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Introduction: Increasing family planning xutilization in low-income countries to improve health outcomes of women and children is a global priority. The Federated States of Micronesia (FSM) has poor maternal child health outcomes; therefore, this study aimed to examine family planning utilization in Pohnpei State, FSM. Methods: This cross-sectional study sought to characterize family planning utilization in adult women of reproductive age and high school age adolescents in Pohnpei using representative survey data collected in 2019 (N = 570 and N = 1726, respectively). Chi-square tests were used to determine significant factors associated with family planning utilization. Results: Among adult women of reproductive age (18–49 years old) not trying to get pregnant, 31.6% reported using contraception during last intercourse. Contraceptive use was significantly lower among younger women (18–24 years old) (21.7%, p = 0.021), unmarried women (18.6%, p < 0.001), those without health insurance (28.7%, p = 0.030), those who have never had a pap smear (20.5%, p < 0.001), and those who have never been pregnant (14.5%, p < 0.002). Among adolescents who reported being sexually active, 28.5% reported using any contraception at last intercourse and 22.6% reported using a condom at last intercourse. Condom use among sexually active adolescents was lowest among 12th graders (13.5%, p < 0.001) and girls (16.8%, p = 0.004). Conclusions: Our findings suggest that young, unmarried, never pregnant women face an unmet need for family planning. Additionally, women with lower access to and use of healthcare services have lower use of family planning. Significance: Data published on reproductive health in FSM have been limited. This study points to several possible interventions to increase family planning utilization in Pohnpei, including the development of a comprehensive school-based health education curriculum, increasing access to and promotion of well-woman visits, and increasing use of long-acting reversible contraception. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether prenatal visits or screening/testing were fewer or occurred later during the initial phase of the COVID-19 pandemic in 2020 (CINT) as compared to the prior year (PreCINT). Methods: A retrospective cohort study compared CINT (n = 2,195) to PreCINT (n = 2,395) at seven public hospitals in New York City. The primary outcome was total number of prenatal-care visits. Secondary outcomes were components of prenatal-care visits completion, timing of standard pregnancy screening tests, and adverse neonatal outcomes. Results: CINT patients had more total prenatal-care visits (B = 1.30, 95% CI:1.04, 1.56, p < 0.001), lower odds for initiation of prenatal care which was inadequate according to widely used criteria (OR:0.39, 95% CI:0.34, 0.45, p < 0.001), and lower gestational age at initial visit (B=-4.51, 95% CI:-5.10, -3.93, p < 0.001) than PreCINT patients. In-person visits did not differ between the two groups. PreCINT patients had no televisits, while CINT patients had a median of one televisit (Median = 1, p < 0.001). CINT patients had increased odds for group B Streptococcus screening (OR:1.27, 95% CI: 1.10, 1.48, p = 0.001), quadrivalent screening (OR:1.30, 95% CI:1.15, 1.48, p < 0.001), and anatomy sonogram (OR:2.30, 95% CI:2.04, 2.59, p < 0.001) but decreased odds for glucose challenge test screening (OR:0.81, 95% CI:0.72, 0.91, p < 0.001). Adverse neonatal outcome did not differ between CINT and PreCINT pregnancies. Conclusions for Practice: Despite the difficulties and perceived dangers of in-person visits during the COVID-19 pandemic, the COVID-19 pandemic had little negative impact upon the outpatient prenatal care received by patients in this hospital system. Significance: What is Already Known on this Subject?: There have been conflicting reports regarding the impact of the COVID-19 epidemic on prenatal care and on the role of telemedicine. What this Study Adds?: There was no decrease in the number and timing of in-person outpatient visits. There was comparable or greater completion of standard tests for patients pregnant during the COVID-19 pandemic as compared to the previous year. These safety net hospitals provided unbroken access to outpatient prenatal services, and patients availed themselves of these services, suggesting that pregnant patients understood the importance of prenatal care. [ABSTRACT FROM AUTHOR]

Objectives: Sleep-related infant deaths are a common and preventable cause of infant mortality in the United States. Moreover, infants of color are at a greater risk of sleep-related deaths than are White infants. The American Academy of Pediatrics (AAP) published safe sleep guidelines to minimize the number of sleep-related infant deaths; however, many families face barriers to following these guidelines. Research on the role of psychosocial risk factors (i.e., depression, stress, domestic violence, substance use) in mothers' engagement in safe sleep practices is limited. The present study examined the role of maternal psychosocial risk factors on maternal safe sleep practices and the moderating effects of maternal race on this relationship. Methods: Participants in this study were mothers (N = 274) who were recruited from a Midwestern hospital postpartum. Data on the participants' psychosocial risk factors, and safe sleep practices were collected via telephone interview 2–4 months following the birth of their infant. Results: Predictive models indicated that depression and stress impacted mothers' engagement in following the safe sleep guidelines. Specifically, higher levels of maternal depression predicted greater likelihood of co-sleeping, regardless of mothers' race. Higher levels of maternal stress also predicted lower engagement in safe sleep behaviors for White mothers only. Conclusion for Practice: Early interventions to address stress and depression may help to increase maternal adherence to the AAP's safe sleep guidelines. Additional research on the underlying mechanisms of depression and stress on maternal safe sleep engagement is needed. Significance: The American Academy of Pediatrics created safe sleep guidelines to reduce infant sleep-related deaths; however, caregivers face barriers to following these guidelines. Psychosocial risk factors may impact caregivers' ability to follow the safe sleep guidelines. Moreover, race may moderate the relation of psychosocial variables to safe sleep engagement. This study found a relation between depressive symptoms and cosleeping, such that depressive symptoms predicted greater likelihood of cosleeping, regardless of maternal race. Stress was also found to decrease engagement in safe sleep practices for White mothers only. These findings suggest that interventions addressing caregiver depression and stress may increase engagement in safe sleep practices. [ABSTRACT FROM AUTHOR]

Background: In the recent years, a high risk of developmental delay not only in very low birth weight infants and late preterm infants but also in early term infants (37–38 weeks) have increasingly been reported. However, in Japan, there are virtually no studies regarding the development delays in early term infants. Methods: This study used the data from the Japan Environment and Children's Study (JECS), a birth cohort study conducted in Japan. Data were selected for analysis from the records of 104,065 fetal records. The risk of neurodevelopmental delays at 6 months and 12 months after birth was evaluated using multivariate analysis for infants of various gestational ages, using the 40th week of pregnancy as a reference value. Neurodevelopment was evaluated at 6 months and 12 months after birth using the Ages and Stages Questionnaires, Japanese translation (J-ASQ-3). Results: The proportion of infants born at a gestational age of 37 to 38 weeks who did not reach the J-ASQ-3 score cutoff value was significantly higher in all areas at both 6 months and 12 months after birth, when compared to that of infants born at 40 weeks. The odds ratio decreased at 12 months after birth compared to that at 6 months after birth. Conclusion: Early term infants in Japan are at an increased risk of neurodevelopmental delay at 12 months after birth. Significance: What's known on this subject: Early term infants with gestational ages of 37 to 38 weeks and not only premature babies may be at an increased risk of developmental delay. What this study adds: This study was conducted using data from a birth cohort of 104,065 fetal records. Early term infants had an increased risk of developmental delay at 6 months, and while the risk decreased by 12 months after birth, it was still high. [ABSTRACT FROM AUTHOR]

Objectives: More than half of women do not achieve appropriate gestational weight gain. Maternal body image may be an important factor associated with gestational weight gain. However, this association has not been thoroughly evaluated. We aimed to elucidate whether body image parameters before and during pregnancy are associated with gestational weight gain in Japanese women. Methods: This prospective cohort study was conducted at a hospital in Osaka, Japan from March 2020 to March 2021. We recruited women with singleton pregnancies in their second and third trimesters. Body image was assessed using the Pregnancy and Weight Gain Attitude Scale and additional questions. Gestational weight gain was classified as insufficient, appropriate, or excessive based on recommended ranges in Japan. One-way analysis of variance, chi-square tests, and multinomial logistic regression analyses were performed to identify factors associated with insufficient or excessive weight gain. Results: Of 266 enrolled women, 47 had insufficient weight gain and 100 had excessive weight gain during pregnancy. Risk factors for excessive gestational weight gain included a history of dietary restriction before pregnancy, negative attitudes toward gestational weight gain, and perception of body shape as fat and body shape dissatisfaction during pregnancy. Perception of body shape as thin during pregnancy was identified as a risk factor for insufficient gestational weight gain. Conclusions: Body image before and during pregnancy may be an important factor in preventing insufficient or excessive gestational weight gain in Japanese women. Healthcare professionals should consider body image when providing health guidance on weight management to pregnant women. Significance: What is Already Known? Body image is a possible factor in gestational weight gain. Compared to women in other countries, Japanese women of reproductive age tend to have a negative body image. What this Study adds? A history of dietary restriction before pregnancy and negative body image during pregnancy were associated with excessive gestational weight gain among Japanese women. Perception of body shape during pregnancy as thin was associated with insufficient gestational weight gain. Thus, even in a Japanese population, characterized by a majority of women with pre-pregnancy underweight or normal body mass index status, associations between negative body image and gestational weight gain were similar to those in other countries. [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]

