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Objectives. To assess the relationship between doula utilization and health outcomes of females enrolled in Medicaid-affiliated plans in the United States. Methods. In this retrospective, observational cohort study, we used Medicaid claims data from a national health insurer to compare health outcomes between females who used and who did not use a doula (2014–2023). We conducted propensity score matching using a 1:1 case‒control match, without replacement, and fit logistic regressions to analyze the relative risks for maternal health outcomes. Results. The study population included 722 matched pairs with and without a doula. Results indicate females with doulas had a 47% lower risk of cesarean delivery and a 29% lower risk of preterm birth, and were 46% more likely to attend a postpartum checkup (all differences P <.05). Conclusions. Doula care is associated with improved health outcomes among Medicaid enrollees. Public Health Implications. Doulas have garnered increasing interest from policymakers as a strategy to address increasing trends in maternal morbidity and persistent health disparities. This study provides evidence from Medicaid enrollees across the United States that doula care can improve maternal health. (Am J Public Health. 2024;114(11):1275–1285. https://doi.org/10.2105/AJPH.2024.307805) [ABSTRACT FROM AUTHOR]

Insurance coverage for prenatal care, labor and delivery care, and postpartum care for undocumented immigrants consists of a patchwork of state and federal policies, which varies widely by state. According to federal law, states must provide coverage for labor and delivery through Emergency Medicaid. Various states have additional prenatal and postpartum coverage for undocumented immigrants through policy mechanisms such as the Children's Health Insurance Program's "unborn child" option, expansion of Medicaid, and independent state-level mechanisms. Using a search of state Medicaid and federal government websites, we found that 27 states and the District of Columbia provide additional coverage for prenatal care, postpartum care, or both, while 23 states do not. Twelve states include any postpartum coverage; 7 provide coverage for 12 months postpartum. Although information regarding coverage is available publicly online, there exist many barriers to access, such as lack of transparency, lack of availability of information in multiple languages, and incorrect information. More inclusive and easily accessible policies are needed as the first step toward improving maternal health among undocumented immigrants, a population trapped in a complicated web of immigration policy and a maternal health crisis. (Am J Public Health. 2024;114(10):1051–1060. https://doi.org/10.2105/AJPH.2024.307750) [ABSTRACT FROM AUTHOR]

The authors discuss a study by Falconi and colleagues published in the issue which assessed the relationship between doula care and pregnancy-related health outcomes in a Medicaid-enrolled population. Topics include strong evidence on benefits of doula care, improvement in health equity through doula access, and equitable implementation of Medicaid coverage of doula support.

Objectives. To examine the accessibility of hospital facilities with maternity care services in 1 rural county in Alabama in preparation for the initiation of prenatal care services at a federally qualified health center. Methods. We analyzed driving distance (in miles) from maternal city of residence in Conecuh County, Alabama to hospital of delivery, using 2019–2021 vital statistics data and geographic information system (GIS) software. Results. A total of 370 births to mothers who have home addresses in Conecuh County were reported, and 368 of those were in hospital facilities. The majority of deliveries were less than 30 miles (median = 23 miles) from the maternal city of residence. Some women traveled more than 70 miles for obstetrical care. Conclusions. Pregnant patients in Conecuh County experience significant geographic barriers related to perinatal care access. Using GIS for this analysis is a promising approach to better understand the unique challenges of pregnant individuals in this rural population. Public health policy efforts need to be geographically tailored to address these disparities. (Am J Public Health. 2024;114(S4):S330–S333. https://doi.org/10.2105/AJPH.2024.307692) [ABSTRACT FROM AUTHOR]

The authors provide information on a training program developed by primary care training and enhancing staff in the Division of Medicine and Dentistry, Bureau of Health Workforce, Health Resources and Services Administration (HRSA) designed to integrate public health and primary care training. Topics discussed include the dual model of training, how the program can improve maternal health, and program activity.

