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Introduction: Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated with worse perinatal outcomes. Reasons for discharges AMA are not well understood. The objective of this study is to identify the obstacles that prevent obstetric patients from accepting recommended care and highlight the structural reasons behind AMA discharges. Methods: Electronic health records of patients admitted to antepartum, peripartum, or postpartum services between 2008 and 2018 who left "AMA" were reviewed. Progress notes from clinicians and social workers were extracted and analyzed. Reasons behind discharge were categorized using qualitative thematic analysis. Results: Fifty-seven (0.12%) obstetric patients were discharged AMA. Reasons for discharge were organized into two overarching themes: extrinsic (50.9%) and intrinsic (40.4%) obstacles to accepting care. Eleven participants (19.3%) had no reason documented for their discharge. Extrinsic obstacles included childcare, familial responsibilities, and other obligations. Intrinsic obstacles included disagreement with provider regarding medical condition or plan, emotional distress, mistrust or discontent with care team, and substance use. Discussion: The term "AMA" casts blame on individual patients and fails to represent the systemic barriers to staying in care. Obstetric patients were found to encounter both extrinsic and intrinsic obstacles that led them to leave AMA. Healthcare providers and institutions can implement strategies that ameliorate structural barriers. Partnering with patients to prevent discharges AMA would improve maternal and infant health and progress towards reproductive justice. Significance: What is Already Known on this Subject?: Obstetric patients who leave "against medical advice (AMA)" have worse perinatal outcomes and often are from marginalized communities. The term, AMA, is also stigmatizing, placing blame on individual decision making rather than systemic barriers to access. Reasons for leaving AMA are not well understood in the obstetric population. What does this Study add?: We reframe the discussion around leaving AMA by describing obstacles in accepting care. Patients experienced both extrinsic and intrinsic obstacles to accepting medical care, from childcare issues to disagreement with treatment plan. Partnering with patients to overcome these obstacles would improve maternal and infant health and increase equity and reproductive justice. [ABSTRACT FROM AUTHOR]

Background: Prenatal depression is associated with adverse health outcomes for both mothers and their children. The worldwide COVID-19 pandemic has presented new risks and challenges for expectant mothers. The aims of the study were to investigate the underlying mechanism between COVID-19 risk perception of Chinese pregnant women and their prenatal depressive symptoms and potential protective factors such as family sense of coherence (FSOC). Method: A total of 181 Chinese pregnant women (Mage = 31.40 years, SD = 3.67, ranged from 23 to 43) participated in an online survey from April 22 to May 16, 2020. Risk perception and negative emotions (fear and anxiety) related with COVID-19, FSOC, and prenatal depressive symptoms were assessed. Results: The experience of maternal COVID-19 related negative emotion fully mediated the positive relationship between COVID-19 risk perception and prenatal depressive symptoms of pregnant women (β = 0.12, 95% CI [0.06, 0.19]). When confronting COVID-19 related fear and anxiety, expectant mothers from higher coherent families experienced a significantly lower level of prenatal depressive symptoms. Conclusions: Contextual negative emotional experience was demonstrated to explain how risk perception impacts depressive symptoms during severe public health crisis for pregnant women. FSOC may be a psychological resource protecting pregnant women from experiencing adverse psychological outcomes during COVID-19 pandemic. Significance: What is already known on this subject?: Robust evidence showed that maternal perinatal mental health was largely harmed during the early stage of COVID-19 pandemic in China. COVID-19 risk perception was one of the significant risk factors for psychological distress. What this study adds?: COVID-19 related negative emotions might serve as a possible mechanism linking risk perception and mental health in the context of COVID-19 pandemic. And the FSOC might serve as a protective factor that buffers the expectant mothers from antenatal depression. These findings clarified mental health vulnerabilities and potential opportunities of intervention for pregnant women during public health crises. [ABSTRACT FROM AUTHOR]

Introduction: This is a systematic review on patient-provider satisfaction in U.S. prenatal care by addressing the following research question: What factors influence patient-provider satisfaction during prenatal care? Methods: Thirty six online databases were searched for peer-reviewed research from February to September of 2018 using 10 key terms published in English on U.S. populations between the years 1993–2018 on the topic of provider communication skills and patient satisfaction in the prenatal context. Searches yielded 2563 articles. After duplicates were reviewed and eligibility determined, 32 articles met criteria and were included in the final content analysis. All reported study variables were entered into EXCEL, data reported in each study were analyzed by two people for inter-rater reliability and included in the qualitative content analysis. Two researchers also utilized assessment tools to assess the quality of the articles. Results: Results indicate the importance of good patient-provider communication, that patients have a need for more information on a plethora of topics, and that Hispanic and African American women reported less satisfaction. Discussion: We recommend that future studies measure potentially significant themes not adequately present in the reviewed studies such as practitioner demographics (e.g. gender, years of experience, or race/ethnicity), mothers under 18 years of age, inclusion of religious minorities, patients with differing immigration statuses, and patients with disabilities. Significance: Patient-centered care has gained attention among healthcare providers, yet to date there are no comprehensive systematic reviews that focus specifically on the components of prenatal care patient satisfaction. Systematic reviews are a growing essential resource in healthcare. We find that prenatal care patients are overall satisfied yet have a need for more information on a plethora of topics, and that Hispanic and African American patients reported less satisfaction with provider communication. [ABSTRACT FROM AUTHOR]

Objectives: Antenatal education (ANE) is part of National Health Service (NHS) care and is recommended by The National Institute for Health and Care Excellence (NICE) to increase birth preparedness and help pregnant women/birthing people develop coping strategies for labour and birth. We aimed to understand antenatal educator views about how current ANE supports preparedness for childbirth, including coping strategy development with the aim of identifying targets for improvement. Methods: A United Kingdom wide, cross-sectional online survey was conducted between October 2019 and May 2020. Antenatal educators including NHS midwives and private providers were purposively sampled. Counts and percentages were calculated for closed responses and thematic analysis used for open text responses. Results: Ninety-nine participants responded, 62% of these did not believe that ANE prepared women for labour and birth. They identified practical barriers to accessing ANE, particularly for marginalised groups, including financial and language barriers. Educators believe class content is medically focused, and teaching is of variable quality with some midwives being ill-prepared to deliver antenatal education. 55% of antenatal educators believe the opportunity to develop coping strategies varies between location and educators and only those women who can pay for non-NHS classes are able to access all the coping strategies that can support them with labour and birth. Conclusions for Practice: Antenatal educators believe current NHS ANE does not adequately prepare women for labour and birth, leading to disparities in birth preparedness for those who cannot access non-NHS classes. To reduce this healthcare inequality, NHS classes need to be standardised, with training for midwives in delivering ANE enhanced. Significance: What is Already Known on this Subject?: There is no detailed national guidance about the content or quantity of antenatal education that should be delivered by the NHS to patients and, how coping strategies are developed within these sessions is unknown. What this Study Adds?: Antenatal educators believe that quality of antenatal education needs to be improved. Access to coping strategies for labour and birth is hindered by the type of class, the educator's approach and socioeconomic status. This study can be used to support an argument for addressing the inequality in access to antenatal preparation, whilst better preparing all women through higher quality of antenatal education provision in the NHS. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate disparities in urine drug testing (UDT) during perinatal care at a single academic medical center. This retrospective cohort study included patients who had a live birth and received prenatal care at our institution between 10/1/2015 and 9/30/2020. The primary outcomes were maternal UDT during pregnancy (UDTPN) and UDT only at delivery (UDTDEL). Secondary outcomes included the number of UDTs (UDTNUM) and the association between a positive UDT test result and race/ethnicity. Mixed model logistic regression and negative binomial regression with clustering based on prenatal care locations were used to control for confounders. Of 6,240 live births, 2,265 (36.3%) and 167 (2.7%) received UDTPN and UDTDEL, respectively. Black (OR 2.09, 95% CI 1.54–2.84) and individuals of Other races (OR 1.64, 95% CI 1.03–2.64) had greater odds of UDTPN compared to non-Hispanic White individuals. Black (beta = 1.12, p < 0.001) and Hispanic individuals (beta = 0.78, p < 0.001) also had a positive relationship with UDTNUM. Compared to individuals with non-Medicaid insurance, those insured by Medicaid had greater odds of UDTPN (OR 1.66, 95% CI 1.11–2.49) and had a positive relationship with UDTNUM (beta = 0.89, p < 0.001). No significant associations were found for UDTDEL and race/ethnicity. Despite receiving more UDT, Black individuals were not more likely to have a positive test result compared to non-Hispanic White individuals (OR 0.95, 95% CI 0.72–1.25). Our findings demonstrate persistent disparities in substance use testing during the perinatal period. Significance: What is already known on this subject?: Prior literature has shown evidence of racial disparities in urine drug testing during pregnancy-related hospital admissions and at delivery. What this study adds?: This paper found that disparities in urine drug testing also exist during the prenatal care period at an urban academic institution. We also found a positive relationship between the number of tests received and being of Black or Hispanic race/ethnicity. Future research should investigate health care system-related interventions to mitigate disparities in urine drug testing. [ABSTRACT FROM AUTHOR]

Objective: Both psychosocial stress and gestational weight gain are independently associated with adverse maternal and fetal outcomes. Studies of the association between psychosocial stress and gestational weight gain (GWG) have yielded mixed results. The objective of this study was to evaluate the association between psychosocial stress and GWG in a large population-based cohort. Methods: Data from the nationally representative Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 7 questionnaire 2012–2015 was utilized. Maternal psychosocial stress was assessed through response to questions designed to examine four domains of psychosocial stress (i.e., traumatic, financial, emotional, partner-related) three months prior to or during pregnancy. GWG was categorized using pre-pregnancy BMI and total GWG into inadequate, adequate, or excessive according to the Institute of Medicine's GWG guidelines. Multinomial logistic regression was used to evaluate the association between psychosocial stressors and adequacy of GWG. Analyses took into account complex survey design. Results: All respondents who delivered ≥ 37 weeks gestation with GWG information available were included in the analysis (n = 119,183). After adjusting for confounders, patients who reported financial stress were more likely to experience excessive versus adequate GWG (RRR 1.09 [95%CI: 1.02–1.17]). Exposure to any of the stressor groups did not significantly increase the risk of inadequate GWG. Conclusions: This large, population-based study revealed that among pregnant people in the US, exposure to financial stress is associated with higher risk of excessive GWG. Understanding the role stress plays in GWG will help to inform initiatives targeting this important aspect of prenatal care. Significance: What is already known on this subject?: Excessive gestational weight gain (GWG) has been linked to postpartum weight retention and long-term adverse maternal and child health outcomes. Multiple studies have shown an association between psychosocial stress and adverse fetal outcomes. Risks of inadequate weight gain include low birthweight and failure to initiate breast-feeding whereas the risks of excessive weight gain include cesarean deliveries and postpartum weight retention for the mother and large-for-gestational-age infants, macrosomia, and childhood overweight or obesity for the offspring. What this study adds?: The 2012–2015 Pregnancy Risk Assessment Monitoring System (PRAMS) provides unique nationally representative data in which birth outcomes and maternal weight are linked to psychosocial stressors. Our study is the largest of its kind examining the link between stress and GWG and reveals that exposure to financial stress is associated with higher risk of excessive GWG in the US. [ABSTRACT FROM AUTHOR]