Objective: Using person-centered analyses, this study examined the trajectories of women's early postnatal adaptation and explored whether there were differences in their trajectories based on women's status as a first-time or more experienced mother. Methods: Data were collected from women (N = 137; Mage = 28.6 years, SD = 4.49; 48.2% first-time mothers) at 2-, 4-, 6-, and 8-weeks postpartum. At each wave of data collection, mothers reported on their parenting self-efficacy, parenting satisfaction, anxiety, parenting stress, and depressive feelings. Results: The creation of an amalgamated measure of postnatal adaptation demonstrated acceptable fit. Latent class growth analysis revealed four distinct trajectories of postnatal adaptation; two revealed stability across the early postnatal period and two had relative stability except for a change between weeks four to six. Women's parity was not associated with differences in their trajectories. Conclusions for Practice: These findings reiterate the importance of collecting data from women in the early postnatal period and identifying if a woman is struggling in those early weeks, as the women in our sample demonstrated relative stability in their postnatal adaptation across the first eight weeks. Furthermore, the findings suggest that work should be taken to dismantle the commonly held belief that parenting is "easier" after having already navigated the early postnatal period with an infant once before. [ABSTRACT FROM AUTHOR]

Objectives: Measuring the value-added impact of Leadership Education in Neurodevelopmental Disabilities and Related Disorders (LEND) training on trainees' leadership and career trajectories is necessary to understand program efficacy. In the current study, we leveraged an existing ex post facto design to develop and test a new measure of LEND competencies and compare outcomes of LEND trainees and comparison peers. Methods: We developed the LEND Outcomes Follow-Up Survey using a multi-step, mixed methods process. A series of focus groups and consultations with key stakeholders identified eight important LEND leadership outcomes: (1) interdisciplinary work; (2) advocacy; (3) intersectional approach; (4) systems perspective; (5) life course perspective; (6) leadership; (7) engagement with maternal and child health populations; and (8) research experience. We developed and piloted this novel survey to measure these LEND leadership outcomes. We used data collected from this novel measure and an existing survey that is used nationally by LEND, to compare the outcomes of 43 LEND trainees and 30 comparison peers at two years post completion of LEND training. Results: We found that, compared to comparison peers, LEND trainees: (1) worked with a greater number of disciplines; (2) were more likely to be engaged in advocacy; (3) were more likely to utilize a systems perspective in their work; (4) were more likely to work with maternal and child health populations; and (5) were more likely to have experience conducting research. Conclusions: Our findings suggested that LEND training improves LEND leadership outcomes at two years post-completion of LEND training. Significance: As federally funded training programs, LEND programs must provide rigorous evidence for program efficacy. This study leveraged an existing, multi-site study design to develop and test a novel survey designed to assess group differences in knowledge, attitudes, and skills related to LEND core competencies in a cohort of LEND trainees and matched comparison peers. Findings suggest that LEND trainees had significantly better leadership outcomes than comparison peers. This study adds to the body of literature that suggests that LEND training is efficacious and that our design can be successfully leveraged to test outcomes two years after completion of LEND training. [ABSTRACT FROM AUTHOR]

Introduction: Immediate postpartum (IPP) Long Acting Reversible Contraception (LARC) is effective in reducing short birth spacing, which is highest among minoritized and younger women with lower socioeconomic status. The structural barrier of cost for pregnant people who desire IPP LARC insertion was alleviated in 2016 when New York State provided statewide reimbursement for Medicaid recipients. Methods: Analyses of existing electronic medical records (EMR) were conducted on women who received IPP LARC between 3/2/17 and 9/2/19 at two hospitals after a term delivery, defined as gestational age 37 0/7 weeks or greater. Descriptive and bivariate statistics, including chi-square tests and Fischer's exact tests, based on cell sizes, were calculated using SAS (version9.4). Results: Prior to the study period, IPP LARC was not placed in these hospitals. After reimbursement policy changes, electronic medical record data identified 501 women with full term delivery and IPP LARC placed, of which the majority were single (82.8%), Black (49.1%), and had public insurance (Medicaid and Medicaid Managed Care) (79.2%). Discussion: Removing structural economic barriers for people using public insurance may increase health equity in contraceptive access and choice. Significance: Implementing different reimbursement policies takes time and effort of multiple stakeholders throughout an institution. This effort is justified when disenfranchised patients become eligible for additional services due to the removal of structural financial barriers. Over a 30-month time period, 397 additional women using public insurance with a term delivery had LARC placed due to the new reimbursement policy, increasing autonomy of these people to plan their next pregnancy. Removing economic structural barriers increases health equity. [ABSTRACT FROM AUTHOR]

Purpose: Undiagnosed urinary tract infections (UTIs) in pregnancy are associated with adverse perinatal outcome. Urine microbiology cultures reported as 'mixed bacterial growth' (MBG) frequently present a diagnostic dilemma for healthcare providers. We investigated external factors contributing to elevated rates of (MBG) within a large tertiary maternity centre in London, UK, and assessed the efficacy of health service interventions to mitigate these. Description: This prospective, observational study of asymptomatic pregnant women attending their first prenatal clinic appointment aimed to establish (i) the prevalence of MBG in routine prenatal urine microbiology cultures, (ii) the association between urine cultures and the duration to laboratory processing and (iii) ways in which MBG may be reduced in pregnancy. Specifically we assessed the impact of patient-clinician interaction and that of an education package on optimal urine sampling technique. Assessment: Among 212 women observed over 6 weeks, the negative, positive and MBG urine culture rates were 66%, 10% and 2% respectively. Shorter duration from urine sample collection to laboratory arrival correlated with higher rates of negative cultures. Urine samples arriving in the laboratory within 3 hours of collection were most likely to be reported as culture negative (74%), and were least likely to be reported as MBG (21%) or culture positive (6%), compared to samples arriving > 6 hours (71%, 14% and 14% respectively; P < 0.001). A midwifery education package effectively reduced rates of MBG (37% pre-intervention vs 19% post-intervention, RR 0.70, 95% CI 0.55 to 0.89). Women who did not receive verbal instructions prior to providing their sample had 5-fold higher rates of MBG (P < 0.001). Conclusion: As many as 24% of prenatal urine screening cultures are reported as MBG. Patient-midwife interaction before urine sample collection and rapid transfer of urine samples to the laboratory within 3 hours reduces the rate of MBG in prenatal urine cultures. Reinforcing this message through education may improve accuracy of test results. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate whether ZIP-code level neighborhood socioeconomic status (SES) is associated with adverse pregnancy outcomes. Methods: A retrospective study of 2009–2014 Oregon Health and Science University (OHSU) births with maternal ZIP codes in one of 89 Portland metropolitan area ZIP codes. Deliveries with ZIP codes outside of the Portland metro area were excluded. Deliveries were stratified by SES based on ZIP code median household income: low (below 10th percentile), medium (11th–89th percentile), and high (above 90th percentile). Univariate analysis and multivariable logistic regression with medium SES as the reference group evaluated perinatal outcomes and strength of association between SES and adverse events. Results: This study included 8118 deliveries with 1654 (20%) classified as low SES, 5856 (72%) medium SES, and 608 (8%) high SES. The low SES group was more likely to be younger, have a higher maternal BMI, have increased tobacco use, identify as Hispanic or Black, and less likely to have private insurance. Low SES was associated with a significantly increased risk of preeclampsia (RR 1.23 95% CI 1.01–1.49), but this was no longer significant after adjusting for confounders (aRR 1.23 95% CI.971–1.55). High SES was negatively associated with gestational diabetes mellitus (GDM), even after adjusting for confounders (aRR 0.710, 95% CI 0.507–0.995). Conclusion: In the Portland metropolitan area, high SES was associated with a lower risk of GDM. Low SES was associated with a higher risk of preeclampsia before accounting for covariates. ZIP code-based risk assessment may be a useful indicator in detecting healthcare disparities. Significance: Low socioeconomic status (SES) is associated with adverse pregnancy outcomes. However, literature exploring neighborhood SES and pregnancy outcomes, particularly using Neighborhood Socioeconomic Status and Perinatal Outcomes ZIP code as a SES surrogate, is limited. Our study suggests that even within a single metropolitan area living in a ZIP-code in the lowest 10th percentile SES is associated with preeclampsia. However, this association is no longer significant after adjusting for confounders such as BMI and tobacco use, suggesting these lifestyle factors may be playing a role in preeclampsia in low SES populations. Understanding this relationship may help guide counseling for this vulnerable population. [ABSTRACT FROM AUTHOR]

