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Context: While low birth weight is the leading cause of infant mortality and morbidity, the factors influencing low birth weight are not well understood. In particular, the relationship between stressful life events and birth outcomes is unclear. It is important for health care providers to better understand the impact of stress on health outcomes., Methods: Data from a statewide case-control study of 2,378 Missouri mothers are used to examine the relationship of perceived stress, pregnancy attitudes and major life events as psychosocial risk factors on very low birth weight (i.e., birth weight lower than 1,500 g). Such births are contrasted with moderately low birth weight births (those weighing between 1,500 and 2,499 g) and normal-birth-weight infants (those weighing 2,500 g or more). A stepwise logistic regression model is used to control for all study and control variables., Results: The risk of very low birth weight is one and one-half times greater if the mother perceived that she "almost always" felt stress during her pregnancy. The regression model confirms that besides perceived stress, several other factors are independently associated with an increased risk of very low or moderately low birth weight. For example, getting back with a husband or partner or experiencing a major injury accident or illness were associated with an elevated risk of low birth weight (odds ratio, 1. 7), as was pregnancy denial (1.4-1.6) and unhappiness about the pregnancy (1.3). On the other hand, a few factors (taking out a mortgage or loan, having a close relative die and having a mistimed pregnancy) appear to have reduced the odds of low birth weight (odds ratio, 0.5-0.8)., Conclusions: Interventions with pregnant women, especially those assessing perceived stress and attitudes toward the pregnancy, have the potential to improve pregnancy outcomes. Additional prospective research with pregnant women on the origins and effects of stress, including the biological effects of stress, is needed.

Context: If the national health objective of reducing unintended pregnancy is to be met, a better understanding is needed of barriers to women's acquisition and use of contraceptives., Methods: A sample of 311 Missouri women who were seeking pregnancy tests in public health department clinics in 1997 and who said their potential pregnancy was unintended were asked about potential barriers to family planning. Factors affecting contraceptive use among these women were examined by frequency of use, insurance status, education and race., Results: In general, the women mostly disagreed that particular factors were potential barriers to contraceptive use. For only one item--worry over the potential side effects of the hormonal injectable contraceptive--did a majority agree or strongly agree that it was a barrier to method use in the previous six months. Women who used a contraceptive infrequently were more likely than frequent users to identify 33 factors in nine areas as being potential barriers to contraceptive use. These ranged from factors involving access to services and condom-specific issues to cost-related concerns, social norms, pregnancy denial, embarrassment over discussing or obtaining birth control, worry about side effects and experience with forced sex, among others. Perceived barriers differed somewhat by insurance status in the areas of access, embarrassment, side effects and forced sex. For example, women with no insurance coverage reported a higher level of agreement that transportation problems had hindered their access to a clinic than did women with private insurance. Level of education affected agreement only in the area of side effects, with more-educated women expressing greater concern about side effects than less-educated women. The respondent's race affected agreement in six areas: access, social norms, pregnancy denial, embarrassment, forced sex and other miscellaneous concerns, such as condom use and relationship issues., Conclusion: Better education and improved access to and delivery of services might address several factors affecting contraceptive use that are associated with unintended pregnancy. Some barriers, however, such as those related to self-efficacy, self-esteem and fatalistic attitudes about pregnancy, would be much harder for family planning providers to resolve.

The relationship between pregnancy wantedness and adverse pregnancy outcomes was studied using data from 2,828 mothers who participated in the Missouri Maternal and Infant Health Survey. The wantedness of a pregnancy was measured using traditional classifications of mistimed and unwanted, as well as additional measures gauging how the woman felt about the pregnancy while she was pregnant. Fifty-eight percent of the very low birth weight infants and 59% of the moderately low birth weight infants resulted from unintended pregnancies, as did 62% of the normal-birth-weight infants. Logistic regression showed that mothers of very low birth weight infants were significantly more likely than those who had a normal-weight baby to report that they had felt unhappy about the pregnancy (odds ratio of 1.53). Very low birth weight was also associated with early denial of the pregnancy (1.54). Odds ratios associating these two unwantedness categories with low-birth-weight babies were higher among Medicaid recipients than among women not receiving Medicaid. Associations between very low birth weight and the denial variable were also significant among white women when very low birth weight outcomes were compared with normal outcomes, but there was no significant association among black women. There were no significant associations between low birth weight and the traditional unwantedness variables.