Purpose: Oral health (OH) has significant effects on pregnancy and infant outcomes. This study assesses the perspectives of obstetrical clinicians about OH education and promotion. Methods: A fifteen-item survey was developed and circulated to obstetrics and gynecology (OBGYN) and family medicine (FM) physicians, and other prenatal health clinicians in Massachusetts (MA). Additionally, eight physicians were purposively sampled for in-depth interviews to discuss their experience with prenatal OH training and practice. Bivariate relationships between outcome variables from the survey (e.g., previous OH training, awareness of OH guidelines, asking about OH during prenatal visits) were analyzed along with coding and analysis of the qualitative interview data. Results: The majority (77%) of the 86 survey respondents did not feel well-trained in OH. We found significant associations between being well-trained in OH and: (1) awareness of state guidelines (X2 = 11.85, p < 0.001); (2) asking about OH during prenatal visits (X2 = 9.21, p = 0.002); and (3) routinely referring patients for dental care (X2 = 15.35, p < 0.001). Lack of access to dental insurance and dental professionals were found to be major perceived barriers to care. Responses from the interviews reinforced these findings. Significance: Poor oral health is associated with adverse outcomes in pregnancy. This study provided a better understanding of how many prenatal clincians in a state like Massachusetts are trained in oral health. This study has also helped to determine what the associations are between adequate oral health training and various clinical outcomes, as well as what the anticipated major barriers are for prenatal patients with regards to accessing oral health. It has also reaffirmed the importance of a standardized oral health training curriculum for prenatal health professionals. [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]

Introduction: Nationally, cesarean birth is one of the most performed surgical procedures, yet cesarean births have been linked to an increased risk of delivery complications. Prenatal care (PNC) and education are possible strategies to reduce the number of cesarean births. However, there is scant research assessing the impact of these strategies on safely reducing primary cesarean births. This study evaluates the association between the adequacy of PNC utilization and primary cesarean birth. Methods: The analysis used 2018 birth certificate data, and the sample included nulliparous women with no reported pregnancy or delivery complications (N = 729,140). Logistic regression was used to model the association between the adequacy of PNC utilization and delivery method, as well as identify other factors associated with the delivery method. Results: Among women with a primary cesarean birth, 36.2% had received adequate plus PNC. After adjustment, there was no significant association between women receiving inadequate, intermediate, or adequate PNC and primary cesarean birth. However, women who received adequate plus PNC had an increased odds of having a primary cesarean birth compared to women with no PNC (OR, 1.23; 95% CI, 1.18–1.28). Discussion: Findings from this study highlight the need to further understand the role of PNC and its potential impact on the delivery method. Within the patient-provider relationship, healthcare providers have the unique opportunity to provide education and inform patients of the risks and benefits of all delivery options. Thus, there is an increased opportunity to safely reduce primary cesarean births. Significance: In the United States, cesarean births remain relatively high and are associated with potentially adverse effects. However, literature describing the potential impact of strategies to reduce cesarean births, such as prenatal care, and its association with the delivery method is lacking. Using 2018 birth certificate data, researchers were able to evaluate the adequacy of prenatal care utilization and primary cesarean birth association. This study found that women with a high utilization of prenatal care were more likely to have a primary cesarean birth; therefore, healthcare providers are essential in advising pregnant women about the risks and benefits of primary cesarean birth. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether Latina women's upward economic mobility from early-life residence in impoverished urban neighborhoods is associated with preterm birth (< 37 weeks, PTB). Methods: Multivariate logistic regression analyses were performed on the Illinois transgenerational birth-file with appended US census income information for Hispanic infants (born 1989–1991) and their mothers (born 1956–1976). Results: In Chicago, modestly impoverished-born Latina women (n = 1,674) who experienced upward economic mobility had a PTB rate of 8.5% versus 13.1% for those (n = 3,760) with a lifelong residence in modestly impoverished neighborhoods; the unadjusted and adjusted (controlling for age, marital status, adequacy of prenatal care, and cigarette smoking) RR equaled 0.65 (0.47, 0.90) and 0.66 (0.47, 0.93), respectively. Extremely impoverished-born Latina women (n = 2,507) who experienced upward economic mobility across their life-course had a PTB rate of 12.7% versus 15.9% for those (n = 3,849) who had a lifelong residence in extremely impoverished neighborhoods, the unadjusted and adjusted RR equaled 0.8 (0.63. 1.01) and 0.95 (0.75, 1.22), respectively. Conclusions for Practice: Latina women's upward economic mobility from early-life residence in modestly impoverished urban neighborhoods is associated with a decreased risk of PTB. A similar trend is absent among their peers with an early-life residence in extremely impoverished areas. Significance: What is Already Known on this Subject?: Robust literature supports a life-course conceptual model of birth outcome. Prior studies have demonstrated associations between upward economic mobility from poverty and decreased rates of preterm birth in non-Latina Black and White women. What this Study Adds?: Upward economic mobility is associated with decreased rates of preterm birth in US-born Latina women. This finding adds context to the life-course conceptual model of birth outcomes and may be salient to understanding the increased risk of adverse birth outcome among US-born (versus foreign-born) Latina women. [ABSTRACT FROM AUTHOR]

Objective: There has been little evidence of the impact of preventive services during pregnancy covered under the Affordable Care Act (ACA) on birthing parent and infant outcomes. To address this gap, this study examines the association between Medicaid expansion under the ACA and birthing parent and infant outcomes of low-income pregnant people. Methods: This study used individual-level data from the 2004–2017 annual waves of the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is a surveillance project of the Centers for Disease Control and Prevention and health departments that annually includes a representative sample of 1,300 to 3,400 births per state, selected from birth certificates. Birthing parents' outcomes of interest included timing of prenatal care, gestational diabetes, hypertensive disorders of pregnancy, cigarette smoking during pregnancy, and postpartum care. Infant outcomes included initiation and duration of breastfeeding, preterm birth, and birth weight. The association between ACA Medicaid expansion and the birthing parent and infant outcomes were examined using difference-in-differences estimation. Results: There was no association between Medicaid expansion and the outcomes examined after correcting for multiple testing. This finding was robust to several sensitivity analyses. Conclusions for Practice: Study findings suggest that expanded access to more complete insurance benefits with limited cost-sharing for pregnant people, a group that already had high rates of insurance coverage, did not impact the birthing parents' and infant health outcomes examined. Significance: Pregnant people had high rates of insurance coverage before the Affordable Care Act, but insurance instability remains high during the perinatal period. The ACA made a substantial number of changes to the cost-sharing of preventive benefits for pregnant people. There is limited research on changes in outcomes related to new preventive benefits for pregnant people. We examined several perinatal outcomes for low-income pregnant people after full enactment of ACA provisions. We find little change in the outcomes examined. Results suggest that ACA policies and insurance expansion that predate the ACA were necessary but insufficient to improve these more intractable outcomes. [ABSTRACT FROM AUTHOR]

Background: Prisons face challenges in meeting the unique health care needs of women, especially those who are pregnant. This retrospective chart review sought to describe the maternal and infant health outcomes of incarcerated women who received prenatal care while in an Arkansas prison. Methods: Using a hospital-based electronic medical records (EMR) system, we examined the maternal health history and current pregnancy characteristics of 219 pregnant women who received prenatal care while incarcerated from June 2014 to May 2019. We also examined labor and delivery characteristics and postpartum and infant birth outcomes for the 146 women from this cohort who delivered a living child while still incarcerated. Results: Most records indicated complex health histories with several chronic illnesses, mental health diagnoses, history of substance use, and lifetime medical complications. Despite comorbid illness, substance use disorder (SUD), trauma-history, and post-traumatic stress disorder (PTSD) prevalence was lower than expected. Previous and current obstetrical complications were common. Although the Neonatal Intensive Care Unit (NICU) admission rate (41%) was high, few infants required extensive treatment intervention. Postpartum complications were rare; however, a small portion of women who gave birth in custody experienced severe complications and were re-admitted to the hospital post-discharge. Conclusions: Incarcerated pregnant women and their infants are a marginalized population in great need of health care advocacy. To optimize maternal-infant outcomes, carceral agencies must recognize the health needs of incarcerated pregnant women and provide appropriate prenatal care. Expansion of carceral perinatal care to include screening for SUD and psychiatric symptoms (e.g., PTSD) and referral to appropriate care is highly encouraged. Policies related to NICU admission for non-medical reasons should be further examined. Significance: What is already known on this subject? Pregnant incarcerated women are at high risk for poor perinatal outcomes; however, knowledge of maternal and infant outcomes remains limited. Studies that exist are limited to a small number of outcomes and focus on immediate birth outcomes (e.g., prematurity, birthweight, NICU admission) with little data related to maternal and infant complications experienced during labor, delivery and postpartum, and infant diagnoses at delivery and discharge. What this study adds? Our study adds to what is known about the outcomes of incarcerated pregnant women by documenting their overall maternal health, previous and current pregnancy characteristics, and maternal and infant outcomes inclusive of the prenatal, labor and delivery, and postnatal periods. [ABSTRACT FROM AUTHOR]