Objectives: In Africa and Asia, 190 million preschoolers are vitamin A deficient. This study examined the social determinants of intake of vitamin A supplementation (VAS) among children aged 6–59 months during three different time periods in Kenya to identify those most vulnerable to vitamin A deficiency and highlight the varied targeting and outreach efforts; before the onset of a national restructuring and targeted distribution of VAS in children below 5 years through a twice-yearly door-to-door campaign called Child Health Weeks, during the implementation period, and several years later. Methods: The cross-sectional, national Demographic and Health Surveys were administered in Kenya in 2003, 2008-09, and 2014. Bivariate and multivariable logistic regression analyses were used to assess variables associated with VAS among children (n = 28,239). Results: An overall two-fold increase in VAS was recorded between 2003 (31.8%) and 2014 (67.5%). In 2008-09, children aged 6–11 months were the most likely to receive VAS. In 2003 and 2014, geographical regions and settings, birth order of the child, educational level of the mother, religion, wealth index, number of antenatal visits, and access to a radio were identified as being significantly associated with VAS, in at least one of the years. These determinants were not significant in 2008-09 during the initial Child Health Weeks promotion campaign. The determinants of VAS varied during the three study periods, particularly in 2008-09 when the Child Health Weeks was first implemented. Conclusion: As efforts to increase VAS continue, addressing child-specific determinants will be essential to reduce health disparities. Significance: Childhood vitamin A deficiency has been identified as one of the public health priorities in Kenyan children below 5 years that causes severe malnutrition. The importance of VAS was identified as a cost-effective strategy of combating and eradicating childhood malnutrition based on a previous national micronutrient survey. However, Kenya's VAS inequities are exacerbated by the social and economic differences of women. The WHO defines these disproportionate differences as the social determinants of health. Identifying these factors will be influential for policy makers to make targeted efforts towards increasing VAS supplementation and contribution towards reducing child mortality. [ABSTRACT FROM AUTHOR]

Objectives: To describe the presence of anti-SARS-CoV-2 IgA and IgG in the blood and colostrum of women with COVID-19 infection during pregnancy and associate the presence of anti-SARS-CoV-2 IgA in colostrum with clinical symptoms of their newborns. Methods: A cross-sectional study was developed with 165 participants with COVID-19 infection during pregnancy and their newborns. Data collected: characteristics COVID-19 infection in pregnant women, gestational age, and clinical symptoms in their newborns (fever, hypothermia, respiratory distress, hypotonia, hypoactivity, hypoglycemia, cyanosis, vomiting/regurgitation, abdominal distention, and jaundice). Maternal blood and colostrum samples were collected postpartum to to detect the presence of IgA and IgG anti-SARS-CoV-2. Results: The median interval between COVID-19 diagnosis and delivery was 37.5 days (IQ = 12.0, 73.0 days). Clinical symptoms during hospitalization were observed in 55 newborns (33.3%), and two (1.6%) tested RT-PCR positive for COVID-19. Positive colostrum for anti-SARS-CoV-2 IgA was found in 117 (70.9%) women. The presence of anti-SARS-CoV-2 IgA in colostrum was associated independently with lower clinical symptoms in their newborns (OR = 0.42; 95% CI 0.202 to 0.84; p = 0.015). Conclusions for Practice: The presence of anti-SARS-CoV-2 IgA in colostrum was detected in more than two-thirds of the women evaluated and was associated with a lower frequency of clinical symptoms in their newborns. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate third-grade reading and math proficiency for children born to adolescent women compared with those born to non-adolescent women. Methods: A statewide, retrospective cohort study was conducted in Rhode Island using third-grade year-end examination data from 2014 to 2017 as part of a statewide initiative to improve third grade reading levels. Children's third-grade reading and math proficiencies were compared between those born to nulliparous adolescent women (age 15–19 at the time of delivery), and nulliparous women 20 years or older at delivery. Bivariate analyses were conducted to compare maternal and child characteristics between adolescent and non-adolescent groups. Multivariable logistic regression was used to examine the association between having an adolescent mother and being proficient in reading and math after adjusting for lunch subsidy, core city residence, child race/ethnicity and sex. Results: Of the 8,248 children meeting the inclusion criteria, 20% were born to adolescent women and the remaining 80% were born to non-adolescent women. After adjusting for potential confounders, children born to adolescent women were significantly less likely to be proficient in both reading (adjusted risk ratio (aRR) 0.77, 95% confidence interval (CI): 0.71–0.83) and math (aRR 0.78, 95% CI: 0.72–0.85). Conclusions for Practice: Children born to adolescent women had significantly lower rates of reading and math proficiency when compared with children of non-adolescent women. These children may benefit from additional resources focused on early academic performance in order to address disparities in reading and math proficiency. [ABSTRACT FROM AUTHOR]

Objective: The goal of this study was to evaluate whether differences in gestational weight gain (GWG) and adverse perinatal outcomes exist for Black and White women who are overweight or have obesity (OW/OB) at entry to prenatal care. Methods: We enrolled 183 pregnant women with BMI 25-45 kg/m2 (71% black, 29% white) prior to 14 weeks gestation. Data were collected on demographic, medical history, diet and physical activity during pregnancy. Relationships between race and maternal outcomes and infant outcomes were assessed using multivariable logistic regression models. Results: The average age of pregnant women were 26 years (±4.8), with a mean BMI of 32.1 (±5.1) kg/m2 at the time of enrollment. At delivery, 60 women (33%) had GWG within Institute of Medicine recommendations and 69% had at least one comorbidity. No significant differences by race were found in GWG (in lbs) (11±7.5 vs. 11.4±7.3, p=0.2006) as well as other perinatal outcomes including maternal morbidity, LBW and PTB. Race differences were noted for gestational diabetes, total energy expenditure and average daily calorie intake, but these differences did not result in significant differences in GWG or maternal morbidity. Conclusion: The lack of racial differences in GWG and perinatal outcomes demonstrated in this study differs from prior literature and could potentially be attributed to small sample size. Findings suggest that race differences in GWG and perinatal outcomes may diminish for women with a BMI in the overweight or obese range at conception. [ABSTRACT FROM AUTHOR]

Objectives: Little is known about the relationships between sex of infant, disappointment with sex of infant, and risk for perinatal depression, particularly in societies where the nature of parental sex preference is thought to be "balanced" between male and female offspring. We sought to explore relationships between these variables in a North American population. Methods: In this exploratory study, we used data from a large Canadian prospective longitudinal study in which data were collected at up to four timepoints: during pregnancy, and at 1 week, 1 month and 3 months postpartum. Data about sex of infant, maternal preference for, and disappointment in sex of infant were recorded at the first possible timepoint; while at each postpartum timepoint infant fussiness and EPDS scores were recorded. We performed a mixed-effects linear regression to evaluate relationships between these variables. Results: In our sample of N = 207 women, EPDS scores were higher for mothers of male versus female infants, and independently associated with infant fussiness. There was no interaction between sex of infant and maternal disappointment, or between maternal disappointment and EPDS scores. Conclusions: Mothers of male infants may have slightly more depressive symptoms than mothers of female infants regardless of maternal preference for, or disappointment in sex of infant; sex-specific biological risk factors for PPD should be explored. [ABSTRACT FROM AUTHOR]

Objectives: Rates of postpartum smoking relapse are high (70–90%) but standard relapse prevention interventions are not effective postpartum. This pilot study evaluated effects of a combined relapse prevention and sleep intervention on sleep and relapse to smoking. Methods: Twenty-eight postpartum mothers were assigned to the intervention group—combined relapse prevention and behavioral sleep intervention—or to the comparison group—relapse prevention alone. Questionnaires and actigraphy were completed at baseline (1-week postpartum), post-treatment (8-weeks postpartum), and follow-up (12-weeks postpartum). Sleep diaries were completed weekly for the first 8 weeks postpartum and once at 12 weeks postpartum. To corroborate abstinence, CO levels in expired air were measured weekly for the first 8 weeks postpartum and at follow-up. Timeline Followback (TLFB) and salivary cotinine analysis were conducted at baseline, post-treatment, and follow-up to assess for nicotine and other substance use (TLFB) and to further corroborate abstinence (salivary cotinine analysis). Results: The sleep intervention lengthened maternal nighttime actigraphic sleep by an average of 48 minutes nightly; lengthened the longest bout of consolidated actigraphic sleep by an average of 42 minutes nightly; increased actigraphic sleep efficiency into the healthy range (> 85%); and lowered subjective ratings of sleep disturbance (ps <.05). Findings were inconclusive regarding whether better sleep was associated with abstinence. Post Hoc analyses identified the presence of an additional support person in the home as well as social and emotional support as being positively correlated with smoking abstinence (p <.05; p <.01). Conclusions for Practice: (1) Postpartum sleep can be improved with behavioral interventions in women with a history of smoking. (2) Social-emotional postpartum support is an important factor in preventing smoking relapse for these women. [ABSTRACT FROM AUTHOR]

