selected hormonal contraceptives safe for breastfeeding women, consistent with evidence-based guidelines. However, certain provider groups might benefit from education regarding the safety of these methods for breastfeeding women. [ABSTRACT FROM AUTHOR]

Objectives We examined the association between prepregnancy body mass index (PP-BMI) and preterm birth (PTB) among women in Puerto Rico (PR) as a potentially modifiable risk factor. Methods We conducted a retrospective study using the birth certificate data files from 2005 to 2012 developed by the PR Department of Health to examine the relationship between PP-BMI and PTB. Logistic regression was used to determine crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) for the categories of PP-BMI of overweight (25–29.9 kg/m2), obesity (≥ 30 kg/m2), and overweight and obesity together (≥ 25 kg/m2) and PTB. Stratified analysis explored the associations between PP-BMI and PTB by region within PR and year. Results Following exclusions of birth records with missing data, 343,508 births were included in our analysis. The percentage of PTB decreased from 18.6 to 15.2 during our study period. Statistically significant differences were observed between preterm and full term births across all covariates. Overweight (OR 1.08, 95% CI 1.06, 1.11), obesity (OR 1.17, 95% CI 1.14, 1.20), and overweight and obesity together (OR 1.11, 95% CI 1.09, 1.14) were significantly associated with increased odds of PTB after adjusting for confounders. The associations between PP-BMI and PTB persisted across all regions and years. Conclusions for Practice PP-BMI is associated with increased odds of PTB among women in PR and the associations were consistent in exploratory analyses. Future research should examine the relationship between PP-BMI and PTB among other Hispanic subgroups and among Puerto Ricans in the mainland United States. [ABSTRACT FROM AUTHOR]

Objectives Maternal depression in the postpartum period is prevalent and associated with negative child outcomes, including behavior problems and cognitive delays. Mothers of children admitted directly after birth to the neonatal intensive care unit (NICU) are at even higher risk for depressive symptoms and infants born premature and/or at low birth weight may be more vulnerable to the adverse effects of maternal depression. Understanding mechanisms, particularly modifiable mechanisms, involved in the development or persistence of depressive symptoms is critically important for developing effective treatments. Methods The longitudinal, secondary analysis investigated the role of psychological inflexibility (rigidly avoiding or attempting to control distressing internal experiences, precluding present moment awareness of contingencies and engagement with important values) as a mediator of the relationship between early (1–2 weeks postpartum) and later (3 and 6 months postpartum) depressive symptoms among mothers with an infant in the NICU. Results Psychological inflexibility measured 2 weeks after infant discharge from the hospital fully mediated the relationship between early and later depressive symptoms at 3 months postpartum, with partial mediation at 6 months, while controlling for factors previously found predictive of postpartum depression. Conclusions for Practice Psychological inflexibility may be a mechanism by which postpartum depressive symptoms persist after hospital discharge among new mothers with a NICU infant. Acceptance and Mindfulness therapies which specifically target psychological inflexibility may be promising interventions to reduce depressive symptoms postpartum. [ABSTRACT FROM AUTHOR]

Objectives Asian Americans are highly diverse in cultural, socioeconomic, and health conditions. We aimed to identify socioeconomic and cultural profiles of subgroups of Asian American children at high risk of obesity or overweight to inform targeted interventions. Methods A sample of 841 Asian American children and adolescents ages 6–19 from the 2011–2016 National Health and Nutrition Examination Survey was used. Multivariable logistic regression modeling was conducted. Analyses were also stratified by age (6–11 vs. 12–19). Key variables of interest were Asian ethnicity (Chinese, Korean/Japanese, Filipino, South Asian, and Southeast Asian) and parental educational level. Models adjusted for age, gender, nativity status, parental nativity status, and health insurance coverage. Results Filipino (AOR 2.79; 95% CI 1.30–6.00), Japanese/Korean (AOR 2.55; 95% CI 1.21–5.38), Southeast Asian (AOR 2.54; 95% CI 1.63–3.94), and South Asian (AOR 2.10; 95% CI 1.01–4.36) children ages 6–19 had higher odds of being obese/overweight than Chinese. Filipino (AOR 3.24; 95% CI 1.11–9.49) and Southeast Asian (AOR 2.47; 95% CI 1.22–5.01) ethnicities were associated with higher risk of obesity/overweight in adolescents ages 12–19. Having a parent with a 4-year college or advanced degree was inversely associated with obesity/overweight in US-born Asian adolescents (AOR 0.34; 95% CI 0.14–0.78). Conclusions for Practice Asian American children and adolescents in some Asian ethnic subgroups may be at higher risk of obesity/overweight than in others. Higher parental education level appears to protect US-born Asian American adolescents from being obese/overweight. Multi-sectoral efforts are needed to better understand and address sociocultural processes that increase childhood obesity/overweight in high-risk Asian subgroups. [ABSTRACT FROM AUTHOR]