The article discusses the need for systematic approaches addressing violence in families and relationships to address U.S. maternal health outcomes. Topics include effects of intimate partner violence (IPV), medical societies that recommend perinatal screening for IPV, and the need for perinatal health care providers and health systems to overhaul their approaches to stopping IPV and its multigenerational impact.

The article discusses health and reproductive injustices experienced by Puerto Rican mothers in the U.S. as of July 2024. Topics covered include their historical roots in colonization and systemic neglect, the determinants of pre- and perinatal health disparities, and the multifaceted issues like provider challenges in care delivery and physician shortage that impact peronatal health. Also noted are evidence-based interventions like telemedicine services, community health workers and doulas.

The article discusses a study by Margerison and colleagues which evaluated changes in five categories of pregnancy-associated death during the first two years of COVID-19 pandemic. Topics include racial/ethnic disparities in each of the incidental or accidental causes, significant increases in different types of pregnancy-associated deaths during the first two years of the pandemic, and a template of evaluations of inequities provided by the researchers outside the perinatal space.

An introduction to articles in the issue is presented on topics including interventions designed to test workforce and other approaches to reducing maternal morbidity and mortality, a quality improvement study which showed an increase in COVID-19 vaccination rates among pregnant and postpartum people, and interventions designed to test workforce and other approaches to reducing maternal morbidity and mortality.

Medicaid is the primary payor for nearly half of all births in the United States and plays a disproportionate role in covering maternity care for low-income people, rural people, and minoritized racial groups. Newly available, modernized Medicaid claims data—the Transformed Medicaid Statistical Information System Analytic Files (TAF)—offer a significant opportunity to conduct novel research that can drive the development of evidence-based programs and policies for Medicaid beneficiaries before, during, and after pregnancy. Yet, the public health research community has so far underused the TAF for maternal health research. We provide an overview of the TAF and how they compare to other major data sets available to study maternal health. We highlight some major limitations of the TAF and offer strategies to maximize the potential of these novel data to accelerate timely, rigorous research to improve maternal health and health equity. (Am J Public Health. 2023;113(7):805–810. https://doi.org/10.2105/AJPH.2023.307287) [ABSTRACT FROM AUTHOR]

Using linked birth and death certificates for participants served by a Healthy Start program in South Carolina and community controls, we found that the Healthy Start program contributed to significant improvements in prenatal care, breastfeeding initiation, and participation in the Special Supplemental Nutrition Program for Women, Infants, and Children and significant reductions in inadequate weight gain and large-for-gestational-age births. However, Healthy Start participants were more likely to gain excessive weight during pregnancy, and there were no significant differences in perinatal outcomes. (Am J Public Health. 2023;113(5):509–513. https://doi.org/10.2105/AJPH.2023.307232) [ABSTRACT FROM AUTHOR]

Objectives. To measure rates of intimate partner violence (IPV) screening during the perinatal period among people experiencing physical violence in the United States. Methods. We used 2016–2019 Pregnancy Risk Assessment Monitoring System data (n = 158 338) to describe the incidence of physical IPV before or during pregnancy. We then assessed the prevalence of IPV screening before, during, or after pregnancy and predictors of receiving screening among those reporting violence. Results. Among the 3.5% (n = 6259) of respondents experiencing violence, 58.7%, 26.9%, and 48.3% were not screened before, during, or after pregnancy, respectively. Those reporting Medicaid or no insurance at birth, American Indian/Alaska Native people, and Spanish-speaking Hispanic people faced increased risk of not having a health care visit during which screening might occur. Among those attending a health care visit, privately insured people, rural residents, and non-Hispanic White respondents faced increased risk of not being screened. Conclusions. Among birthing people reporting physical IPV, nearly half were not screened for IPV before or after pregnancy. Public health efforts to improve maternal health must address both access to care and universal screening for IPV. (Am J Public Health. 2023;113(3):297–305. https://doi.org/10.2105/10.2105/AJPH.2022.307195) [ABSTRACT FROM AUTHOR]

The article discusses issues concerning high maternal mortality in the U.S. Topics include definition given by the World Health Organization on maternal deaths, persistence of racial/ethnic inequities in pregnancy-associated mortality, and ways the vast majority of pregnancy-associated deaths occurring in the U.S. can be prevented.