Objectives: The COVID pandemic has had widespread impacts on maternal mental health. This research aims to examine the relationship between psychosocial stressors and symptoms of depression and anxiety and the extent to which emotional support or resilient coping moderates the relationship between psychosocial stressors and maternal mental health during the first wave of the COVID pandemic. Methods: This analysis includes data collected in October and November 2020 from a geographically and sociodemographically diverse sample of 776 mothers in the U.S. with children ≤ 18 years of age. Log binomial models were used to estimate the association between moderate or severe symptoms of anxiety and depression and psychosocial stressors. Results: Symptoms of moderate or severe anxiety and depression were reported by 37.5% and 37.6% of participants, respectively. Moderate (aRR 2.76 [95% CI 1.87, 4.07]) and high (aRR 4.95 [95% CI 3.40, 7.20]) levels of perceived stress were associated with greater risk of moderate or severe anxiety symptoms. Moderate and high levels of parental burnout were also associated with greater prevalence of moderate or severe anxiety symptoms in multivariable models. Results were similar when examining the relationship among stress, parental burnout, and depressive symptoms. Neither resilient coping nor social support modified the relationship between psychosocial stressors and mental health. Conclusions for Practice: Evidence-based strategies to reduce stress and parental burnout and improve the mental health of mothers are urgently needed. Strategies focused on bolstering coping and social support may be insufficient to improve maternal mental health during acute public health emergencies. [ABSTRACT FROM AUTHOR]

Objectives: A high rate of preterm birth has been reported in Okinawa Prefecture, the southernmost island prefecture of Japan. Hence, this study aimed to identify the risk factors for preterm birth in this prefecture. Methods: This retrospective study included data from January 2013 to December 2019 from three facilities in Okinawa Prefecture. Of 13,468 cases of preterm birth at ≥ 22 weeks of gestation, 11,868 were included in this study. Stillbirth and multiparity cases were excluded. First, we compared the overall preterm and full-term birth groups by categorizing the patient background, obstetric, and fetal risk factors. Further, we categorized preterm births into three groups (22–27, 28–33, and 34–36 weeks of gestation) and examined patient background factors to identify potential risk factors for the occurrence of preterm birth in each group. Results: Preterm births accounted for 21.2% (2,521 cases) of all cases, with the rates of 2.6% (317 cases), 6.7% (800 cases), and 11.8% (1,404 cases) at 22–27, 28–33, and 34–36 weeks of gestation, respectively. To prevent preterm birth in Okinawa Prefecture, the present study specifically focused on patient background characteristics. In the multinomial logistic regression, the risk factors for preterm birth at 22–27 weeks of gestation were previous preterm birth (P < 0.0001) and lower age (P = 0.026); at 28–33 weeks of gestation, the risk factors were previous preterm birth (P < 0.0001) and history of cervical conization (P = 0.009); and at 34–36 weeks of gestation, only previous preterm birth (P < 0.0001) was a risk factor. Conclusions for practice: Previous preterm birth, younger age, and history of cervical conization were risk factors for Preterm birth in Okinawa. To reduce premature births in Okinawa Prefecture, it is important to pick up women with these risk factors and provide them with appropriate guidance and education on an ongoing basis. Significance: What is already known about this subject? Previous studies have shown that smoking and short stature increase the rate of preterm birth in Okinawa Prefecture. What does this study add? Previous preterm birth, younger age, and history of cervical conization were risk factors for preterm birth in Okinawa Prefecture. [ABSTRACT FROM AUTHOR]

Introduction: Community health worker (CHW) interventions have been utilized to address barriers that prevent pregnant women from delivering in health facilities in low- and middle-income countries (LMICs). The objective of this research was to assess the programmatic factors that increase the likelihood of health facility delivery within a large digital health-supported CHW program in Zanzibar, Tanzania. Methods: This study included 36,693 women who were enrolled in the Safer Deliveries program with a live birth between January 1, 2017 and July 31, 2019. We assessed whether long-term enrollment, recency of CHW pregnancy visit prior to delivery, and number of routine home pregnancy visits were associated with an increased likelihood of health facility delivery compared to home delivery. We used Chi-squared tests to assess bivariate relationships and performed logistic regression analyses to assess the association between each programmatic variable and health facility delivery, adjusting for relevant confounders. Results: We found that long-term enrollment was significantly associated with increased likelihood of health facility delivery, with the strongest relationship among women with a previous home delivery (OR = 1.4, 95%CI [1.0,1.7]). Among first-time mothers, two or more pregnancy visits by a CHW was positively associated with health facility delivery (OR = 1.8, 95%CI [1.2, 2.7]). Recent pregnancy visit by a CHW was positively associated with health facility delivery, but was not significant at the α = 0.05 level. Discussion: In this program, we found evidence that at least two routine home pregnancy visits, longer length of enrollment in the program, and recency of home visit to the delivery date were strategies to increase health facility delivery rates among enrolled mothers. Maternal and child health programs should undertake similar evaluations to improve program delivery. [ABSTRACT FROM AUTHOR]

Aim: The aim of this study was to evaluate if overweight and obesity in the offspring is reduced by a low-intensity antenatal primary care intervention with focus on diet and physical activity for pregnant women with obesity, comparing children to mothers receiving the intervention with children to mothers who did not. Methods: This study is a follow-up of children 2.5 years of age after their mothers' participation in a non-randomised controlled intervention intending to limit gestational weight gain. All study participants received standard antenatal care. The intervention group received lifestyle support via motivational talks with midwife and support from dietician. Data on child weight were collected by medical records, letter and phone. Results: There was no significant difference between the groups 2.5 years after intervention (International Obesity Task Force ISO-BMI 25 (child BMI corresponding to adult BMI of 25): 20% vs. 21%; ISO-BMI 30: 4.6% vs. 1.3%). The mother's BMI at the beginning of pregnancy significantly influenced child BMI at 2.5 years (r = 0.13, p = 0.014, r2 = 0.017). For each unit of increase in maternal BMI at enrollment, the probability of child ISO-BMI ≥ 25 increased by 7.5% (p = 0.021) and of ≥ 30, by 12.9% (p = 0.017). Conclusion: The frequency of overweight and obesity of the children at 2.5 years of age was significantly correlated to the mother's BMI, but not correlated to the mothers' participation in the antenatal lifestyle intervention. Thus, it seems important to address obesity and lifestyle issues before and between pregnancies. Trial registration The study has been registered at ClinicalTrials.gov, Identifier: NCT03147079. [ABSTRACT FROM AUTHOR]

Background: Despite the implementation of essential newborn care (ENC) by the World Health Organization, knowledge gaps among postpartum women persist. Inappropriate breastfeeding practices and lack of knowledge regarding ENC among mothers has resulted in higher neonatal mortality. Purpose: Our study focused on evaluating the effectiveness of flip-chart assisted postpartum maternal education in improving ENC knowledge and skills. Material and Methods: A single blind parallel randomized controlled trial was carried out with 120 primigravidae. Participants were allocated to the intervention group (IG) or the control group (CG) by block randomization. A pretested validated questionnaire was administered to participants in both groups within 24 h post-delivery. Women in the IG were provided flip-chart assisted education regarding ENC approximately 24 h post-delivery. Women in both groups received verbal advice on ENC from the postnatal ward nurses, as per the existing hospital policy. ENC skills were observed in all participants in postnatal wards by independent observers. 6 months later, knowledge retention was assessed and analyzed in both groups. Results: Antenatal education remained at 32% among all postnatal women. Postnatal flip-chart-assisted maternal education had a significant impact on ENC skills in the IG (p < 0.01) and precipitated higher knowledge scores at the end of 6 months (p < 0.01) in the IG. Conclusion for Practice: Flip-chart assisted education soon after delivery had a sustained effect on ENC knowledge and practices that persisted for 6 months post-delivery. [ABSTRACT FROM AUTHOR]

Objectives: Rates of perinatal depression and pregnancy hyperglycemia are higher in Hispanic women as compared to non-Hispanic white women. In turn, depressive symptoms may reduce a woman's ability to engage in lifestyle changes that could reduce their subsequent diabetes risk. Methods: We conducted a secondary analysis using data from Estudio Parto to evaluate sociodemographic, behavioral, psychosocial, and medical factors associated with perinatal depressive symptoms. Estudio Parto was a randomized controlled trial conducted in Western Massachusetts from 2013 to 17. Eligible participants had pregnancy hyperglycemia. The Edinburgh Postnatal Depression Scale (EPDS) was administered at 24–28 weeks gestation and at 6 weeks, 6 months, and 12 months postpartum. An EPDS cutpoint of 10 or greater defined the presence of depressive symptoms. Results: In this sample of Puerto Rican women with pregnancy hyperglycemia, 32% and 27% showed prenatal and postpartum depressive symptoms, respectively. Among participants, 35.5% were diagnosed with GDM, 44.3% with isolated hyperglycemia, and 20.2% with impaired glucose tolerance. In multivariable models, being unmarried (OR 3.87; 95% CI 1.51–9.94), prenatal substance use (smoking or alcohol consumption; OR 2.96; 95% CI 1.41–6.18), and maternal age (1.11 for each year; 95% CI 1.04–1.18) were associated with higher odds of prenatal depressive symptoms. None of the risk factors were associated with subsequent postpartum depression in adjusted analyses. Conclusions: Identifying factors associated with prenatal and postpartum depression in Puerto Rican women with pregnancy hyperglycemia can inform targeted lifestyle interventions in this at-risk group, increase the likely adoption of healthy lifestyle behaviors, and thereby work to address health disparities. Clinicaltrials.gov NCT01679210; date of registration 08/07/2012. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to assess oral health knowledge, attitudes, and practices of women who had given birth in the United States within the past 2 years, and to evaluate factors affecting women's dental service utilization during pregnancy. Methods: This study used a descriptive, cross-sectional design and employed non-probability sampling methods. The 47-item questionnaire included: oral health behaviors (8), knowledge (5), attitudes (12), and practices during pregnancy (10), and demographic (12) questions. Participants were recruited through multiple postpartum support group forums on Facebook. Logistic regression was used to identify potential predictors of dental utilization during pregnancy. Results: Ninety-one percent of the participants had at least an associate's degree, and 85.6% had dental insurance coverage during pregnancy. Approximately 56% knew the connection between poor oral health and pregnancy complications; however, only 11% obtained this information from their OBGYNs and 10% from their dental offices. Although women aware of the association were more likely to visit the dental office during pregnancy (64%, p <.001), the majority (74%) who experienced tooth or gum related issues during pregnancy reported not receiving any dental or gum treatment. Women, who had positive dental attitudes and awareness of an increased risk of pregnancy complications due to poor oral health, were more likely to receive dental care during pregnancy regardless of dental coverage. Conclusion: Medical and dental providers could play an active role in educating women on the importance of having good oral health, potential oral/systemic relationships, and the benefits of receiving dental care during pregnancy. [ABSTRACT FROM AUTHOR]