Objective Examine agreement with the medical record (MR) when gestational weight loss (GWL) on the Florida birth certificate (BC) is ≥ 0 pounds (lbs). Methods In 2012, 3923 Florida-resident women had a live, singleton birth where BC indicated GWL ≥ 0 lbs. Of these, we selected a stratified random sample of 2141 and abstracted from the MR prepregnancy and delivery weight data used to compute four estimates of GWL (delivery minus prepregnancy weight) from different sources found within the MR (first prenatal visit record, nursing admission record, labor/delivery records, BC worksheet). We assessed agreement between the BC and MR estimates for GWL categorized as 0, 1-10, 11-19, and ≥ 20 lbs. Results Prepregnancy or delivery weight was missing or source not in the MR for 23-81% of records. Overall agreement on GWL between the BC and the four MR estimates ranged from 39.1 to 57.2%. Agreement by GWL category ranged from 10.6 to 38.0% for 0 lbs, 47.6 to 64.3% for 1-10 lbs, 49.5 to 60.0% for 11-19 lbs, and 47.8 to 67.7% for ≥ 20 lbs. Conclusions Prepregnancy and delivery weight were frequently missing from the MR or inconsistently documented across the different sources. When the BC indicated GWL ≥ 0 lbs, agreement with different sources of the MR was moderate to poor revealing the need to reduce missing data and better understand the quality of weight data in the MR. [ABSTRACT FROM AUTHOR]

Objectives Viral bronchiolitis is the most common cause of infant hospitalization. Folic acid supplementation is important during the periconceptional period to prevent neural tube defects. An area of investigation is whether higher prenatal folate is a risk factor for childhood respiratory illnesses. We investigated the association between maternal 2nd trimester plasma folate levels and infant bronchiolitis. Methods We conducted a retrospective cohort analysis in a subset of mother-infant dyads (n = 676) enrolled in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study and Tennessee Medicaid. Maternal folate status was determined using 2nd trimester (16-28 weeks) plasma samples. Bronchiolitis diagnosis in the first year of life was ascertained using International Classification of Diagnosis-9 codes from Medicaid administrative data. We used multivariable logistic regression to assess the adjusted association of prenatal folate levels and infant bronchiolitis outcome. Results Half of the women in this lower-income and predominately African-American (84%) study population had high levels of folate (median 2nd trimester level 19.2 ng/mL) and 21% of infants had at least one bronchiolitis healthcare visit. A relationship initially positive then reversing between maternal plasma folate and infant bronchiolitis was observed that did not reach statistical significance (poverall = .112, pnonlinear effect = .088). Additional adjustment for dietary methyl donor intake did not significantly alter the association. Conclusions for Practice Results did not confirm a statistically significant association between maternal 2nd trimester plasma folate levels and infant bronchiolitis. Further work is needed to investigate the role of folate, particularly higher levels, in association with early childhood respiratory illnesses. [ABSTRACT FROM AUTHOR]