Objectives. To describe prevalence of breast milk feeding among people with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy and examine associations between breast milk feeding, timing of maternal infection before delivery, and rooming-in status during delivery hospitalization. Methods. We performed a retrospective cohort study using data from Massachusetts, Minnesota, Nebraska, Pennsylvania, and Tennessee of whether people with confirmed SARS-CoV-2 infection during pregnancy in 2020 initiated breast milk feeding at birth. Results. Among 11 114 (weighted number) people with SARS-CoV-2 infection in pregnancy, 86.5% (95% confidence interval [CI] = 82.4%, 87.6%) initiated breast milk feeding during birth hospitalization. People with infection within 14 days before delivery had significantly lower prevalence of breast milk feeding (adjusted prevalence ratio [APR] = 0.88; 95% CI = 0.83, 0.94) than did those with infection at least 14 days before delivery. When stratified by rooming-in status, the association between timing of infection and breast milk feeding remained only among infants who did not room in with their mother (APR = 0.77; 95% CI = 0.68, 0.88). Conclusions. Pregnant and postpartum people with SARS-CoV-2 infection should have access to lactation support and be advised about the importance of breast milk feeding and how to safely feed their infants in the same room. (Am J Public Health. 2022;112(S8):S787–S796. https://doi.org/10.2105/AJPH.2022.307023) [ABSTRACT FROM AUTHOR]

The article provides information on the study "Denial of Abortion Because of Provider Gestational Age Limits in the U.S." by Ushma D. Upadhyay and colleagues, which examined the factors influencing delay in seeking abortion and the outcomes for women denied abortion care because of gestational age limits at abortion facilities. Topics discussed include methodology of the study, reasons for delay and access barriers, and factors associated with obtaining an abortion after being denied one.

An introduction to the supplement which showcases the grant recipients' learning activities and preliminary outcomes during the first two to three years of the five-year grant is presented.

The authors talk about a Family Medicine obstetric (FMOB) care residency program developed by the departments of Family and Community Medicine (FCM) and obstetrics and gynecology (OB/GYN) at the University of Oklahoma School of Community Medicine to address the lack of rural obstetric care in Oklahoma. Topics discussed include ways FMOB track residents received expanded obstetrics education, details of the program, and evaluation of the FMOB program.

The authors discuss the factors that affect the likelihood of choosing to provide maternity care and care of persons with opioid use disorder (OUD). Topics include percentage of residents who had treated at least one patient with buprenorphine in the previous 12 months, assessment made on physician childhood socioeconomic status (SES), and some of the changes that illustrate the importance and clinical aspects of SUDs and buprenorphine prescribing.

The article presents a study which explored innovative interventions in which Maternal Mortality Review Committees (MMRCs) actively engaged physician trainees, enhancing their understanding of maternal population health. Topics discussed include evaluation method and findings, challenges to the training model, and analysis of integrating trainees into local and state MMRCs.

The article describes a Perinatal Extension for the Community Healthcare Outcomes (ECHO) program to improve rural obstetrics care. Topics discussed include an overview of the Perinatal Tele-ECHO, participants invited to attend the Perinatal Tele-ECHO including physicians providing maternal health care or caring for prenatal patients, and evaluation method and findings.

The article provides information on interpersonal training developed and implemented by faculty in Texas A&M Schools of Medicine and Nursing to prepare future health care workers for high-risk, maternal-neonatal emergencies to improve outcomes. Topics discussed include goals of the training, issues addressed in the clinical simulations of obstetrical and neonatal emergencies involving residents and nursing students, and evaluation method and findings.