Objective: To study the relationship between cesarean Delivery (CD) and overweight in preschool children, considering the presence of birth aspects and demographic characteristics that have been associated with the risk of excess weight. Methods: This retrospective cross-sectional analysis used representative data of children from 2 to 6 years of age at municipal daycare centers in Taubaté, São Paulo, Brazil. The sample included 752 preschoolers. Weight and height were collected in daycare centers, and the nutritional status classification was performed using z scores of Body Mass Index (zBMI). Data analysis was performed in the bivariate and multivariate manner, the latter with the inclusion of another possible risk factor. Adjustments were made for daycare centers time, sex, birth length and weight and maternal schooling. Results: The mean age of preschool children was 4.7 years, and 53.8% were boys. The prevalence of overweight children was 21.7%. The median zBMI of the children born by CD was higher than that of vaginal Delivery (p = 0.0194). The prevalence of overweight showed association with CD (p = 0.0196; PR = 1.397 with 95% CI of 1065–1831). Logistic binary multivariate regression analysis confirmed the association, even in the presence of other possible risk factors (CR: 1.580, 95% CI: 1.072–2.330). Conclusion for Practice: Birth by CD is one of the factors that are associated with the early development of overweight in preschoolers. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to 1) Examine factors associated with cessation of exclusive breastfeeding in Israel and 2) Develop predictive models to identify women at risk for early exclusive breastfeeding cessation. Methods: The study used data from longitudinal national representative infant nutrition survey in Israel (n = 2119 participants). Logistic regression was used to identify risk factors and build predictive models. Results: The rate of exclusive breastfeeding cessation increased from 45.4% at 2 months to 85.7% at 6 months. Five factors were significantly associated with higher odds of exclusive breastfeeding cessation at 2 months: being a primapara, low educational level, lack of previous breastfeeding experience, negative attitude towards birth, and lack of intention to breastfeed. Six factors were significantly associated with higher odds of exclusive breastfeeding cessation at 6 months: younger age, being in a relationship with a partner, lower religiosity level, cesarean delivery, not taking folic acid during pregnancy, and negative attitude towards birth. Both 2 and 6-months models had good predictive performance (C-statistic of.72 and.68, accordingly). Conclusions for Practice: This nationwide study successfully identified several predictors of exclusive breastfeeding cessation and created breastfeeding cessation prediction tools for two time periods (2 and 6 months). The resulting tools can be applied to identify women at risk for stopping exclusive breastfeeding in hospitals or at community clinics. Further studies should examine practical aspects of applying these tools in practice and explore whether applying those tools can lead to higher exclusive breastfeeding rates. [ABSTRACT FROM AUTHOR]

Objectives: Opioid exposed infants born to incarcerated women represent a vulnerable and understudied subset of infants with neonatal abstinence syndrome (NAS). The impact of maternal incarceration on length of stay (LOS) for infants with NAS is unknown. We hypothesized that infants with NAS born to incarcerated women have longer hospitalizations compared to infants with NAS born to non-incarcerated women. Methods: This is a retrospective cohort study of infants with NAS born between 2011 and 2018 at the primary delivery site for Connecticut's only women's prison. Opioid exposed infants were assessed by Finnegan Scores for withdrawal and received morphine as a first line agent and phenobarbital as a second line agent. LOS was compared using Poisson regression. Results: Of 206 infants identified, 166 were included in the analysis, with 28 born to incarcerated women and 138 to non-incarcerated women. Incarcerated women were more likely to report prenatal alcohol use, 14.3% vs 2.2% p = 0.016 and benzodiazepine use 21.4% vs 7.3% p = 0.032. Infants of incarcerated women were less likely to be fed breast milk at discharge, 3.6% vs 37% p < 0.001. Adjusted mean LOS was longer among infants born to incarcerated women, 18.5 vs 16.6 days (p = 0.009). Conclusions for Practice: Infants with NAS born to incarcerated women in Connecticut had longer LOS, lower rates of being fed breast milk, and different prenatal substance exposures than infants with NAS born to non-incarcerated women. Supporting the maternal–infant dyad until infant discharge may mitigate the potential negative impact of maternal incarceration on the care of infants with NAS. [ABSTRACT FROM AUTHOR]

Objectives: The scale of overweight and obesity amongst women of childbearing age or mothers to be, living in Wales, places a considerable burden on the NHS and public health. High BMI (over 30) during pregnancy increases the health risks for mother and baby. Policy advice recommends weight management services are available to help women lose weight before and whilst planning pregnancy. In parts of Wales, NHS partnerships with commercial companies provide weight management services for women considering or planning pregnancy. This study evaluates whether an established referral Weight Watchers (WW) programme, known to be effective in adults in England, can help mothers-to-be living in North Wales lose weight. Methods: Analysis used routine data from 82 referrals to WW between June 2013 and January 2015. Participants received a referral letter inviting them to attend face-to-face group workshops combined with a digital experience. The programme encompassed healthy eating, physical activity and positive mind-set. Trained WW staff measured bodyweight before, during and at 12 weeks. On entry to the course, participants had a median age of 31.4 years (interquartile range (IQR) 28–34) with a median BMI of 36.8 kg/m2 (IQR 33.3–43.7). Results: Women completing the course (n = 34) had a median weight loss of 5.65 kg (IQR 0.45–10.85), equating to 5.7% (SD 3.46) of initial body weight. Intention-to-treat analysis (last observation carried forward), which included lapsed courses n = 66, showed a median weight loss of 3.6 kg (IQR − 2.53 to 9.73), equating to 3.7% (SD 3.62) of initial body weight. Overall, there was significant weight loss during the WW programme (Wilcoxon signed rank test Z = − 6.16; p < 0.001). Weight loss was significantly correlated with the number of workshops attended (Spearman correlation coefficient 0.61 p < 0.001). The proportion of all 82 participants (intention to treat, baseline observation carried forward) that achieved a weight loss of ≥ 5% initial weight was 30.5%. Conclusions for Practice: Referral of obese mothers-to-be into WW can successfully achieve short-term weight loss, at or above 5%, in approximately one third of participants. The dose–response effect supports a causal inference. Successful weight loss at this critical life stage may provide women with the necessary motivation to initiate weight loss for healthy pregnancy, however further research is required. [ABSTRACT FROM AUTHOR]

Objectives: This study examined the contribution of postpartum depressive symptoms (PDS) on select maternal health practices among Texas women, using 2012–2015 survey data from the Pregnancy Risk Assessment Monitoring System. Methods: Multiple logistic regression was used to assess the effect of PDS on postpartum checkups, postpartum dental visits, and use of postpartum birth control. Covariates included maternal age, race/ethnicity, marital status, education, and depression before birth. Results: Data from 4679 respondents were used in analyses, and the prevalence of women reporting PDS was 13.8 percent. Women without PDS were more likely to attend a postpartum checkup (adjusted OR = 1.5; 95% CI 1.1–2.1) or have a postpartum dental visit (adjusted OR = 1.4, 95% CI 1.0–1.8) than women with PDS. There was insufficient evidence to conclude any association between PDS and use of postpartum birth control. Conclusions: These findings highlight adverse effects of PDS on maternal health practices not previously studied. Results stress the importance of healthcare professionals monitoring the moods and actions of women of childbearing age to provide early interventions for women experiencing PDS, and of emphasizing positive maternal health practices after childbirth. [ABSTRACT FROM AUTHOR]