Purpose: Women and children continue to miss preventive visits. Which neighborhood factors predict inadequate prenatal care (PNC) and well-child visit (WCV) attendance remain unclear. Description: In a retrospective case–control study at Virginia Commonwealth University Health System, mothers with less than 50% adherence or initiation after 5 months gestation were eligible as cases and those with ≥ 80% adherence and initiation before 5 months were eligible as controls. Children in the lowest quintile of adherence were eligible as cases and those with ≥ 80% of adherence were eligible as controls. Cases and controls were randomly selected at a 1:2 ratio and matched on birth month. Covariates were derived from the 2018 American Community Survey. A hotspot was defined as a zip code tabulation area (ZCTA) with a proportion of controls less than 0.66. ZCTAs with fewer than 5 individuals were excluded. Weighted quantile regression was used to determine which covariates were most associated with inadequate attendance. Assessment: We identified 38 and 35 ZCTAs for the PNC and WCV analyses, respectively. Five of 11 hotspots for WCV were also hotspots for PNC. Education and income predicted 51% and 34% of the variation in missed PNCs, respectively; language, education and transportation difficulties explained 33%, 29%, and 17% of the variation in missed WCVs, respectively. Higher proportions of Black residents lived in hotspots of inadequate PCV and WCV attendance. Conclusion: Neighborhood-level factors performed well in predicting inadequate PCV and WCV attendance. The disproportionate impact impact of inadequate PCV and WCV in neighborhoods where higher proportions of Black people lived highlights the potential influence of systemic racism and segregation on healthcare utilization. Significance: What is already known on this subject? Many pregnant women and children continue to miss preventive visits. It is not known what geographic factors contribute to missed visits. What this study adds? Neighborhood-level factors performed well in predicting inadequate prenatal care and well-child attendance. There were disproportionate missed preventive visits in neighborhoods where higher proportions of Black people lived, highlighting the role of systemic racism and segregation on healthcare utilization. [ABSTRACT FROM AUTHOR]

Objective: To identify knowledge, attitudes, and practices toward COVID-19 among pregnant and postpartum women in rural Bangladesh, and to assess any association with antenatal care attendance (ANC). Methods: This cross-sectional study was conducted in Northern Bangladesh's Sherpur district with a sample of pregnant and post-partum women enrolled in 'Poriborton', a community-based cluster Randomised Controlled Trial. Knowledge, attitude, and practices toward COVID-19, and any association with antenatal care practices were assessed through face-to-face interviews using a structured questionnaire. Composite measures for knowledge, attitude, and practices of COVID-19 were generated. Specific knowledge on COVID-19 and the association of antenatal care were presented as descriptive statistics. An adjusted odds ratio was used to examine the association between categorical variables. Results: Out of 4835 women, 34.0% correctly identified five or more COVID-19 symptoms, 31.8% knew three or more modes of coronavirus transmission, and 57.0% knew five or more preventive measures. Most (90.1%) had a "more positive attitude to testing" and 65.1% reported adequate practice of preventive measures. Women with adequate knowledge of COVID-19 were more likely to report both a positive attitude to testing (OR:2.96; 95% CI: 1.38–6.37) and adopt adequate practices of preventive measures (OR: 4.30;95% CI: 2.90–6.36). Education and being employed influenced KAP related to COVID-19. Only 14.9% were satisfied with their knowledge of COVID-19. Television was the main source of COVID-19-related specific information. Conclusions: We found that improved knowledge was associated with positive attitudes and behaviours that lead to the adoption of preventive measures. There was no association with ANC practices as attendance was very low in this region. The findings could be utilised to develop communication strategies for future public health emergencies in similar settings. Significance: Women with increased knowledge of COVID-19, led to more receptive attitudes and behaviors to reduce the risk of corona virus infection. This was modified by sociodemographic factors in this rural Bangladeshi community. These findings can be used to develop more targeted communication strategies for future public health emergencies. [ABSTRACT FROM AUTHOR]

Background and Purpose: The World Health Organization (WHO) states that good quality antenatal care should strive for both mother and child achieving their best possible health. On a policy level, in Europe these goals are reached with varying approaches. This research offers a fresh look on the underlying assumptions embedded in the ANC policies in three European countries. Methods: A framing analysis was conducted to publicly available ANC policies on uncomplicated pregnancies in Finland, England, and the Netherlands. Analysis was guided by van Hulst and Yanowa and included the following phases: a) Sense-making, b) Selecting, naming, and categorizing and c) Storytelling. Main Findings: Findings of this study demonstrate how ANC is organized with distinct frames. The Finnish ANC policies emphasized equity in care and instead of focusing on women, the ANC focused on the family. In England the pregnant woman was central, and it is seen as her responsibility to understand the ANC protocols. The ANC in the Netherlands focused on the pregnant woman's pregnancy experience and freedom. Conclusion: The three studied countries had individual priorities and values guiding ANC provision. Despite each country being in line with the WHO ANC recommendations, areas requiring improvement should not be overlooked. Significance: What is Already Known on this Subject?: Antenatal care is organized differently in European countries depending on their health system. These varying approaches lead to women's unequal access to good quality care during their pregnancies. Despite maternal mortality being the lowest in Europe compared to other continents, disparities and challenges remain. What this Study Adds?: This study contributes with improved understanding on how antenatal care aims to achieve good maternal health in three European countries by framing the ANC in Finland, England, and the Netherlands. [ABSTRACT FROM AUTHOR]

Background: Neonatal care visit is one of the efforts to reduce the neonatal mortality rate. In Indonesia, few studies have analyzed neonatal care visits by region in the last decade. The purpose of this study was to analyze factors associated with neonatal care visits by region in Indonesia. Method: This study was a quantitative study with a cross-sectional design. It used secondary data from Riskedas (Basic Health Research). The total sample size was 64,321 female respondents of childbearing age who had babies aged 29 days to 59 months. The dependent variable was the completeness of neonatal care visits measured through at least one at the first neonatal care visit (KN 1), at least one at the second neonatal care visit (KN 2), and at least one at the third neonatal care visit (KN 3). Data were analysed using a statistical binary logistic regression test. Results: The respondents who had complete neonatal care visits in Indonesia was 47.9%. The region with the highest proportion was Java-Bali at 58.5%, while the region with the lowest proportion was Papua at 23.8%. Variables influencing the completeness of neonatal care visits were delivery attendant, urban residence, secondary and higher education background, parity, delivery at a healthcare facility and compete antenatal care visits. Of these variables, delivery attendant (p < 0.05) was the most significant variable in all regions. Conclusion: This study showed that there were significant differences in complete neonatal care visits between regions in particularly between the ones in the west and east part of Indonesia. The government is expected to be able to provide equal distribution of and access to health facilities in rural and eastern Indonesia, especially neonatal services. Significance: Neonatal care is one of the strategies recommended by the World Health Organization (WHO) to reduce neonatal mortality and morbidity both in the community and at delivery facilities. Previous studies exploring the factors associated with neonatal care visits in Indonesia have focused more on the scope and factors related to neonatal visits. Limited study explored the implementation of neonatal care visits by region in Indonesia. It is important to know for reducing disparity of neonatal services based on region in Indonesia. Our study provides information about factors associated with neonatal care visit by region in Indonesia. [ABSTRACT FROM AUTHOR]

Background: Maternal healthcare service utilization is a pivotal indicator of a nation's progress in safeguarding the health and well-being of its women and children. In this context, women's empowerment emerges as a critical determinant influencing the utilization of maternal healthcare services. The study aims to assess the relationship between women's level of empowerment and utilization of maternal healthcare services among currently married women in India. Data and Methods: The study uses data from the fifth round of the National Family Health Survey conducted in 2019–2021 and analyzed 26,552 (15–49 aged) currently married women who had a live birth in the last 5 years preceding the survey. Additionally, univariate and bivariate analyses, multivariate logistic regression, and the SWPER index were used for the analysis. Results: Over the years, utilization of antenatal care, skilled birth attainment, and postnatal care has increased extensively in India. However, the study found that utilization of services was higher among empowered women, and it varies across the state with the extent of empowerment. State-level analysis shows that the extent of women empowerment was higher in Goa, followed by Tamil Nadu and Kerala, and lower in Jharkhand, followed by Tripura, so as the utilization of maternal and health care services. The extent of empowerment and utilization of services also varies by level of educational attainment, employment, and socio-economic status. Conclusion: There is a need for comprehensive strategies to enhance women's empowerment through education, employment, political participation, self-awareness, and reduction in gender-based violence and child marriages, which may improve awareness demand for better public health structure, and may ensure higher utilization of maternal healthcare services. Ultimately, these strategies may converse the higher maternal death and child mortality. Significance: What is already known about this subject? Existing literature in India mostly highlights a clear connection between women's autonomy and maternal healthcare services utilization. Women with higher autonomy, decision-making power, and mobility are more likely to use these services. However, in exploring the link between women's empowerment and maternal healthcare, some studies focus on education, employment, and media access among Indian mothers, sidelining broader empowerment dimensions. What this study adds? This study is likely the first to investigate the relationship between women's empowerment and the level of maternal healthcare service utilization in India. It covers key dimensions of women's empowerment, including Attitude to Violence, Social Independence, and Decision-making Power. Moreover, it is possibly the first Indian research paper to employ a survey-based women's empowerment index in this context. Notably, the assessment highlights Social Independence as a significant dimension. [ABSTRACT FROM AUTHOR]

Objective: COVID-19 disrupted health service delivery and weakened global and national health systems. The objective of this study was to describe the changes in health service utilization in three local government areas (LGAs) in Nigeria and examine factors involved. Methods: A cross-sectional mixed-methods approach was used. A total of 315 pregnant women seen for antenatal care in 80 health facilities in three LGAs between October 1 and November 30, 2020, participated in exit interviews; 93 women participated in focus group discussions (FGDs). Descriptive analyses and a multivariable logistic analysis were conducted to examine associations between characteristics and decreased service utilization. Content analysis was used to identify the emerging themes related to health service utilization during the pandemic. Results: One quarter of women reported that they reduced or ceased health service. The biggest reported changes were in immunization (47 to 30%, p < 0.001) and a small but statistically significant decline in antenatal care (98.7 to 93.8%, p < 0.001) was observed. Qualitative findings show that lockdowns, transportation issues, increased costs and fear of contracting COVID-19 or being labeled as COVID-positive were the most common reasons for not seeking care during this period of the pandemic. Conclusions: The pandemic negatively impacted health service utilization amongst pregnant women in Nigeria. A better understanding of differences in state response could help inform future actions. The findings highlight the need for health systems to consider how to facilitate service utilization during a pandemic, such as providing safe transport or increasing outreach, and to minimize stigma for those seeking care. Significance: What is already known on this subject? The COVID-19 pandemic has disrupted health systems worldwide and service utilization decreased as a result, including the utilization of maternal and child health services. What this study adds? This study shows that there were significant declines in service utilization and provides insight into why pregnant woman did or did not alter their care-seeking for antenatal care and immunizations services. The qualitative results indicate that pregnant women responded to or interpreted State and facility-level responses differently, which resulted in increased or decreased utilization. These insights can inform future emergency responses and policies to build more resilient health systems and communities. [ABSTRACT FROM AUTHOR]