An editorial is presented in which the author discusses the Strong Start for Mothers and Newborns Initiative established by the U.S. Centers for Medicare and Medicaid Innovation, and its role in the promotion of health equity for newborns with low birth weight (LBW) and their mothers. The article also discusses reform for the U.S. maternity care system, the role of midwives, and access to birth centers.

The author reflects on significance of women's health, nutrition and well-being across the continuum of preconception, pregnancy, and postpartum for ensuring positive pregnancy outcomes and long-term outcomes for both mothers and their offspring. Topics discussed include global prevalence of maternal underweight and short stature in 2015, causes of maternal malnutrition, and important priority areas and knowledge gaps for improving women's nutrition.

The author reveals that the U.S. lags behind other countries when it comes to reducing maternal mortality ratio (MMR). Topics discussed include pregnancy-related deaths in the U.S., significance of maternal nutrition to maternal health, and reason it is important to integrate nutrition in medical education.

Objectives. To better understand racial and ethnic disparities in US maternal mortality. Methods. We analyzed 2016–2017 vital statistics mortality data with cause-of-death literals (actual words written on the death certificate) added. We created a subset of confirmed maternal deaths that had pregnancy mentions in the cause-of-death literals. Primary cause of death was identified and recoded using cause-of-death literals. We examined racial and ethnic disparities both overall and by primary cause. Results. The maternal mortality rate for non-Hispanic Black women was 3.55 times that for non-Hispanic White women. Leading causes of maternal death for non-Hispanic Black women were eclampsia and preeclampsia and postpartum cardiomyopathy with rates 5 times those for non-Hispanic White women. Non-Hispanic Black maternal mortality rates from obstetric embolism and obstetric hemorrhage were 2.3 to 2.6 times those for non-Hispanic White women. Together, these 4 causes accounted for 59% of the non-Hispanic Black‒non-Hispanic White maternal mortality disparity. Conclusions. The prominence of cardiovascular-related conditions among the leading causes of confirmed maternal death, particularly for non-Hispanic Black women, necessitates increased vigilance for cardiovascular problems during the pregnant and postpartum period. Many of these deaths are preventable. [ABSTRACT FROM AUTHOR]

The article announces that the editors for the journal supplement, "Improving Maternal Health Outcomes" have no conflicts of interest to disclose.

Safe Start is a community health worker program representing a partnership between a high-volume, inner-city, hospital-based prenatal clinic; a community-based organization; a large Medicaid insurer; and a community behavioral health organization to improve perinatal outcomes among publicly insured pregnant women with chronic health conditions in Philadelphia, Pennsylvania. As of June 2019, 291 women participated in the program. Relative to a comparison group (n = 300), Safe Start participants demonstrate improved engagement in care, reduced antenatal inpatient admissions, and shorter neonatal intensive care unit stays. [ABSTRACT FROM AUTHOR]

Objectives. To examine relationships among actionable drivers and facilitators of stigma and nurses' intentions to provide the standard of maternal care recommended by the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) for incarcerated women. Methods. We conducted a Web-based survey of perinatal nurses in the United States (n = 665; participation rate 98.0%; completion rate 95.3%) in July through September 2017. We used multivariable logistic regression to predict higher than median intentions to provide the standard of care. Results. Lower stigmatizing individual attitudes and institutional norms and higher perceived autonomy when caring for an incarcerated woman were significantly associated with higher care intentions. Knowledge of the AWHONN position statement on the standard of care or their own state's shackling laws was not associated with higher care intentions. Conclusions. We documented significant associations among actionable drivers and facilitators of stigma and the intentions of a key health care provider group to deliver the standard of maternal care to incarcerated women. Individual- and institutional-level stigma-reduction interventions may increase the quality of maternal care and improve perinatal outcomes for women who give birth while incarcerated. [ABSTRACT FROM AUTHOR]