Objective: This study assessed whether having continuous support during labor is associated with better person-centered maternity care (PCMC) among women in rural Kenya. Methods: Data are from a cross-sectional survey with women aged 15–49 years who delivered in the 9 weeks preceding survey completion (N = 865). PCMC was operationalized using a validated 13-item scale, with a summative score developed from responses that capture dignity and respect, communication and autonomy, and supportive care from providers (excluding support from a lay companion). Continuous support was operationalized as the continuous presence of a lay companion (friend or family) during labor. We carried out bivariate analyses using chi-squared and t-tests and ran multivariable linear regression models to examine the association between continuous labor support and PCMC. Results: The average PCMC score was 24.2 (SD = 8.4) out of a total score of 39. About two-thirds (68%) of women had continuous support during labor. The average PCMC scores among women who had continuous support was 25.7 (SD = 8.4) compared to 21.0 (SD = 7.6) among those who did not have continuous support (p-value ≤ 0.001). After controlling for various confounders this association was still significant (coefficient = 4.0; 95% CI 2.9, 5.2; p-value ≤ 0.001). Conclusions: Women who have continuous labor support during childbirth are more likely to have improved PCMC. Efforts to promote PCMC should thus include continuous labor support. [ABSTRACT FROM AUTHOR]

Introduction: The birth of a second child to an adolescent woman worsens the adverse medical, socioeconomic, educational, and parenting outcomes for the woman and her children. Despite the known high efficacy of long-acting reversible contraception (LARC), many postpartum adolescents use less effective or no contraception. Interconception care (ICC) focuses on modifying maternal risks between pregnancies and promoting healthy birth spacing to improve outcomes for women and children. Research shows that women regularly attend their child's health care visits even if they do not seek care for themselves between pregnancies. These visits present a potential opportunity for providers to educate women on available LARC options. Methods: In an adolescent mother–child clinic, demographic and ICC screening data were collected on women presenting for well child visits of children age 0–24 months. These data were analyzed using logistic regression models to identify independent predictors of LARC initiation and repeat pregnancy. Results: Mother–child dyads were screened an average of two times in the study period. Participants with only one visit were less likely to initiate LARC. Of the participants, 5.5% became pregnant again, with patients having only one ICC visit being slightly, but not significantly more likely. Hispanic ethnicity and having ≥ 2 visits were significant independent predictors of LARC initiation. The only independent predictor of repeat pregnancy was not initiating LARC. Conclusions: This study suggests that optimal ICC may rely on consistent and frequent touch points with providers and not solely on the medical management during the interconception period, making it adaptable to a traditional pediatric medical home. Tying the worlds of pediatric and maternal healthcare is pivotal for successful ICC. [ABSTRACT FROM AUTHOR]

Objectives: With a fourth of all under-five children affected, stunting remains one of the biggest health challenges worldwide. Even though the main underlying factors are known, the exact pathways to stunting varying in affected regions, and interventions thus need to be tailored to the local contexts. This study aimed assessing and comparing factors associated with stunting in two understudied sub-Saharan urban contexts with some of the highest stunting prevalence globally: Bangui, Central African Republic (~ 36%) and Antananarivo, Madagascar (42%). Methods: We performed a case–control study on 175 + 194 stunted and 237 + 230 non-stunted control children aged 2–5 years and matched for age, gender and district of residency. Factors associated with stunting were identified using a standardized, paper questionnaire delivered by trained interviewers. Statistical analysis was done using logistic regression modelling. Results: In both sites, formal maternal education lowered the risk of being stunted and restricted access to soap, suffering of anaemia and low birth weight were associated with higher risk of stunting. Short maternal stature, household head different from parents, diarrhoea and coughing were associated with an increased risk and continuing breastfeeding was associated with a lower risk of stunting in Antananarivo. Previous severe undernutrition and dermatitis/ fungal skin infections were associated with higher and changes in diet during pregnancy with lower risk of stunting in Bangui. Conclusions: Our results suggest maternal education, antenatal care, iron supplementation and simple WASH interventions such as using soap and infection control as general and breastfeeding (Antananarivo) or better nutrition (Bangui) as area-specified interventions. [ABSTRACT FROM AUTHOR]

Objectives: The cesarean delivery (CD) rate is increasing worldwide. An internationally recognized classification system had been required to analyse the trend and its possible consequences in a standardized manner. The goal of this study was to identify the main contributors to the CD rate at the Medical University of Vienna in an 11-year time period (2003–2013) and to analyse neonatal outcome parameters within the ten Robson categories. Methods: This is a retrospective data-analysis of singleton and twin pregnancies in cephalic, breech and transverse presentation with a gestational age between 23 and 42 weeks. The cases were divided into ten classes based on the Robson criteria. CD rates and perinatal outcome parameters were analysed within each Robson class. The outcome parameters included: NICU-admission rate and 5 min Apgar score values < 7. Results: The overall CD rate was at 44.2%. Within Robson class 5 the CD rate was the highest at 99.1%. Main contributors were Robson class 5 at 20.6%, followed by class 2 at 17.1% and class 8 at 15.0%. Neonatal outcome analyses revealed significant differences between the Robson classes. Conclusions: The main contributors to the CD rate were determined. We suggest reconsidering the frequently applied birth mode especially for Robson class 2, 4, 5 and 8. Lowering the CD rate could be achievable, if a careful delivery management and an individual risk evaluation is provided. It is important to reduce the CD rate in the individual Robson classes under consideration of perinatal outcome parameters, since a reduction should only take place where it is clinically useful and relevant. [ABSTRACT FROM AUTHOR]

Objectives: To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care. Methods: We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18–45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics. Results: Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women's health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively). Conclusions for Practice: Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care. [ABSTRACT FROM AUTHOR]

Introduction: Known as the "pinnacle of patient-centered care," shared decision-making (SDM) is the process that enables and encourages the health care provider, the patient, and/or their caregiver (parent or guardian) to participate collaboratively in medical decisions. Prior research indicates that children with emotional, developmental, or behavioral health conditions (EDB) are less likely to attain SDM than children with other special health care needs (SHCNs). This study investigates whether the presence of a medical home reduces disparities in SDM among children with EDB when compared to children with other SHCNs and the general pediatric population. Methods: Using the 2016 National Survey of Children's Health, we conducted weighted descriptive statistics to investigate the prevalence of medical home and SDM for children with (1) EDB, (2) other SHCNs, and (3) no SHCNs. We then employed a nested multivariate logistic regression model to examine whether the presence of a medical home reduced the disparity between children with EDB and their counterparts. Results: Nationally, 21% of children with EDB (n = 647,274), 14.0% of children with other SHCNs (n = 1,086,068), and 13% of children with no SHCNs (n = 883,969) did not attain caregiver-reported SDM in medical care. In each of the health condition groups, the presence of a medical home significantly improved the odds of SDM (p < 0.001). Presence of a medical home also reduced the disparities observed in caregiver-reported SDM among children with EDB as compared to those with other SHCNs and no SHCNs. Discussion: Ongoing investment in medical homes may reduce disparities in SDM experienced by children with EDB. [ABSTRACT FROM AUTHOR]

Objective: To assess and compare the associations between household socioeconomic (SES) factors with birth outcomes (low birth weight (LBW), small-for-gestational age (SGA) and preterm birth (PTB)) in the Democratic Republic of Congo (DRC) and South Africa (SA). Methods: Cross-sectional data of mother-newborn pairs collected in 2017 in the DRC were compared with mother-newborn pairs data from the SA Soweto first 1000-days pregnancy cohort study (2013–2016). Country-specific and pooled multivariable logistic regressions analyses assessed the associations between maternal education, marital status, and housing with LBW, SGA, and PTB adjusted for maternal anthropometry and obstetric factors. Results: 1084 mother-newborn pairs were recruited (DRC: 256; SA: 828). The rates of LBW, PTB and SGA were, 11.5%, 17.1% and 32.8% in the DRC and 15.9%, 10.5% and 20.1% in SA. SES factors differed between countries and sex. In the DRC, being married decreased the odds of having LBW and PTB children by 86% and 80%, respectively. In SA, being a mother with secondary level of education and above was associated with 86% reduced odds of SGA. In the pooled analyses, women with secondary level of education and above had a 2.2-fold increase in odds of giving birth to a PTB newborn. Country of residence and maternal nutritional status were stronger predictors of birth outcomes than SES factors. Conclusion for Practice: In sub-Saharan Africa, policies aiming to alleviate women's education combined with improved social support and household SES prior to and during pregnancy are critical to optimal neonatal outcomes and strategic to achieve the Sustainable Development Goals. [ABSTRACT FROM AUTHOR]

Introduction: Maternal depression, which includes depression in the prenatal and postpartum periods, is estimated to affect between 10 and 20% of women globally but the rate is higher in the Middle East. Research focused on maternal depression in Iraq is limited to one study focused on postpartum depression. This paper identifies the prevalence and factors associated with antenatal depression among pregnant Iraqi women. Methods: Women seeking maternal health services at primary health centers were invited to participate. Data were collected by trained midwifery students in Erbil, Iraq. Responses to the PHQ-2 PRIME-MD depression questions were used to identify depressive symptoms. Chi-square and logistic regression analyses were used to analyze findings. Results: Of the 179 participants, 86 (48%) reported depressive symptoms. In bivariate analysis, antenatal depression was associated with gestational age (p = 0.03), first prenatal visit in the second trimester (p = 0.003), loss of appetite (p = 0.003), not having help at home (p = 0.03), and use of prenatal vitamins (p = 0.002). Gravida approached significance (p = 0.07). In adjusted analysis, women reporting loss of appetite were more likely to report depressive symptoms (OR = 3.09, 95% CI: 1.47–6.51). Discussion: Consistent with other research from the region, nearly half the women reported depressive symptoms. Because lack of appetite is associated with depressive symptoms, women reporting loss of appetite should be prioritized for depression screening in time-constrained settings. [ABSTRACT FROM AUTHOR]