Purpose: Prenatal stress is a known risk for poor birth outcomes. This study specifically looked at reported stress during pregnancy and low birth weight (LBW) in Rhode Island. Methods: Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2016 to 2018 for the state of Rhode Island was utilized. Stress during most recent pregnancy was dichotomized as: 'none to minimal' and 'moderate to high.' LBW was defined as less than 2,500 g. Multivariable regression analysis was performed, accounting for complex survey design. Results: In this cohort, 24% of pregnant people reported moderate to high stress leading to an adjusted odds of 1.70 (95% CI 1.43–2.03) of having a LBW newborn compared to those with none to minimal stress. Primiparity, previous preterm birth, racism, smoking history, and history of chronic medical problems were also associated with LBW newborns. Conclusion: We recommend screening and provision of support services for stress in all settings where pregnant people access care. Significance statement: Stress during pregnancy has been highlighted as a risk for poor birth outcomes. There are different measurements of prenatal stress ranging from stressful life events (SLEs) to direct pregnancy related stress, which have differential impacts on perinatal health. In our study, pregnant people who reported moderate to high stress were more likely to have LBW newborns compared to those who reported none to minimal stress. This study assessed self-reported stress during pregnancy as opposed to discrete SLE or chronic stressors. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to investigate the impact of reduced contact prenatal care necessitated by the COVID-19 pandemic on meeting standards of care and perinatal outcomes. Methods: This was a retrospective case-control study of patients in low-risk obstetrics clinic at a tertiary care county facility serving solely publicly insured patients comparing reduced in-person prenatal care (R) over 12 weeks with a control group (C) receiving traditional prenatal care who delivered prior. Results: Total 90 patients in reduced contact (R) cohort were matched with controls (C). There were similar rates of standard prenatal care metrics between groups. Gestational age (GA) of anatomy ultrasound was later in R (p = 0.017). Triage visits and missed appointments were similar, though total number of visits (in-person and telehealth) was higher in R (p = 0.043). R group had higher GA at delivery (p = 0.001). Composite neonatal morbidity and length of stay were lower in R (p = 0.017, p = 0.048). Maternal and neonatal outcomes did not otherwise differ between groups. Using Kotelchuck Adequacy of Prenatal Care Utilization index, R had higher rates of adequate prenatal care (45.6% R vs. 24.4% C, p = 0.005). Discussion: Our study demonstrates the non-inferiority of a hybrid, reduced schedule prenatal schedule to traditional prenatal scheduling. In a reduced contact prenatal care model, more patients met criteria for adequate prenatal care, likely due to higher attendance of telehealth visits. These findings raise the question of revising the prenatal care model to mitigate disparities in disadvantaged populations. Significance: Recent studies have explored the impact of reduced prenatal care models on obstetrical outcomes with overall mixed findings. We aimed to investigate the impact of a reduced contact prenatal care model necessitated by the COVID-19 pandemic on meeting standards of care and obstetric outcomes. We found that in a reduced contact prenatal care model, more patients obtained adequate prenatal care, standards of care were met, and obstetrical outcomes were similar to that of controls. These findings raise the question of raising the question of pursuing a revised prenatal care model in the future. [ABSTRACT FROM AUTHOR]

Purpose: This report describes a multifaceted, trauma-informed initiative developed to address racial/ethnic maternal and infant health inequities in Washington, D.C. Description: Structural racism and systemic oppression of marginalized communities have played a critical role in maternal and infant health inequities in the United States. Black birthing individuals are exponentially more likely to experience adverse birth outcomes, including preterm birth, low birth weight and maternal mortality. In response to these statistics, the Safe Babies Safe Moms (SBSM) initiative was developed to support patients of marginalized identities and improve health outcomes. SBSM Women's and Infants' Services Specialty Care (WIS-SC) is one component of this initiative focused on perinatal services. Assessment: SBSM WIS-SC includes trauma-informed clinical services, nurse navigation, lactation, diabetes and nutrition education, social work services, medical-legal services, and behavioral health support. Services are delivered by a multidisciplinary team trained on the following domains: (1) building connection within diverse care teams; (2) recognizing systemic barriers to trauma-informed approaches; (3) learning the brain science of implicit bias, trauma, and resilience; (4) Integrating self-care practices; and (5) acknowledging progress. Since the inception of the program, SBSM WIS-SC has served over 1500 patients. Conclusion: The SBSM WIS-SC intervention reflects a patient-centered approach to care, offering the multidisciplinary services required for perinatal patients with complex medical, psychosocial, and legal needs. Trauma informed training and team building is foundational to successful service delivery to address these multifaceted health needs of historically marginalized perinatal populations nationwide. Significance: What is Already Known on this Subject?: The consequences of structural racism have a profound impact on infant and maternal health outcomes among racial and ethnic minorities. Trauma informed, patient centered care models are integral to dismantling such disparities within healthcare systems. What does this Study adds?: This from-the-field article provides an in-depth glance at the workings of Safe Babies Safe Moms Women's and Infants' Services Specialty Care (SBSM WIS-SC), a Washington D.C. based initiative designed to serve as a comprehensive and multifaceted intervention to identify, support, and connect perinatal patients of marginalized identities to trauma-informed resources. [ABSTRACT FROM AUTHOR]

Purpose: Perinatal substance use disorders (SUDs) remain an urgent public health concern in the United States and are associated with increased maternal and infant morbidity and mortality. Establishing holistic prenatal care among this population allows for engaging or re-engaging the pregnant population in appropriate medical care, including treatment for SUD. Description: The Florida Department of Health in Citrus County (DOH-Citrus) noticed an increase in SUD among their pregnant population and developed a pilot program that incorporates Medication for Opioid Use Disorder (MOUD) and mental health services during routine prenatal care appointments. Assessment: Since the launch of the pilot program, DOH-Citrus has provided prenatal programs with buprenorphine assistance to 23 members of the community. Conclusion: A growing number of local health departments (LHDs) provide harm reduction supplies, overdose prevention education, and local resources for treatment and other life-saving services. In many communities, LHDs are typically the most accessible sources of public health information and health care services. By framing the pilot program as a prenatal care center that incorporates SUD treatment as the prescribed standard of care, DOH-Citrus has implemented a holistic model for treating SUD and reducing barriers while improving continuity of care. LHDs are uniquely positioned to implement harm reduction strategies that address perinatal SUDs, treatment, and recovery within maternal and child health populations. As a health department located in a state without expanded Medicaid and with high rates of uninsured people, this pilot program has the potential to be replicated in other states facing similar challenges. Significance: What is already known on this subject? Pregnant people face barriers to care due to various regulations including mandatory reporting of perinatal substance use to authorities including child protective services, preventing them from accessing treatments such as MOUD treatment and behavioral therapy. Establishing SUD treatment as part of prenatal care allows for the ability to engage or reengage this population into appropriate medical care. What this study adds? Equipping other health departments to address SUD in the perinatal period is essential for improving care for pregnant people and infants who have been exposed to SUD, and this holistic program has the potential to be replicated in other states facing similar challenges. [ABSTRACT FROM AUTHOR]

Introduction: The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend that expectant parents receive a preventive visit with a pediatrician in the prenatal period (a pediatric prenatal visit, or PPV). Discussing newborn health topics in the prenatal period tends to be more effective than immediately postpartum, and research suggests, for example, that the PPV increases timely childhood immunizations. However, only 22% of expectant parents have these visits, and there are significant disparities by race and income. Methods: A 2-min online survey with open-ended questions was emailed to 304 eligible obstetrics providers in Rochester, NY. Simple descriptive statistics and chisquare analysis were applied to survey responses. Responses were organized within the framework of knowledge, attitudes, and practices to identify barriers to guideline adherence resulting in chronic under-utilization of the PPV. Results: Ninety obstetric providers completed the survey. 66 reported awareness of the PPV, and 45 reported referring patients for a PPV. However, in open-ended questions, respondents expressed confusion between the PPV and a "meet and greet" visit with a pediatrician. Some respondents believed that the PPV is not covered by insurance, even though these visits are covered by Medicaid and marketplace insurance. Providers who had personally received one as a parent expressed positive attitudes. Discussion: These findings indicate that unfamiliarity with the PPV is one barrier to referral. Educating providers about the guideline recommendations, evidence base, and insurance coverage could overcome this barrier. Doing so could reduce disparities in utilization of the pediatric prenatal visit. Significance: What's Known on This Subject The pediatric prenatal visit is an opportunity to deliver anticipatory guidance and to gather family information. Despite evidence indicating that pediatric prenatal visits enhance outcomes like immunization rates, few expectant parents receive this service—especially in low-income and BIPOC populations. What This Study Adds Even after recent joint AAP and ACOG guidelines recommending the pediatric prenatal visit, it appears that awareness among obstetrics providers remains low. Disseminating information about existing evidence-based guidelines to patients and providers could increase PPV awareness, reduce disparities in its utilization, and improve health outcomes for mothers and children. [ABSTRACT FROM AUTHOR]