We describe how mass incarceration directly undermines the core values of reproductive justice and how this affects incarcerated and nonincarcerated women. Mass incarceration, by its very nature, compromises and undermines bodily autonomy and the capacity for incarcerated people to make decisions about their reproductive well-being and bodies; this is done through institutionalized racism and is disproportionately done to the bodies of women of color. This violates the most basic tenets of reproductive justice—the right to have a child, not to have a child, and to parent the children you have with dignity and in safety. By undermining motherhood and safe pregnancy care, denying access to abortion and contraception, and preventing people from parenting their children at all and by doing so in overpoliced, unsafe environments, mass incarceration has become a driver of forms of reproductive oppression for people in prison and jails and in the community. [ABSTRACT FROM AUTHOR]

An editorial is presented in which the authors discuss various strategies for assisting perinatal patients, parents, and children concerning the use of stimulants such as prescription drugs, cocaine, and methamphetamines amid the opioid crisis in the U.S. The authors urge dyadic care, increased access to health services, and systemic healing. The authors also mention health disparities that increased during the COVID-19 pandemic.

The article offers advice on how to achieve sufficient levels of folic acid in humans without causing excess. The author describes the importance of balancing folic acid with other nutrients like iron and vitamin B12. Other topics discussed include how folic acid supplementation in mothers prevents neural tube defects (NTDs), congenital heart diseases (CHDs) and facial clefts, the sources and functions of folic acid and a reappraisal of strategies for supplementation.

The makes the call for well-integrated, high-functioning maternity care systems in the U.S. This type of care can be designed to support parents giving birth at home or in birth centers. Midwife-attended home and birth center births are associated with fewer maternal procedural interventions and lower rates of intervention-related morbidity. Because of the strain the Covid-19 pandemic is putting on hospitals and the healthcare system, low-risk births are more often being moved to temporary birth center spaces, existing independent birth centers, or home.

Objectives. To describe characteristics of rural hospitals in the United States by whether they provide labor and delivery (obstetric) care for pregnant patients. Methods. We used the 2017 American Hospital Association Annual Survey to identify rural hospitals and describe their characteristics based on the lack or provision of obstetric services. Results. Among the 2019 rural hospitals in the United States, 51% (n = 1032) of rural hospitals did not provide obstetric care. These hospitals were more often located in rural noncore counties (counties with no town of more than 10 000 residents). Rural hospitals without obstetrics also had lower average daily censuses, were more likely to be government owned or for profit compared with nonprofit ownership, and were more likely to not have an emergency department compared with hospitals providing obstetric care (P for all comparisons <.001). Conclusions. Rural US hospitals that do not provide obstetric care are located in more sparsely populated rural locations and are smaller than hospitals providing obstetric care. Public Health Implications. Understanding the characteristics of rural hospitals by lack or provision of obstetric services is important to clinical and policy efforts to ensure safe maternity care for rural residents. [ABSTRACT FROM AUTHOR]

We evaluated the effectiveness of a community health worker–supported home visitor program on perinatal outcomes of 455 at-risk pregnant women with program data merged with electronic medical records from July 2015 through October 2017 in Rochester, New York. Program participants had fewer adverse outcomes than did nonparticipants, including lower rates of preterm birth (12% vs 20%; χ2, P =.05) and low birth weight (14% vs 22%; χ2, P =.05). This program was effective at achieving improved perinatal outcomes. [ABSTRACT FROM AUTHOR]

The article discusses an increase in maternal mortality in the U.S. as quantified by the U.S. Centers for Disease Control and Prevention (CDC), identifies it as a public health crisis, and presents various possible solutions to the crisis. Such possible solutions included an expansion of the Medicaid coverage to eligible women, best practices for guidelines for women in danger of maternal mortality, and what is identified as fourth trimester treatment.