Introduction: Most screening tools identifying women with substance use are not validated, used once in pregnancy, and are not reflective of continued substance use. We hypothesized that serial early prenatal substance screening leads to decreased substance use by the end of pregnancy and improved outcomes. Methods: This is a retrospective cohort study of mothers and their infants between 1/2015 and 12/2017. A self-reported substance screening tool was administered on the first prenatal visit and subsequent visits until delivery. For analysis, mothers were divided into three groups based on the trimester of their first screen and adjusted for demographics and risk factors. Results: Early first trimester screening resulted in 52% of mothers having ≥ 3 screens throughout pregnancy vs. 6% of mothers with late third trimester screens (p < 0.001). Compared to third trimester screening, there was a five-fold decrease of any substance use at second trimester, a seven-fold decrease at first trimester, and a nine-fold decrease for marijuana at first trimester. Compared to third trimester screening, there was a significant five-fold increase of negative maternal urine drug screen, 3 ½ -fold increase in well newborn diagnosis, and a five-fold increase of no infant morphine treatment at first trimester. Discussion: We identified improved maternal and infant outcomes with serial early prenatal substance use screening. Early maternal substance use identification is crucial for immediate referral for prevention and treatment, and for social and community services. Further research is needed on universal serial early prenatal screenings. [ABSTRACT FROM AUTHOR]

Introduction: From the ecological perspective of multifactorial causal mechanism, the communicative interaction environment has been less studied in early childhood which is the most sensitive phase for language development. We aimed to research simultaneous communicative environmental factors including maternal depression and media usage patterns in young children aged 1–31/2 years. Methods: One hundred and one participants were included in the study; fifty-one children with language delay as the case group and fifty children with typical development as the control group. Maternal depressive symptoms were evaluated by Beck Depression Inventory. The general development of each child was evaluated by Denver II Screening Test and Bayley-Third Edition. Language development was evaluated by the Preschool Language Scale-5. The questionnaire for the sociodemographic data and media usage patterns was prepared by the study team. Results: Maternal depression scores, duration of TV viewing, background TV were higher in the children with language delay and they started earlier using screen devices in comparison with the control group (p < 0.05). The total amount of interaction time and co-viewing were less in children with language delay and more parents intended to keep their children occupied by watching in the case group (p < 0.05). Mother care-giving (p = 0.002, OR = 5.80, CI 1.93–17.4) and absence of co-viewing (p = 0.000, OR = 9.46, CI 2.69–33.3) were the significant factors associated with language delay. Discussion: Young children with language delay were more exposed to communicative environmental risk factors than children with typical development. The integration of this perspective to child health care practices should be encouraged in early childhood. [ABSTRACT FROM AUTHOR]

Introduction: The rapid and unexpected increase in the sex ratio at birth in Nigeria between 1996 and 2014 is yet to be fully explained. The contribution of sex-selective abortion has not been explored. Methods: A cross-sectional survey of pregnant women was employed to address this need. Results: Preference for sex-selective abortion was noted in 8.6% of the respondents. The association between parity ≥ 4 and preference for sex-selective abortion was statistically significant. Women who were child gender-biased were significantly more likely to prefer sex-selective abortion. Experiencing intimate partner violence, and having problems with in-laws for inability to give birth to their desired gender, were predictors of maternal preference for sex-selective abortion. Women who preferred sex-selective abortion, however, felt it was necessary to campaign against gender preference. Conclusion: Preference for sex-selective abortion exists in Nigeria, despite our restrictive abortion laws. However, the women's underlying reasons may include gender balancing in the family and an escape from discrimination. Improving contraceptive uptake, restriction of disclosure of fetal sex for non-medical indications, and sanctions against violent partners/oppressive in-laws are advocated. Rapid progress towards achieving a world free of the offensive gender inequalities that force women to opt for sex-selective abortion ab initio is desirable. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the association between mother–child bonding at 6–9 months after birth and suicidal ideation Methods: A cross-sectional study embedded in a clinical trial with 358 low-income postpartum women who had antenatal depression in São Paulo, Brazil. The Postpartum Bonding Questionnaire and the Patient Health Questionnaire-9 were used Results: The percentage of the main outcome, suicidal ideation (SI) was 10.3%. Using logistic regression models, bonding impairment (BI) was associated with SI even after controlling for postpartum depression and other covariates. Conclusions for Practice: SI affects 10% of vulnerable postpartum women. BI is independently associated with SI. Treating BI may prevent SI [ABSTRACT FROM AUTHOR]

Objectives: This study examined maternal pregnancy wantedness and perceptions of paternal wantedness, and their associations with maternal perinatal mental health symptoms and relationship dynamics. Methods: Low-income, ethnically-diverse pregnant women (N = 101, Mage = 29.10 years, SDage = 6.56, rangeage = 18–44; 37% Latina, 22% African-American, 20% White, 21% biracial/multiracial/other) completed semi-structured interviews of pregnancy wantedness coded by trained raters, and standardized instruments of depression and PTSD symptoms during pregnancy and at 3–4-months postpartum. Results: While maternal pregnancy wantedness (rated from 0-Predominately Ambivalent, 1-Mixed, and 2-Predominately Positive) showed no significant associations, a couple-level scale that combined maternal wantedness and her perceptions of paternal wantedness (Equally Positive Wantedness, Mom Wants More, Dad Wants More and Equally Ambivalent) showed several significant associations. Compared to women in the Equally Positive group, women in the Mom Wants More group had significantly higher prenatal and postnatal depression symptoms, prenatal PTSD symptoms, and prenatal and postnatal relationship conflict; and lower prenatal and postnatal relationship support. Women in the Mom Wants More group also had significantly higher prenatal and postnatal depression symptoms and prenatal conflict; and lower prenatal support than women in the Dad Wants More group. Conclusions for Practice: Women who perceive themselves as wanting the pregnancy more than their baby's father are at higher risk for mental health and relationship problems than women who perceive themselves and their partners as equally ambivalent. Providers should ask women about their perceptions of partners' pregnancy wantedness to inform delivery of targeted mental health and relationship-based intervention during pregnancy. [ABSTRACT FROM AUTHOR]

Background: Despite the well-known role of parents as caregivers, few studies have addressed their health outcomes related to the Zika virus epidemic. Methods: A cross-sectional study was carried out with 146 primary caregivers of children 15–26 months of age, with laboratory and/or clinical evidence of Zika infection between August and October 2017 in three Brazilian municipalities: João Pessoa and Campina Grande in the state of Paraíba and Fortaleza in the state of Ceará. Caregivers reported on their child's life and health, family circumstances and underwent screening for stress using the Parenting Stress Index-Short Form. Children were evaluated for developmental delays and clinical outcomes. Differences in the prevalence of risk factors between caregivers with high or clinically relevant stress and those with normal stress were evaluated. Results: Of the 146 participants, 13% (n = 19) were classified as having high or clinically relevant stress, all of them mothers. The two risk factors significantly and independently associated with high levels of stress, compared with individuals with normal stress levels, were "reporting difficulty in covering basic expenses" (adjusted OR 3.6 (95% CI 1.1–11.8; p = 0.034)) and "having a child with sleep problems" (adjusted OR 10.4 (95% CI 1.3–81.7; p = 0.026)). Conclusions: Some factors seem to contribute significantly more than others to the level of stress experienced by caregivers of children with evidence of Zika virus congenital infection. Interventions and preventive strategies should also target caregivers, who in turn will be able to respond to the unique characteristics of their child. [ABSTRACT FROM AUTHOR]

Purpose: Smoking during pregnancy may be linked to other problematic prenatal health behaviors in women. We examined interrelationships among prenatal smoking, prenatal health behaviors and mental health. The objective of this study was to examine factors that may contribute to variations in prenatal health practices among women who smoke during pregnancy. Methods: Birth mothers from an adoption study (N = 912) were interviewed about prenatal smoking, health behaviors, and mental health symptoms at 5 months postpartum. Results: One-quarter of participants (N = 222) reported smoking 6 or more cigarettes daily for at least 1 trimester. For mothers who smoked more than 6 cigarettes daily, higher levels of antisocial behaviors (β = −.14, p =.03) and depressive symptoms (β = −.17, p =.03) were associated with less frequent prenatal folate use; antisocial behaviors and depressive symptoms were not associated for prenatal folate use among women who did not smoke more than 6 cigarettes daily. For mothers who did not smoke more than 6 cigarettes daily, more depressive symptoms were associated with fewer prenatal care visits (β =.12, p =.01). Antisocial behaviors and anxiety symptoms were not associated with prenatal care visits in either group of mothers. Conclusions for Practice: Maternal antisocial behaviors and depressive symptoms during pregnancy may be markers for poorer adherence to recommendations for folate supplementation among women who smoke 6 or more cigarettes daily during pregnancy, independent of adequacy of prenatal care. [ABSTRACT FROM AUTHOR]