Objectives: To analyze adverse childhood experiences (ACEs) among mothers of newborns referred to a hospital's child protection team (CPT) for suspected substance exposure. Researchers hypothesized that a higher prevalence of these mothers have ≥ 4 ACEs than female counterparts in the general population. The study team also explored whether associations existed between type of maternal ACEs and substance use in pregnancy. Methods: Retrospective review of infant referrals to the CPT in the 3 years after adding an ACEs questionnaire to the consultation process. Bivariate analyses and multivariate logistic regression models examined associations between prenatal substance use and maternal ACEs prevalence, controlling for demographics. Results: Data from 222 infants (four sets of twins) and 218 mothers were analyzed. Half (50.0%) the infants had withdrawal symptoms. Most (67.0%) women had positive toxicology screens, while 85.0% reported prenatal substance use. Half (50.9%) the mothers reported ≥ 4 ACEs and these individuals had significantly higher odds of cannabinoid use [adjusted odds ratio (aOR), 3.7; 95%CI 2.0, 6.9, p < 0.001) than those with < 4 ACEs. A significant association was found between substance use and ACEs in the household challenges category (p = 0.03), especially parental separation/divorce (p < 0.001). Conclusions for Practice: As hypothesized, a higher prevalence of mothers referred to the CPT had ≥ 4 ACEs than women in the general population (50.9% vs. 15.2%), and a large proportion had used substances while pregnant. Routine prenatal ACEs screening and universal, nonpunitive toxicology testing of infants and mothers at birth may provide opportunities for intervention while reducing the transgenerational impact of ACEs. Significance: It is known that Adverse Childhood Experiences (ACEs) put people at risk of poor health choices and outcomes later in life. Pregnant people who have experienced ACEs—especially those with ≥ 4 events —are at risk for prenatal substance use, exposing their infants in utero. The high prevalence of people in this study with ≥ 4 ACEs whose infants tested positive for substance exposure provides further evidence of the association between ACEs and substance use in pregnancy. Prenatal screening for childhood adversity may identify people at risk and provide opportunities for intervention, thus reducing the transgenerational impact of ACEs. [ABSTRACT FROM AUTHOR]

Objectives: Some states, including Massachusetts, require automatic filing of child abuse and neglect for substance-exposed newborns, including infants exposed in-utero to clinician-prescribed medications to treat opioid use disorder (MOUD). The aim of this article is to explore effects of these mandated reporting policies on pregnant and postpartum people receiving MOUD. Methods: We used modified grounded research theory, literature findings, and constant comparative methods to extract, analyze and contextualize perinatal experiences with child protection systems (CPS) and explore the impact of the Massachusetts mandated reporting policy on healthcare experiences and OUD treatment decisions. We drew from 26 semi-structured interviews originally conducted within a parent study of perinatal MOUD use in pregnancy and the postpartum period. Results: Three themes unique to CPS reporting policies and involvement emerged. First, mothers who received MOUD during pregnancy identified mandated reporting for prenatally prescribed medication utilization as unjust and stigmatizing. Second, the stress caused by an impending CPS filing at delivery and the realities of CPS surveillance and involvement after filing were both perceived as harmful to family health and wellbeing. Finally, pregnant and postpartum individuals with OUD felt pressure to make medical decisions in a complex environment in which medical recommendations and the requirements of CPS agencies often compete. Conclusions for Practice: Uncoupling of OUD treatment decisions in the perinatal period from mandated CPS reporting at time of delivery is essential. The primary focus for families affected by OUD must shift from surveillance and stigma to evidence-based treatment and access to supportive services and resources. Significance: What is already known on this subject? Child protection systems (CPS) reporting is associated with barriers to prenatal care and family resources and services. Some state policies in the United States mandate reporting to CPS for prenatal substance exposure, including prescribed medications for opioid use disorder. What this study adds? This study centers the experiences of pregnant and postpartum people with opioid use disorder with mandated reporting policies for prenatal substance exposure, describes the harms to families associated with these policies, and makes recommendations for policy change. Findings emphasize the need to uncouple medical decisions from CPS reporting and involvement. [ABSTRACT FROM AUTHOR]

Background: Neonatal deaths remain a serious public health concern in Ethiopia; being one of the top five countries contributing to half of the neonatal deaths worldwide. Although antenatal care (ANC) is assumed as one of the viable options that contribute to neonatal survival, findings from original studies indicated disparities in the effect of ANC on neonatal mortality. Thus, this review aimed to determine the pooled effect of ANC on neonatal mortality in Ethiopia. Methods: Databases such as PubMed, EMBASE, CINAHL, HINARI, and Cochrane Central Library were searched for articles using keywords. Selection of eligible articles and data extraction were conducted by an independent author. The risk of a bias assessment tool for non-randomized studies was used to assess the quality of the articles. Comprehensive meta-analysis version 2 software was used for meta-analysis. Heterogeneity and publication bias of included studies were assessed using I2 test statistic and Egger test, respectively. The random-effect model was employed; an outcome is reported using a risk ratio with a 95% confidence interval. Results: Of 28 included studies, 20 showed receiving at least one ANC visit had a significant association with neonatal mortality. Accordingly, the estimated pooled risk ratio for neonatal mortality was 0.59 (95% CI 0.45, 0.77) among infants born to women who had at least one ANC visit compared to infants born to women who had no ANC visits. Conclusion: This finding indicated that neonatal mortality was decreased among infants born to women who had at least one ANC visit compared to infants born to women who had no ANC visit. Therefore, promoting and strengthening ANC service utilization during pregnancy would accelerate the reduction of neonatal mortality in Ethiopia. Significance: In some studies, providing ANC services reduces the risk of neonatal mortality, in others, the ANC visits did not significantly decrease neonatal mortality in Ethiopia, which represents a dismal picture of neonatal mortality (NM) in sub-Saharan Africa (SSA) region. Therefore, evidence emanated from comprehensive searches of review performed with several studies represented from various regions of the country which determine the effect of ANC on NM is essential to reinforce strategies that could help for newborn survival and wellbeing of neonates in Ethiopia. Hence, this study aimed to systematically examine the effect of ANC on NM by combining a wide range of reviews, to provide concrete evidence for policymakers. [ABSTRACT FROM AUTHOR]

Introduction: Preventing new parents who use drugs from bonding with and bodyfeeding their babies undermines public health. Because U.S. culture treats substance use as a moral failing rather than a health concern, punitive responses to perinatal substance use continue to dominate. This is particularly true for families of color, who are more likely to be targeted by the family regulation system. These approaches fail to protect families, and cause their own, separate harm. This article will lay out existing evidence surrounding bodyfeeding. Then, it will debunk harmful mythologies about drug use and human milk, and compare the risks associated with using drugs while bodyfeeding to those inherent in family separation. Finally, it will make the case for harm-reduction approaches over criminal ones. Objectives: The health risks associated with family separation are only rarely weighed against those associated with drug exposure through human milk. Our objective for this paper is to contribute new ways of framing the importance of keeping families together at birth, even when perinatal substance use is detected. Methods: This manuscript is not based upon clinical study or patient data, and exclusively references studies and research publications that have been approved by the appropriate ethics committee and which have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Results: Significant research data support the position that the risks associated with family separation are arguably greater than those associated with exposure to substance use in human milk. Conclusions for Practice: Harm reduction approaches should be favored over criminal approaches when perinatal substance use is detected or confirmed. Significance: The harms of family separation have already been well-documented by public health and social science researchers. The risks associated with substance use and human milk have also been the subject of significant academic research. However, the authors have not come across any articles that weigh the health risks associated with family separation against those associated with drug exposure through human milk. This paper contributes new ways of framing the importance of keeping families together at birth, even when perinatal substance use is detected. [ABSTRACT FROM AUTHOR]

Objectives: To investigate maternal prenatal anxiety and depression in high-risk pregnancies and examine their influence on maternal–fetal attachment. Methods: We included 95 hospitalized high-risk pregnant women. The Hospital Anxiety and Depression Scale (HADS) and the Prenatal Attachment Inventory (PAI) were used to assess the primary objective. Internal consistency and construct validity of the PAI were investigated. Results: The average age was 31 years and gestational age ranged from 26 to 41 weeks. Prevalence of depressive symptoms was 20% and anxiety symptoms 39%. Cronbach alpha coefficient of the PAI Tunisian version was 0.8 and the construct validity in favour of one factor model. PAI scores correlated negatively and significatively with the HADS total score (r = − 0.218, p = 0.034) and was attributed to the depression dimension only (r = − 0.205, p = 0.046). Conclusions for Practice: Emotional wellbeing of pregnant women especially in high-risk pregnancies should be explored in order to prevent consequences on women, their growing fetus, and prenatal attachment. Significance: What is already known? Maternal prenatal emotional well-being influences maternal–fetal attachment which has important implications on postnatal bonding. Anxiety and depression disorders during pregnancy could affect women's attachment to their unborn child in a negative way. Research has largely been conducted with the general pregnant population with little focus on at-risk pregnancies, which are associated with increased levels of mood disorders. What this paper adds? This study highlights the impact of depression but not situational anxiety on maternal–fetal attachment in women with high-risk pregnancies, highlighting the importance of assessing and managing psychological disorders during pregnancy to enhance the quality of prenatal bonding. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the metabolic pattern of illicit fentanyl in a sample of pregnant patients with opioid use disorder. Fentanyl pharmacokinetics during pregnancy are currently understudied yet the interpretation of a fentanyl immunoassay during pregnancy has significant implications on maternal legal custody and child welfare. Through this medical-legal lens, we demonstrate the utility of an emerging metric, the metabolic ratio, for accurate analysis of fentanyl pharmacokinetics during pregnancy. Methods: We conducted a retrospective cohort analysis using the electronic medical records of 420 patients receiving integrated prenatal and opioid use disorder care at a large urban safety net hospital. Data related to maternal health and substance use were collected for each subject. The metabolic ratio was calculated for each subject to measure their rate of metabolism. The sample's (n = 112) metabolic ratios were compared with a large non-pregnant sample (n = 4366). Results: The metabolic ratios of our pregnant sample were significantly (p =.0001) higher than the metabolic ratios of our non-pregnant sample, indicating that the rate of conversion to the major metabolite was faster in pregnant people. The effect size for this difference between the pregnant and non-pregnant sample was large (d = 0.86). Conclusions for Practice: Our findings characterize the unique metabolic pattern of fentanyl in pregnant people who use opioids, providing guidance for institutional policies around fentanyl drug testing. Additionally, our study warns of misinterpretation of toxicology results and stresses the importance of physician advocacy on behalf of pregnant women who use illicit opioids. Significance: What is already known on the subject? Widespread use of illicit fentanyl is a dangerous public health threat yet little is known about fentanyl metabolism. What this study adds? This study highlights the difference between fentanyl metabolism in pregnant and non-pregnant people. Providers caring for pregnant patients must be cautious when interpreting fentanyl test results since a positive test may not always indicate recent use. These data can assist in accurate interpretation of urine fentanyl tests during pregnancy. [ABSTRACT FROM AUTHOR]