Objectives. To evaluate the impact of the Southern Public Health Regions’ (Regions IV and IV) Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality, supported by the US Health Resources and Services Administration. Methods. We examined pre–post change (2011–2014) for CoIIN strategies with available outcome data from vital records (early elective delivery, smoking) and the Pregnancy Risk Assessment Monitoring System (safe sleep) as well as preterm birth and infant mortality for Regions IV and VI relative to all other regions. Results. For most outcomes, CoIIN improvements were greater in Regions IV and VI than in other regions. For example, early elective delivery decreased by 22% versus 14% in other regions, smoking cessation during pregnancy increased by 7% versus 2%, and back sleep position increased by 5%versus 2%. Preterm birth decreased by 4%, twice that observed in other regions, but infant mortality reductions did not differ significantly. Conclusions. The CoIIN approach to public health improvement shows promise in accelerating progress in intermediate outcomes and preterm birth. Impact on infant mortality may require additional strategies and sustained efforts. [ABSTRACT FROM AUTHOR]

An editorial is presented which addresses recommendations for a pilot expansion of Medicaid health insurance coverage for doulas in New York, and it mentions New York Governor Andrew Cuomo's launch of an initiative to reduce maternal mortality and racial disparities in health outcomes in 2018. Medicaid expansion for doula services in Oregon and Minnesota is examined, along with fees for out-of-pocket doula services and Medicaid reimbursement rates.

Objectives. We aimed to contribute to growing research and theory suggesting the importance of examining patterns of change over time and critical life periods to fully understand the effects of discrimination on health, with a focus on the period of pregnancy and postpartum and mental health outcomes. Methods. We used hierarchical linear modeling to examine changes across pregnancy and postpartum in everyday discrimination and the resulting consequences for mental health among predominantly Black and Latina, socioeconomically disadvantaged young women who were receiving prenatal care in New York City. Results. Patterns of change in experiences with discrimination varied according to age. Among the youngest participants, discrimination increased from the second to third trimesters and then decreased to lower than the baseline level by 1 year postpartum; among the oldest participants, discrimination decreased from the second trimester to 6 months postpartum and then returned to the baseline level by 1 year postpartum. Within-subjects changes in discrimination over time predicted changes in depressive and anxiety symptoms at subsequent points. Discrimination more strongly predicted anxiety symptoms among participants reporting food insecurity. Conclusions. Our results support a life course approach to understanding the impact of experiences with discrimination on health and when to intervene. [ABSTRACT FROM AUTHOR]

We conducted in-depth interviews in May to July 2012 to evaluate the effect of Alabama’s 2011 omnibus immigration law on Latina immigrants and their US- and foreign-born children’s access to and use of health services. The predominant effect of the law on access was a reduction in service availability. Affordability and acceptability of care were adversely affected because of economic insecurity and women’s increased sense of discrimination. Nonpregnant women and foreign-born children experienced the greatest barriers, but pregnant women and mothers of U.S.-born children also had concerns about accessing care. The implications of restricting access to health services and the potential impact this has on public health should be considered in local and national immigration reform discussions. [ABSTRACT FROM AUTHOR]

Evidence suggests national- and community-level interventions are not reaching women living at the economic and social margins of society in Pakistan. We conducted a 10-month qualitative study (May 2010-February 2011) in a village in Punjab, Pakistan. Data were collected using 94 in-depth interviews, 11 focus group discussions, 134 observational sessions, and 5 maternal death case studies. Despite awareness of birth complications and treatment options, poverty and dependence on richer, higher-caste people for cash transfers or loans prevented women from accessing required care. There is a need to end the invisibility of low-caste groups in Pakistani health care policy. Technical improvements in maternal health care services should be supported to counter social and economic marginalization so progress can be made toward Millennium Development Goal 5 in Pakistan. [ABSTRACT FROM AUTHOR]