Objective: To identify maternal characteristics associated with 24-month postpartum weight retention. Methods: Data were collected from the 2016 Los Angeles Mommy and Baby (LAMB) Follow-Up Survey, a population-based prospective cohort study that assesses maternal and infant health in Los Angeles County. In 2014, LAMB initially surveyed 6035 women 6 months following a live birth. The 2016 LAMB Follow-Up reevaluated this same cohort after the index child's second birthday. 2679 women completed 2016 LAMB Follow-Up (52% adjusted response rate). The final sample size was 1524 after excluding subjects with subsequent pregnancies after the index child and missing information for postpartum weight. Eight predictors were included in this analysis: gestational weight gain, pre-pregnancy BMI, exercise, depressed mood since having child, age, race, education, and job loss during pregnancy. Chi-square tests and logistic regression analyses were performed using SAS 9.3. Results: Two years after delivery, women with postpartum weight retention weighed on average of 15.3 lb. more than before the index pregnancy. Women were more likely to retain postpartum weight when they exceeded gestational weight gain guidelines (AOR = 2.03, 95% CI = 1.40–2.93), did not exercise (AOR = 3.32, CI = 1.85–5.98), were between ages 20–29 (AOR = 1.54, CI = 1.01–2.36), were Hispanic (AOR = 1.51, CI = 1.02–2.24), completed high school only (AOR = 1.77, CI = 1.15–2.73), or lost a job during pregnancy (AOR = 2.62, CI = 1.39–4.93). Conclusions: Modifiable risk factors and sociodemographic characteristics can impact maternal weight retention 24 months after pregnancy. Understanding postpartum weight retention is essential for guiding future public health research, programming, and policy. Tailoring appropriate public health interventions may help women sustain healthy weight during their reproductive years and beyond. [ABSTRACT FROM AUTHOR]

Objective: To analyze municipal- and individual-level factors related to the prevalence of teenage pregnancy in Colombia during 2015. Methods: We analyzed 660,767 births registers, of which 21.5% recorded adolescent women. At an individual level, marital status, educational level, area of residence, and access to health services were included in the analysis. At the contextual level, Colombian municipal socioeconomic characteristics and proxies of violence and poverty were analyzed. A multilevel logistic regression model was generated with a Markov Chain Monte Carlo estimation method using 100,000 simulations in MLwiN 2.32 software. Results: Multilevel modeling revealed an increased risk of teenage pregnancy in municipalities with the highest numbers of people expelled by forced displacement (OR 1.21; CI 95%, 1.13–1.29) and with unsatisfied basic needs (OR 1.09; CI 95%, 1.02–1.17). At an individual level, the majority of the teenage women were unmarried and/or had an unstable partnership, a low level of educational, a subsidized health regimen, and resided in the municipal seat. Conclusions: Municipal contextual variables related to poverty, violence, and social inequity contribute to an increase in teenage pregnancy in Colombia. At the individual level, marital status, educational level, and area of residence is associated with teenage pregnancy. It is therefore imperative to include municipal contextual characteristics in the design of the national political agenda. [ABSTRACT FROM AUTHOR]

Objectives: Despite health risks for themselves and their children, urban underserved women smoke at high rates postpartum. The postpartum period is a stressful transition time that presents unique barriers to sustained cessation. There is limited extant evidence of efficacious psychosocial programs to maintain postpartum smoking cessation. Methods: Guided by the Cognitive-Social Health Information Processing model, we explored the feasibility of TxT2Commit, a text-messaging intervention designed to prevent postpartum smoking relapse. Participants (n = 43) received supportive cessation-focused text messages for one month postpartum. Using a convergent mixed method design, surveys and interviews assessed changes in psychosocial factors and smoking status through a three month follow-up. Results: Participants reported satisfaction with TxT2Commit, rating text messages as helpful, understandable, supportive, and not bothersome. However, a majority of women (n = 28, 65.1%) relapsed by three months. Participants who stayed smoke free (i.e., non-relapsers) reported significantly less temptation to smoke at one and three months postpartum compared to relapsers (ps <.01). While relapsers had significantly less temptation at one month compared to baseline, temptation increased by three months (p <.01). Consistent with the quantitative results, qualitative interviews identified informational and coping needs, with continued temptation throughout the three months. Non-relapsers were able to manage temptation and reported greater support. Conclusions for Practice: TxT2Commit demonstrates preliminary feasibility and acceptability among urban, underserved postpartum women. However, most participants relapsed by three months postpartum. Additional research is needed to identify targeted messaging to best help women avoid temptation and bolster support to stay smoke free in this uniquely stressful period. [ABSTRACT FROM AUTHOR]

Objectives: To describe the prevalence of overweight and obesity among children under 5 years old, assess the indicators of breastfeeding practices, and explore the associations between breastfeeding practices and early childhood overweight/obesity. Methods: The survey was conducted in 20 counties in central and western China in 2016. All children under 5 years old were physically measured for anthropometric data and their breastfeeding practices were obtained through a face-to-face questionnaire interview. We performed logistic regressions to assess the associations of different breastfeeding practices with overweight/obesity. Results: The prevalence of overweight and obesity among children under 5 years old were 8.7% and 2.6%, respectively. Overall, 93.6% of children were breastfed, while only 20.7% had exclusive breastfeeding under 6 months of age and about half of the children under 5 years old were weaned at 12 months. Compared with children with a duration of breastfeeding ≥ 12 months, children who have been breastfed for < 6 months were significantly associated with a 97% increased risk of overweight/obesity (OR 1.97, 95% CI 1.34–2.88, P = 0.001). Conclusions for Practice: The present study showed that overweight and obesity among children under 5 years old in central and western China remained an important childhood health concern. The rates of most indicators of breastfeeding practices were low, which needed more public attention. Moreover, we found that a shorter duration of breastfeeding was associated with an increased risk of overweight/obesity among children in central and western China. [ABSTRACT FROM AUTHOR]

Introduction: Unplanned pregnancies lead to adverse health outcomes and contribute to economic burdens. A lack of continuity and consistency in immediate postpartum care may be a contributor. The most frequent postpartum medical encounters occur with the child's pediatric health care provider, which represents an opportunity to discuss postpartum contraception. Therefore, our objective was to evaluate postpartum family planning knowledge and behavior in women, and to assess the potential acceptability of a pediatrician-delivered intervention to improve knowledge of and convenient access to contraception among postpartum women. Methods: This was a non-interventional pilot study that employed survey and interview methodology. Results: Women attending pediatric visits for their newborn or infant (N = 346) were surveyed; 35 were interviewed. On average, respondents were 27 years old (SD = 6), 6 months postpartum (SD = 5), and resumed sex 8 weeks after delivery (SD = 6). Of those who had resumed sex, 68% were not using contraception at the time. However, only 18% of survey respondents wanted to have another child. Few exhibited accurate knowledge of birth spacing or long acting reversible contraception. Most interviewees (86%) supported the idea of pediatricians providing contraceptive counseling. Concerns identified included whether it was "allowable" and pediatrician's lack of knowledge of complex maternal health histories. Discussion: This study highlights a gap between contraceptive need and provision in postpartum women. However, the findings suggest women's willingness to engage in conversations with their child's pediatrician about family planning. Future research should assess the feasibility and impact of integrating postpartum counseling into pediatric visits. [ABSTRACT FROM AUTHOR]

Objective: As noninvasive biological markers gain increasing popularity in pediatric research, it is critical to understand how study participants perceive these measures, especially among groups underrepresented in biobehavioral research, like children and people of color. The purpose of this study was to examine acceptability and feasibility of hair and salivary biomarker collection in an urban community sample of ethnically diverse children (age 4 to 10 years). Methods: Ninety-seven mother–child dyads were recruited for a cross-sectional follow up study of the Minding the Baby® home visiting intervention. Children were Hispanic (63%), Black (34%), and multi-racial (3.1%). A conventional content analysis was conducted using two sources of data: (1) mothers' responses to open-ended interview questions on their views and suggestions regarding biomarker collection, and (2) field notes recorded by investigators. Results: Forty-four percent of mothers reported biomarker-related questions or concerns, including questions about the purpose of biomarker testing, and concerns about cosmetic issues, child discomfort, and future use of biomarker data. Mothers also offered positive feedback and advice for collection. Issues affecting feasibility included children's hair length and style, refusal to participate, and behavioral or developmental issues. Conclusions: Hair and salivary biomarker collection was largely acceptable and feasible in this sample. Strategies for promoting ethical and sensitive biomarker collection include respectful explanations and parental involvement, creating a comfortable and safe environment for the child, flexible collection strategies, and attention to development, cultural preferences and perspectives. [ABSTRACT FROM AUTHOR]