Objectives: Pregnant women are likely to experience high levels of stress during the COVID-19 pandemic. However, the factors that might influence the extent of experienced emotional distress are poorly understood. Therefore, we aimed to investigate potential correlates of prenatal emotional distress during the COVID-19 pandemic. Methods: In total, N = 1437 pregnant women from Germany and Switzerland participated in an online study during the first wave of the COVID-19 pandemic (May–August 2020). The survey assessed prenatal distress, pandemic-related pregnancy stress, general anxiety, fear of childbirth, and several socio-demographic, pregnancy- and COVID-19-related factors. Linear multivariate regression models were the main analytical strategy. Results: The results highlight that several factors such as full-time employment, nulliparity, high-risk pregnancy, emotional problems, cancelled prenatal appointments, and stating that COVID-19 affected the choice of birth mode were significantly associated with elevated prenatal distress, anxiety, pandemic-related pregnancy stress, and fear of childbirth. Conversely, access to an outdoor space was a protective factor for pandemic-related pregnancy stress and prenatal distress. Conclusions for Practice: Overall, the study highlights significant correlates influencing the levels of emotional distress pregnant women experienced during the COVID-19 pandemic. These findings may contribute to the improvement of maternal prenatal medical and psychological care during a public health crisis of international concern, such as the COVID-19 pandemic. Significance: Pregnancy is a time of increased vulnerability to mental problems. There still is insufficient information on the psychological impact of the COVID-19 pandemic on pregnant women's mental responses. Our findings suggest that high-risk pregnancy, full-time employment, cancelled prenatal care appointments, and stating that COVID-19 affected the choice of birth mode were risk factors for pandemic-related pregnancy stress. Additionally, current emotional problems, nulliparity, chronic disease, history of abuse, and income loss were linked to higher prenatal distress. Similarly, these factors increased anxiety and fear of childbirth. Access to an outdoor space was a protective factor for pandemic-related pregnancy stress and prenatal distress. [ABSTRACT FROM AUTHOR]

Background: Latina women are less likely to start prenatal care in the first trimester and to attend the recommended amount of prenatal visits compared to their non-Latina white counterparts. Objectives: This study aimed to assess challenges and facilitators to first-trimester prenatal care (FTPNC) and prenatal care utilization (PNCU) in a Midwestern urban area with a growing immigrant Latino community. Methods: This study used a mixed-method approach based on the Theoretical Domains Framework. Nine semi-structured interviews were conducted with healthcare professionals that worked in birth centers, clinics, or hospitals that provided prenatal care (PNC) services for Latina women. Eight focus groups and quantitative surveys were conducted with Latina women and their supporters in Kansas City metropolitan area. Results: FTPNC was challenged by women's immigrant status, lack of healthcare coverage due to immigrant status, and complexity of Medicaid application. PNCU was challenged by the cost of PNC when diagnosed with gestational diabetes, lack of healthcare coverage, PNC literacy, late access to gynecologists/obstetricians, inadequate interpretation services, transportation, and mental health distress. Meanwhile, FTPNC was facilitated by social support and connectedness. PNCU was facilitated by Spanish-proficient providers and interpreters, effective nonverbal communication and education techniques, and pregnancy prevention access and education. Conclusions for Practice: Results from this study highlight important targets to improve PNC for Latina women. Participants called for various types of support to address identified challenges, ranging from information on social media about PNC services to broader efforts such as building trust from the community toward PNC providers and making PNC services affordable for women with gestational diabetes. Significance: Minoritized communities have historically low FTPNC and PNCU. However, access and use of PNC may be affected and improved by specific communities' cultural, social, and patient-provider interactions within specific geographical areas. For a primarily immigrant Latino community living in a midwestern metropolitan area, FTPNC and PNCU were challenged by immigration status, lack of healthcare coverage, difficulty completing public healthcare coverage application, cost of PNC when diagnosed with gestational diabetes, PNC literacy, limited access to women's health providers, inadequate interpretation services, transportation, and mental health distress. However, social support, connectedness, appropriate interpretation services, bilingual providers, empathetic nonverbal communication, spoken communication strategies delivered at the provider's office, access to PNC, and pregnancy prevention education were considered facilitators to FTPNC and PNCU. [ABSTRACT FROM AUTHOR]

Objective: To describe the risk factors among mothers in four central hospitals and two provincial hospitals in the Lao PDR, a lower-middle-income country in Southeast Asia. Method: The study used a hospital-based matched case–control design study. Purposive sampling was used to select 320 mothers (80 cases and 240 controls) from the six hospitals. Cases were mothers who had delivered a live newborn between 28 and 36 weeks and 6 days, while controls were mothers who had delivered a live newborn within 37 and 40 weeks. Data were collected through a review of medical records and face-to-face interviews using a structured questionnaire. Data were entered into EPI info (Version 3.1) then exported to the STATA programme (Version 14) for univariate and conditional multiple logistic regressions to identify risk factors for PTD at p ≤ 0.05. Results: The mean maternal age of cases and controls was 25.2 (SD = 5.33) and 25.8 (SD = 4.37), respectively. In the multivariate analysis, factors with statistically significant relationships with PTD were the mother's religion (AOR: 3.01; 95% CI 1.24–7.26), the number of antenatal care visits (AOR: 3.39; 95% CI 1.6–7.18), having a pre-pregnancy maternal weight of less than 45 kg (AOR: 3.05; 95% CI 1.66–10.5), having had a premature preterm rupture of the membrane (AOR: 7.13; 95% CI 2.44–20.8) and vaginal bleeding during pregnancy (AOR: 6.89; 95% CI 3.02–15.73). Conclusions for Practice: Improving capacity of the Laotian health system to provide quality ANC and increasing the number of ANC contacts is critical. This requires context specific strategies that also address the socio-economic factors, such as access to a nutritious diet, that contribute to PTD. Significance: Few studies sin lower-middle income countries have investigated risk factors associated with preterm birth. This study adds to the emerging evidence of preterm birth risk factors in these countries. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate differences in health characteristics and birth outcomes for participants of a prenatal education and support program for pregnant teens, "Starting Out Right" (SOR) compared to nonparticipant pregnant teens in Pima, Maricopa, and Gila counties in Arizona to gauge benefits of program participation. Description: The SOR program is a community education and support program for pregnant teens based on a structured curriculum. All pregnant teens living in the service area are eligible to participate. Assessment: Vital statistics birth data from 2014 to 2019 were obtained from three counties in Arizona that identified SOR and non-SOR program participants. Logistic regression was used to calculate multivariable -adjusted odds ratios (aOR) for specific health characteristics (smoking, hypertensive disorders, overweight and obesity, gestational diabetes, sexually transmitted infections) and birth outcomes (C-section, preterm birth, NICU admission, birthweight, and breastfeeding) for SOR participants compared with nonparticipants. Variables in the adjusted models included age, BMI, smoking, gestational diabetes, race, ethnicity, county, WIC participation, insurance type, plurality, and month and year prenatal care began. Conclusion: These results suggest that participation in SOR was associated (p ≤ 0.06) with a reduced odds for low birthweight [aOR 0.7(95% CI 0.5,1.0)] and increased odds (p ≤ 0.05) of breastfeeding [aOR 1.3(95% CI 1.0,1.7)] compared to nonparticipants. These results provide evidence that the education components in the SOR program support improved pregnancy and breastfeeding outcomes for pregnant teens. Significance: Pregnant teens and their infants are at risk for adverse pregnancy outcomes including low birth weight infants, preterm delivery, and reduced breastfeeding. There have been a variety of programs developed for pregnant teens, however model evidence-based programs to improve birth outcomes are not well established. The results of this study present an evidence-base for the "Starting Out Right" program with participants having a reduced odds for low birthweight and increased odds of breastfeeding at time of discharge from the hospital compared to nonparticipants. [ABSTRACT FROM AUTHOR]

Objective: To determine the proportion of small for gestational age (weight < 10th percentile, SGA) births among fathers with lifelong low (compared to high) socioeconomic position (SEP) attributable to white and African-American women's unhealthy pregnancy-related behaviors. Methods: Oaxaca-Blinder decomposition methods were conducted on the Illinois transgenerational dataset of infants (1989–1991) and their Chicago-born parents (1956–1976) with appended US census income data. The neighborhood income of father's residence at the time of his birth and at the time of his infant's birth were used to estimate his lifetime SEP. Maternal unhealthy pregnancy-related behaviors were defined as cigarette smoking, inadequate prenatal care, and/or low weight gain during pregnancy. Results: Among African-American women, births (n = 4426) to fathers with lifetime low SEP had an SGA rate of 14.8% compared to 12.1% for those (n = 365) born to fathers with lifetime high SEP (p < 0.0001). Among white women, births (n = 1430) to fathers with lifetime low SEP had an SGA rate of 9.8% compared to 6.2% for those (n = 9141) born to fathers with lifetime high SEP (p < 0.0001). Adjusting for maternal age, marital status, education, and parity, African-American and white women's unhealthy pregnancy behaviors accounted for 25% and 33%, respectively, of the disparity in SGA rates among infants of lifetime low (compared to high) SEP fathers. Conclusion: A significant proportion of the disparity in SGA rates between fathers with lifelong low (compared to high) SEP is explained in both races by maternal unhealthy pregnancy behaviors. Significance: What is already known on this subject? An expanding published literature show that father's low socioeconomic position (SEP) is a risk factor for adverse birth outcome, including small for gestational age (< 10th percentile, SGA) births, independent of maternal demographic characteristics. Mechanisms underlying this association remain unclear. What this study adds? This study identified maternal unhealthy pregnancy behaviors (including cigarette smoking, inadequate prenatal care, and low pregnancy weight gain) as factors which explain a substantial proportion of the disparity in SGA rates between infants of low (compared to high) SEP fathers. [ABSTRACT FROM AUTHOR]