In Sri Lanka, women do not have access to legal abortion except under lifesaving circumstances. Clandestine abortion services are, however, available and quite accessible. Although safe specialist services are available to women who can afford them, others access services under unsafe and exploitative conditions. At the time of this writing, a draft bill that will legalize abortion in instances of rape, incest, and fetal abnormalities awaits approval, amid opposition. In this article, I explore the current push for legal reform as a solution to unsafe abortion. Although a welcome effort, this amendment alone will be insufficient to address the public health consequences of unsafe abortion in Sri Lanka because most women seek abortions for other reasons. Much broader legal and policy reform will be required. [ABSTRACT FROM AUTHOR]

Objectives. We investigated early childhood disparities in high body mass index (BMI) between Black and White US children. Methods. We compared differences in Black and White children's prevalence of sociodemographic, prenatal, perinatal, and early life risk and protective factors; fit logistic regression models predicting high BMI (‡ 95th percentile) at age 4 to 5 years to 2 nationally representative samples followed from birth; and performed separate and pooled-survey estimations of these models. Results. After adjustment for sample design-related variables, models predicting high BMI in the 2 samples were statistically indistinguishable. In the pooled-survey models, Black children's odds of high BMI were 59% higher than White children's (odds ratio [OR] = 1.59; 95% confidence interval [CI]= 1.32, 1.92). Sociodemographic predictors reduced the racial disparity to 46% (OR = 1.46; 95% CI = 1.17, 1.81). Prenatal, perinatal, and early life predictors reduced the disparity to nonsignificance (OR = 1.18; 95% CI = 0.93, 1.49). Maternal prepregnancy obesity and short-duration or no breastfeeding were among predictors for which racial differences in children's exposures most disadvantaged Black children. Conclusions. Racial disparities in early childhood high BMI were largely explained by potentially modifiable risk and protective factors. [ABSTRACT FROM AUTHOR]

Objectives. We examined whether interpersonal processes of care (IPC) were associated with cesarean delivery. Methods. We performed a cross-sectional study of 1308 postpartum women at Kaiser Permanente Medical Center in Walnut Creek, CA (KP-WC), and San Francisco General Hospital (SFGH) from 2004 to 2006. Using interview and medical record data, logistic regression analyses estimated the odds of cesarean delivery as a function of IPC domains. Results. After adjustment for demographic and reproductive factors, women at KP-WC who reported higher scores for their provider's "elicitation of patient concerns and responsiveness" were less likely to have delivered by cesarean, whereas women who reported higher scores for "empowerment and self-care" were more likely. At KP-WC, women who reported low English proficiency were less likely to have delivered by cesarean than women who reported high proficiency. At SFGH, none of the IPC measures were significant; however, younger age was associated with a lower risk of cesarean delivery, whereas higher educational attainment was associated with an increased risk. Conclusions. To reduce record-high rates of cesarean delivery, more emphasis should be placed on addressing the nonmedical factors associated with operative delivery. [ABSTRACT FROM AUTHOR]

Objectives. We sought to determine whether an HIV prevention program bundled with group prenatal care reduced sexually transmitted infection (STI) incidence, repeat pregnancy, sexual risk behavior, and psychosocial risks. Methods. We conducted a randomized controlled trial at 2 prenatal clinics. We assigned pregnant women aged 14 to 25 years (N=1047) to individual care, attention-matched group care, and group care with an integrated HIV component. We conducted structured interviews at baseline (second trimester), third trimester, and 6 and 12 months postpartum. Results. Mean age of participants was 20.4 years; 80% were African American. According to intent-to-treat analyses, women assigned to the HIV-prevention group intervention were significantly less likely to have repeat pregnancy at 6 months postpartum than individual-care and attention-matched controls; they demonstrated increased condom use and decreased unprotected sexual intercourse compared with individual-care and attention-matched controls. Sub-analyses showed that being in the HIV-prevention group reduced STI incidence among the subgroup of adolescents. Conclusion. HIV prevention integrated with prenatal care resulted in reduced biological, behavioral, and psychosocial risks for HIV. (Am J Public Health. 2009; 99:2079-2086. doi:10.2105/AJPH.2008.154476) [ABSTRACT FROM AUTHOR]