Objectives Previous studies have identified racial/ethnic disparities in infertility care, but patterns among American Indian/Alaska Natives (AI/AN) have not been reported. Our objective was to evaluate infertility services use in the US by race/ethnicity using data from the National Survey of Family Growth (NSFG). Methods We analyzed female respondent data from the pooled NSFG cycles 2002, 2006-2010 and 2011-2013. Respondents reported use of infertility services and types of services. We calculated weighted crude and adjusted prevalence proportion ratios (PPR) and 95% confidence intervals (95% CI) using modified Poisson regression with robust error variances accounting for the complex survey design to compare infertility services use across race/ethnicities. Results Overall, 8.7% of women reported using medical services to get pregnant. The prevalence of using any medical service to help get pregnant was lower for American Indian/Alaska Native (AI/AN) (PPR: 0.60, 95% CI 0.43-0.83) and black (PPR: 0.53, 95% CI 0.44-0.63) compared to white women and in Hispanic compared to non-Hispanic women (PPR: 0.57, 95% CI 0.48-0.67). The prevalence of accessing treatment, testing, and advice also differed by race and ethnicity. Conclusions for Practice We observed disparities in accessing services to get pregnant among AI/AN and black women and reduced use of advice among Asian/Pacific Islanders compared to whites. We also observed reduced service utilization for Hispanic compared to non-Hispanic women. Differential utilization of specific services suggests barriers to infertility care may contribute to reproductive health disparities among underserved populations. [ABSTRACT FROM AUTHOR]

This study set out to (1) estimate the prevalence of three forms of feeding intention among 2,178 pregnant women in six of Hong Kong’s regional hospitals and (2) identify the associated demographic, socioeconomic, obstetric and relational correlates. The research design was exploratory, cross-sectional, and quantitative. The Chinese version of a self-administered questionnaire was used to collect the demographic, socio-economic, and obstetric characteristics of the women. Couples’ relationships were investigated using the Dyadic Adjustment Scale. All women in the second trimester of their pregnancies who attended the target antenatal clinics within the data collection period of December 2004 to December 2006 were recruited. The prevalence rates of breastfeeding, mixed feeding and artificial feeding were 53.9%, 14.8%, and 31.3%, respectively. Women who had been born in Hong Kong, lived in accommodation that was ≥300 feet (~30 m), had made an early antenatal booking, had a planned pregnancy, were experiencing their first pregnancy, and had a lower level of conflict with their partners were significantly more likely to opt for breastfeeding. Women who had been born in Hong Kong and already had children were significantly more likely to choose mixed feeding, compared with the artificial group in a multinomial logistic regression model. These findings suggest that effective promotion of breastfeeding during the prenatal period must target the correlates of feeding intention. [ABSTRACT FROM AUTHOR]

In populations where the majority of pregnancies occur to unmarried women, exploring the quality of partner relationships and reproductive health is warranted. This study assesses differences in psychosocial characteristics, health behaviors, and birth outcomes between unmarried pregnant women who reported having a ‘good’ relationship with their baby’s father, compared to those who reported having a ‘fair’ or ‘poor’ relationship with their baby’s father. This research was part of a prospective study of low-income urban women. All unmarried women ( n = 3,633) enrolled during their first prenatal visit were asked questions designed to differentiate between being in a good, fair or poor relationship with the baby’s father. The worse the quality of the relationship, the worse the outcome, with dose–response associations between the quality of the relationship, emotional health, health behaviors, and birthweight. Compared to women in good relationships, those in poor relationships were more likely to have depressive symptoms (aPR 1.93; 95% CI: 1.65, 2.25), stress (aPR 1.24; 95% CI: 1.14, 1.35), use drugs (aPR 1.34; 95% CI: 1.11, 1.61) and smoke (aPR 1.28; 95% CI: 1.10, 1.49). Although infants born to mothers in poor relationships had the highest rate of low birth weight, the differences were not significant. Delving beyond marital status to assess the quality of partner relationships among unmarried mothers is important. Further research is needed to understand the complex interplay of individual, social and environmental factors promoting or hindering stable and supportive partner relationships among socially disadvantaged populations of pregnant women. [ABSTRACT FROM AUTHOR]