Objectives: Social determinants of health (SDOH) and stress during pregnancy may contribute to adverse pregnancy outcomes. The objective of this in the field pilot project was to develop a comprehensive screening tool by combining existing validated screeners. Additionally, implement use of this tool within routine prenatal visits and assess feasibility. Methods: Pregnant patients accessing prenatal care at a single site of an urban Federally Qualified Health Center were recruited during prenatal visits to complete a Social Determinants of Health in Pregnancy Tool (SIPT). SIPT combines a series of questions from existing and well-validated tools and consists of five domains: (1) perceived stress, (2) relationship and family stress, (3) domestic violence, (4) substance abuse, and (5) financial stress. Results: Between April 2018 and March 2019, 135 pregnant participants completed SIPT. Ninety-one percent of patients scored positive on at least one screener, 54% to three or more screeners. Conclusions: Despite guidelines to screen for SDOH during pregnancy there is no universal tool. Our pilot project demonstrated the concurrent use of adapted screening tools where participants reported at least one area of potential stress, and that linking to resources at the time of a visit is plausible. Future work should examine if screening and point of care linkages of services improves maternal child outcomes. Significance: What is already known about this subject? The American College of Obstetrics and Gynecology acknowledges to improve care and decrease inequalities prenatal providers should routinely screen for SDOH within prenatal visits. What does this study add? Our study aimed to implement a comprehensive stress and SDOH tool that could be used quickly within a prenatal visit by the provider to enable timely linkage of services. While national recommendations emphasize screening and need for possible referrals this study demonstrates the feasibility of screening, implementation, and follow up. [ABSTRACT FROM AUTHOR]

Objectives: Our aim was to assess the use of dual/poly tobacco in a sample of pregnant women. Design: cross-sectional survey. Methods: Twenty prenatal care units in Botucatu, Sao Paulo, Brazil. We evaluated 127 high-risk pregnant smokers during prenatal care. Those who were 12–38 weeks pregnant and were currently smoking conventional cigarettes. The study enrollment took place between January 2015 and December 2015. The dual/poly prevalence of tobacco products during pregnancy and the characteristics related to smoking in pregnant smokers through a specific questionnaire containing questions related to sociodemographic characteristics, comorbidities, gestational history, smoking history, secondhand smoke exposure, nicotine dependence, motivation stage and use of alternative forms of tobacco. Results: Mean age was 26.9 ± 6.6 years, most had only elementary education and belonged to lower income economic groups. Twenty-five (19.7%) smoked conventional cigarettes only while 102 used conventional and alternative forms of tobacco products. Smoking pack-years was significantly lower in those only smoking conventional cigarettes than in dual/poly users. Proportion of patients with elevated degree of nicotine dependence was higher in conventional cigarettes users. On the other side, alcohol intake was higher in dual/poly smokers when compared to conventional cigarettes group. The alternative forms of smoking were associated with significantly higher occurrences of comorbidities as pulmonary, cardiovascular and cancer. Conclusions for Practice: The prevalence of alternative forms users of smoking products is high during pregnancy. These data reinforce the importance of a family approach towards smoking in pregnant women and education about the risks of alternative forms of tobacco. Significance: What is Already Known? Studies show that the prevalence of pregnant women who consume alternative forms of tobacco is high, and that these types of smoking are also harmful to pregnancy. What this Study Adds? Our study describes the characteristics related to smoking in pregnant smokers and identifies dual/poly use of tobacco products. [ABSTRACT FROM AUTHOR]

Objective: This cohort study was to investigate maternal knowledge of the oral health of woman and children during pregnancy and after childbirth, and the associated factors. Methods: Groups of women participating in a public prenatal dental care programme in Brazil were assessed, in two different stages. In the first stage, pregnant women were assessed for their own oral health. In the second stage, after childbirth, women were assessed for the oral health of their child. The examiner assigned a maternal knowledge score to the questionnaires, considering the ideal alternatives within the context of oral health promotion as correct answers. Statistical analysis included the Kruskal-Wallis and multiple linear regression tests, considering a level of significance of P < 0.05. Results: Ninety-eight women were included in the study, with a mean age 26.27 years (SD 6.51). In the regression analysis, the maternal knowledge score was associated with the presence of myths about oral health (P < 0.01), the children first dental appointment in the first year of life (P = 0.07), the presence of a non-nutritious sucking habit (P < 0.01), considering dental treatment to be important during pregnancy (P < 0.01), and having been instructed on oral health during pregnancy (P < 0.01) and after the children birth (P = 0.02). Conclusion: This study suggests that the women showed a regular score of knowledge about their oral health and that of their children, as they still believed in some myths about oral health and the risks of dental treatment during pregnancy. Women who received guidance on oral health in pregnancy and after birth showed higher knowledge of their oral health and that of their children, demonstrating the importance of carrying out health promotion actions during pregnancy and the first years of the child's life. Significance: The importance of oral health during pregnancy for women's health and preventive actions for the control of oral diseases in childhood is well established in the literature. However, even with significant advances in this regard, early childhood caries remain prevalent. During the first years of life, the child is highly dependent on maternal care. Therefore, there is essential to understand maternal knowledge about their own oral health and that of their children, to better target public prevention actions. [ABSTRACT FROM AUTHOR]

Introduction: During the SARS-CoV-2 pandemic, maternity care has been substantially altered to reduce transmission of the SARS-CoV-2 virus. Many antenatal services are now restricted or delivered online, and visiting has been restricted during labour and in the postnatal period. Methods: We conducted an online survey from 1st August to 31st December 2020 to investigate the experiences of women who were pregnant or breastfeeding in the UK during the SARS-CoV-2 pandemic. The survey included 55 open and closed questions and required 5 min to complete. We publicised the survey using social media. Results: We received 96 responses, including 66 currently pregnant women and 22 women who were pregnant during the pandemic. The response rate was 70.1% of survey views. We found mixed experiences of the impact of the pandemic on antenatal and perinatal care, notably with some women feeling visiting restrictions were insufficient and others feeling they were too strict. Twenty-nine women received no information about COVID-19, and 6 women found it very difficult to find information. Thirty-nine women would have liked to have more information about breastfeeding after a pregnancy affected by COVID-19, and 37 women wanted more information about antibody persistence and transfer. Discussion: Additional support is required for pregnant and lactating women during the current pandemic. Provision of information and support, including via social media, may improve women's experiences of pregnancy in the current environment. Significance: Maternity services in the UK have been significantly restructured to prevent transmission of the SARS-CoV-2 virus, including restrictions to in-person antenatal care, and perinatal visiting. It is not fully known how these changes are perceived by pregnant and breastfeeding women. Reactions to changes in antenatal care are mixed, including whether restrictions were too lenient or too strict. Most women underwent online antenatal care in addition in-person visits. Some received no information about COVID-19, and a significant proportion of women would have liked more information, particularly regarding antibody transfer and benefits of breastfeeding during the pandemic. [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]

Objectives: We investigated the relationship between maternal hepatitis C virus (HCV) infection and infant health. Furthermore, we evaluated racial disparities with these associations. Methods: Using 2017 US birth certificate data, we investigated the association between maternal HCV infection and infant birthweight, preterm birth, and Apgar score. We used unadjusted and adjusted linear regression and logistic regression models. Models were adjusted for use of prenatal care, maternal age, maternal education, maternal smoking status, and the presence of other sexually transmitted infections. We stratified the models by race to describe the experiences of White and Black women separately. Results: Maternal HCV infection was associated with reduced infant birthweight on average by 42.0 g (95% CI: -58.81, -25.30) for women of all races, 64.6 g (95% CI: -81.91, -47.26) for White women and 80.3 g (95% CI: -162.48, 1.93) for Black women. Women with maternal HCV infection had increased odds of having a preterm birth of 1.06 (95% CI: 0.96, 1.17) for women of all races, 1.06 (95% CI: 0.96, 1.18) for White women and 1.35 (95% CI: 0.93, 1.97) for Black women. Overall, women with maternal HCV infection had increased odds 1.26 (95% CI: 1.03, 1.55) of having a low/intermediate Apgar score; White and Black women with HCV infection had similarly increased odds of an infant with low/intermediate Apgar score in a stratified analysis: 1.23 (95% CI: 0.98, 1.53) for White women and 1.24 (95% CI: 0.51, 3.02) for Black women. Conclusions: Maternal HCV infection was associated with lower infant birthweight and higher odds of having a low/intermediate Apgar score. Given the potential for residual confounding, these results should be interpreted with caution. [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]

Background: Hypertensive disorders of pregnancy is one of the leading causes of adverse infant outcomes. Black women are disproportionately affected by hypertensive disorders of pregnancy, and it associated adverse outcomes. Adequate prenatal care may improve adverse infant outcomes. However, the evidence on adequate prenatal care improving birth outcomes for women with hypertensive disorders of pregnancy especially for Blacks is limited. This study examined the role of adequate prenatal care and race/ethnicity as moderators of hypertensive disorders of pregnancy on infant outcomes. Methods: The sample was obtained from the 2016–2019 Pregnancy Risk Assessment Monitoring Surveillance dataset from North Carolina. We compared adequate prenatal care among women with hypertensive disorders of pregnancy (n = 610) to women without(n = 2,827), and women with hypertensive disorders of pregnancy with adequate prenatal care to women hypertensive disorders of pregnancy with inadequate prenatal care. Results: The weighted prevalence of hypertensive disorders of pregnancy was 14.1%. Adequate prenatal care was associated with better infant outcomes for low birth weight (AOR = 0.72; 95% CI = 0.58, 0.90) and preterm birth (AOR = 0.62; 95% CI = 0.46, 0.82). Although these effects were not moderated by Black race/ethnicity, Black women independently also had worse outcomes for preterm birth (AOR = 1.59; 95% CI = 1.11, 2.28) and low birth weight (AOR = 1.81; 95% CI = 1.42, 2.29). Conclusions: Moderation of hypertensive disorders of pregnancy effects on infant outcomes by prenatal care and race/ethnicity was not found. Women with hypertensive disorders of pregnancy who received inadequate prenatal care experienced worse adverse birth outcomes compared to women without hypertensive disorders of pregnancy. Strategies to improve prenatal care, particularly among underserved populations at risk for hypertensive disorders of pregnancy, need to be a public health priority. Significance: What is already known on this subject? Racial/ethnicity disparities persist in birth outcomes in the United States despite the continuous efforts to improve birth outcomes. What this study adds? Although, adequate prenatal care improves preterm birth, low birth weight, and small for gestational age, adequate prenatal care or race/ethnicity did not moderate adverse birth outcomes. Healthcare provider contacts during the pregnancy period may not be enough to address birth outcomes disparities. Preconception interventions should be encouraged, especially for Black women. [ABSTRACT FROM AUTHOR]