Objectives. We analyzed trends in maternal, newborn, and child mortality in Chile between 1990 and 2004, after the introduction of national interventions and reforms, and examined associations between trends and interventions. Methods. Data were provided by the Chilean Ministry of Health on all pregnancies between 1990 and 2004 (approximately 4000000). We calculated yearly maternal mortality ratios, stillbirth rates, and mortality rates for neonates, infants (aged >28 days and <1 year), and children aged 1 to 4 years. We also calculated these statistics by 5-year intervals for Chile's poorest to richest district quintiles. Results. During the study period, the maternal mortality ratio decreased from 42.1 to 18.5 per 100000 live births. The mortality rate for neonates decreased from 9.0 to 5.7 per 1000 births, for infants from 7.8 to 3.1 per 1000 births, and for young children from 3.1 to 1.7 per 1000 live births. The stillbirth rate declined from 6.0 to 5.0 per 1000 births. Disparities in these mortality statistics between the poorest and richest district quintiles also decreased, with the largest mortality reductions in the poorest quintile. Conclusions. During a period of socioeconomic development and health sector reforms, Chile experienced significant mortality and inequity reductions. {Am J Public Health. 2009;99:1220-1226. doi:10.2105/AJPH.2008.143578) [ABSTRACT FROM AUTHOR]

Objectives. We sought to identify characteristics associated with use of skilled birth attendants where health services exist in Afghanistan. Methods. We conducted a cross-sectional study in all 33 provinces in 2004, yielding data from 617 health facilities and 9917 women who lived near the facilities and had given birth in the past 2 years. Results. Only 13% of respondents had used skilled birth attendants. Women from the wealthiest quintile [vs the poorest quintile) had higher odds of use (odds ratio [OR] = 6.3; 95% confidence interval [CI] = 44, 8.9}. Literacy was strongly associated with use (OR = 2.5; 95% CI = 2.0, 3.2), as was living less than 60 minutes from the facility (OR = 1.5; 95% CI = 1.1, 2,0) and residing near a facility with a female midwife or doctor (OR = 1.4; 95% CI = 1.1, 1.8). Women living near facilities that charged user fees (OR = 0.8; 95% CI = 0.6, 1.0) and that had male community health workers (OR = 0.6; 95% CI = 0.5, 0.9) had lower odds of use. Conclusions. In Afghanistan, the rate of use of safe delivery care must be improved. The financial barriers of poor and uneducated women should be reduced and culturally acceptable alternatives must be considered. (Am J Public Health. 2008;98:1849-1856. doi:10.2105/AJPH.2007.123471) [ABSTRACT FROM AUTHOR]

Objectives. We analyzed trends in mortality among infants born to White and to Black or mixed-race women in 3 population-based cohorts representing all births in 1982, 1993, and 2004 in Pelotas, southern Brazil. Methods. Births were assessed during daily visits to all maternity hospitals. Maternal skin color was classified by the interviewers as White or Black or multiracial. We used logistic regression to adjust for socioeconomic, demographic, and health services variables. Results. The mortality rate among infants born to White mothers declined from 30.4 per 1000 live births in 1982 to 13.9 per 1000 in 2004, compared with 53.8 per 1000 to 30.4 per 1000 among those born to Black and mixed-race mothers. Differences for neonatal mortality were even more marked, with reductions of 47% and 11% for infants born to White and Black or mixed-race women, respectively. Adjusted analyses showed that ethnic group differences in neonatal and infant mortality were partly explained by differences in poverty and prenatal care. Conclusions. Over a 22-year period, improvements in health indicators were greater for infants born to White women than for other infants. The widening racial gap requires special attention from policymakers. (Am J Public Health. 2008; 98:692-698. doi:10.2105/AJPH.2006.093492) [ABSTRACT FROM AUTHOR]