Objectives: We evaluated differences in vaccination rates of patients of teaching and private practices, and explored the rate of vaccine hesitancy in pregnant women. Methods: This was a cross-sectional study of a convenience sample of recently delivered women. Women completed a survey, which included a question about whether they received the influenza and/or Tdap vaccine, and a vaccine hesitancy scale for both influenza and Tdap vaccines. We also reviewed prenatal records to confirm vaccine administration and collected demographic data. Patients who received care on the teaching service (care by residents supervised by faculty) were compared with those who received care from 26 private practitioners in nine groups. The primary outcome was rate of vaccination. Fisher's exact test was performed to compare groups. Results: Of the 231 women approached, 208 (90.0%) agreed to participate. Of the 208 participants, 70 (33.7%) had prenatal care with a teaching practice, and 138 (66.3%) with a private practice. Patients of teaching practices had a higher influenza and Tdap vaccination rate compared with patients of private practices (Influenza: 70% versus 54.3%, p = 0.036; Tdap: 77.1% versus 58.4%, p = 0.009). Among the entire cohort, 55.3% had some degree of vaccine hesitancy. This did not differ between teaching and private practices (54.3% versus 55.8%, p = 0.883). Conclusions: In spite of similar prevalence of vaccine hesitancy, pregnant women cared for in teaching practices had higher vaccination rates than those cared for in private practices. Significance: What is Already Known on this Subject? Prior studies have assessed individual patient characteristics as predictors of influenza and tetanus, diphtheria, and pertussis (Tdap) vaccination in pregnancy, but little is published on the role of provider type. What this Study Adds? Teaching practices had higher vaccination rates in pregnancy than private practices despite similar prevalence of vaccine hesitancy between groups. Areas of future research should focus on incorporating evidence-based strategies in practices, particularly private practices, to improve vaccination rates in pregnancy. [ABSTRACT FROM AUTHOR]

Introduction: Pregnancy is a time of increased vulnerability to mental health disorders. Additionally, the COVID-19 pandemic has increased the incidence of depression and anxiety. Thus, we aimed to assess mental health and associated healthy behaviors of pregnant people in California during the pandemic in order to contextualize prenatal well-being during the first pandemic of the twenty-first century. Methods: We conducted an online cross-sectional study of 433 pregnant people from June 6 through July 29, 2020. We explored 3 hypotheses: (1) mental health would be worse during the pandemic than in general pregnant samples to date; (2) first-time pregnant people would have worse mental health; and (3) healthy behaviors would be positively related to mental health. Results: Many of our participants (22%) reported clinically significant depressive symptoms and 31% reported clinically significant anxiety symptoms. Multiparous pregnant people were more likely to express worries about their own health and wellbeing and the process of childbirth than were primiparous pregnant people. Additionally, as pregnancy advanced, sleep and nutrition worsened, while physical activity increased. Lastly, anxious-depressive symptomology was significantly predictive of participant sleep behaviors, nutrition, and physical activity during the past week. Discussion: Pregnant people had worse mental health during the pandemic, and this was associated with worse health-promoting behaviors. Given that the COVID-19 pandemic and associated risks are likely to persist due to low vaccination rates and the emergence of variants with high infection rates, care that promotes mental and physical well-being for the pregnant population should be a public health priority. Significance: Consistent with other studies, we found that anxiety, depression, and stress levels in our pregnant cohort were higher than reported pre-pandemic and that anxious-depressive symptomology predicted worse sleep, poorer nutrition, and less physical activity. New in this study was that these relationships were the same for primiparous and multiparous pregnant people, did not change with gestational age, and that while sleep and nutrition worsened throughout pregnancy, physical activity actually increased, regardless of anxious-depressive symptomology. Also new to this study was that multiparous pregnant people had more worries about their and their baby's wellbeing than first time mothers. [ABSTRACT FROM AUTHOR]

Objectives: (1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity. Methods: This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors. Results: A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS. Conclusions for Practice: MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy. Significance: What is already known on this subject? The use of MOUD during pregnancy improves fetal outcomes, while antenatal exposure to MOUD increases the risk of NOWS. The severity of NOWS is influenced by MOUD type, co-exposures, adequacy of prenatal care, and the infant's gestational age. What this study adds? This study identifies factors that mediate the direct influence of antenatal MOUD exposure on the severity of NOWS and quantifies the degree to which this mediation influences outcomes in a large and geographically diverse population. Thus, providing clinicians with potential targets to improve care for this vulnerable population. [ABSTRACT FROM AUTHOR]

Purpose: Prenatal care is important for positive outcomes for both mother and infant. The traditional one-on-one method remains the most common. This study aimed to compare perinatal outcomes of patients attending group prenatal care with traditional prenatal care. Most previously published comparisons did not match for parity, a key predictor of perinatal outcome. Description: We collected perinatal outcome data for 137 group prenatal care patients and 137 traditional prenatal care patients, matched for contemporaneous delivery and parity, who delivered at our small rural hospital during 2015–2016. We included key public health variables, including the initiation of breastfeeding, and smoking at the time of delivery. Assessment: There was no difference between the two groups for maternal age or infant ethnicity, induced or augmented labor, preterm deliveries, APGAR scores less than 7, low birth weight, NICU admissions, or cesarean deliveries. Group care patients had more prenatal visits and were more likely to initiate breastfeeding and were less likely to report smoking at the time of delivery. Conclusion: In our rural population matched for contemporaneous delivery and parity, we found no difference in traditional perinatal outcome measures and that group care was positively associated with the key public health variables of not smoking and initiating breastfeeding. If future studies in other populations have similar findings, it may be wise to provide group care more widely to rural populations. Significance: We provide a comprehensive table comparing previous studies of group care with a focus on differences in the populations studied. Ours is the first to provide perinatal outcomes from a rural population in the US and only the second to match for parity, a key predictor. Our groups were smaller than previous reports, but our complete matching on parity and contemporaneous delivery of the control group are strengths. We found no difference in traditional perinatal outcome, but group care patients reported higher rates of breastfeeding and not smoking, a difference only found in two previous urban-based reports. [ABSTRACT FROM AUTHOR]

Objectives: To propose a measure for adverse maternal experiences (AMEs) and examine if AMEs are independently associated with delivery of a neonatal abstinence syndrome (NAS) diagnosed infant. Methods: Using the Pregnancy Risk Assessment Monitoring System (PRAMS) stressful life events questions, we constructed a composite measure of AMEs. We conducted a retrospective analysis of linked Birth Certificate Data, Hospital Discharge Data and PRAMS data for 2012–2018 using the composite measure. Our analytic sample included 6358 singleton deliveries. We calculated prevalence of NAS and AMEs and prevalence odds ratio (POR) for delivery of an NAS-diagnosed infant adjusting for maternal sociodemographic characteristics, pre-pregnancy depression, prescription medicine 12 months prior to pregnancy, and smoking during pregnancy. Results: The overall prevalence of NAS in Delaware during 2012–2018 was 2.2% (95% CI 1.8–2.6); 9.5% (95% CI 8.7–10.2) of women reported AMEs. After adjustment, women with AMEs had 1.1 times greater odds (aPOR 2.1; 95% CI 1.3–3.3) to deliver a NAS-diagnosed infant as compared with women without AMEs. Conclusions: Although the cross-sectional nature of the study limits drawing any causal inferences, there are co-occurring factors that support plausibility of an association between AMEs and delivering NAS-diagnosed infants. Addressing AMEs, mental health and substance use screening and treatment as part of preconception and prenatal care may mitigate risks. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the extent to which spatial social polarization is associated with preterm birth among urban African-American and non-Latinx white women, and whether prenatal care modifies this relationship. Methods: We performed multilevel logistic regression analyses on a 2013–2017 dataset of Chicago vital records (N = 29,179) with appended Index of Concentration at the Extremes (ICE) values for race and income. Results: Women who resided in the bottom ICE quintile neighborhoods had a preterm birth rate of 11.5%, compared to 7.3% for those who live in the top ICE quintile areas; adjusted odds ratio (aOR) equaled 1.72 (95% confidence interval [CI] = 1.39, 2.12). This disparity widened for early (< 34 weeks) preterm birth rates, aOR = 2.60 (1.77, 3.81). These associations persisted among women with adequate prenatal care utilization. Conclusions for Practice: Spatial polarization of race and income in urban African-American and non-Latinx white women's residential environment is strongly associated with preterm birth rates, even among those who receive adequate prenatal care. These findings highlight the benefit of using ICE to contextualize the impact of urban neighborhood-level characteristics on preterm birth rates. Significance: To better understand the social determinants of preterm birth, research efforts have shifted from women's individual-level characteristics toward their exposure to contextual markers. The Index of Concentration at the Extremes (ICE) is a novel measure of spatial social polarization that quantifies the extremes of both privilege and deprivation. Our population-based study adds to the limited published literature on the relation of ICE to preterm birth rates among African-American and non-Latinx white women. We found that the high degree of both racial and income polarization within communities was associated with preterm birth rates even among those who received adequate prenatal care [ABSTRACT FROM AUTHOR]

Introduction: The THRIVE (Toward Health Resiliency and Infant Vitality & Equity) program aims to reduce racial disparities in birth outcomes by addressing individual risks and social determinants of health using the Pathways Community HUB model. This study examines (1) racial disparities among THRIVE participants and propensity score matched (PSM) comparisons in adequacy of prenatal care, and whether THRIVE participation (2) attenuates such disparities, and (3) improves odds of having adequate prenatal care. Methods: Birth certificate and Care Coordination Systems client data were merged for analysis. PSM was employed for 1:1 matching per birth year (2017–2020) and race for participating and non-participating first-time births in Stark County, Ohio. Additional matching variables were age, marital status, education attainment, birth quarter, census tract poverty rate, and Women Infant & Children (WIC) enrollment. Logistic regression assessed racial differences in adequate prenatal care utilization (APNCU) and examined differences between the intervention and comparison groups on APNCU. Results: THRIVE participants averaged more prenatal care visits and had a higher percentage of adequate care utilization than the comparison group. THRIVE program participation, educational attainment, and WIC enrollment were associated with higher odds of adequate prenatal care utilization (OR 4.74; 95% CI 2.62, 8.57). Race was not significant for APNCU. Discussion: Although accessing and maintaining prenatal care is only one aspect of improving birth outcomes, the findings contribute to the understanding of the effects of the program of interest and other similar programs on factors which may promote desired birth outcomes in high-risk populations. [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]