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Introduction Maternal mortality and morbidity rates have risen significantly, yet little research has focused on how severe maternal morbidity (SMM) is associated with future reproductive health, such as birth spacing or the likelihood of subsequent SMM. This study focuses on the risk of SMM recurrence and the association of interpregnancy intervals with SMM. Methods This population-based, retrospective cohort study used Iowa hospital discharge data longitudinally linked to birth certificate data between 2009 and 2014. To examine recurrence of SMM, crude and adjusted multivariable logistic regression models were generated. The associations between varying interpregnancy intervals and subsequent SMM were examined. Crude, stratified, and adjusted risk ratios and their associated 95% confidence intervals were estimated. Results A total of 36,190 women were included in this study. Women with SMM in the index delivery had significantly higher odds of SMM in the subsequent delivery (adjusted odds ratio, 8.16; 95% confidence interval, 5.45–12.24) compared with women without SMM. Women with an interpregnancy interval of less than 6 months compared with 18 months or longer were more likely to experience SMM during their subsequent delivery, although the difference was not statistically significant (adjusted odds ratio, 1.41; 95% confidence interval, 0.99, 2.03). Conclusions This study demonstrates that women who experience SMM are at markedly increased risk of subsequent SMM. Further investigation is necessary to inform optimal interpregnancy interval recommendations based on prior maternal health outcomes.

Objective To examine the association between subjective norms and breastfeeding behaviors and to assess whether individual characteristics modify this association. Design Retrospective cohort study. Setting Florida, 2004 to 2005; Louisiana, 2004; and Ohio, 2009 to 2010. Participants Stratified systematic sample of respondents who completed the Pregnancy Risk Assessment Monitoring System (PRAMS) survey from three states (N = 5,378). Methods We used PRAMS data to examine the associations between three independent variables (breastfeeding discouragement by others and number and type of normative referents) and three breastfeeding behaviors (breastfeeding initiation and breastfeeding duration at 4 weeks and 10 weeks after birth) using multivariable log binomial regression. We also examined whether maternal characteristics modified the association between breastfeeding discouragement by others and breastfeeding behaviors. Results Respondents who reported that others discouraged them from breastfeeding were more likely to initiate breastfeeding (adjusted relative risk (RR) = 0.78, 95% confidence interval [CI] [0.64, 0.96]) than those who were not discouraged. Furthermore, in the total sample, breastfeeding discouragement from others was not associated with breastfeeding discontinuation by 4 weeks and 10 weeks after birth. Breastfeeding discouragement from health care providers was associated with a greater incidence of noninitiation among respondents who reported breastfeeding discouragement from others (adjusted RR = 2.82, 95% CI [1.88, 4.22]). Conclusions Findings suggest that women may be motivated to initiate breastfeeding because of their beliefs and emotions despite being discouraged by others. However, discouragement by health care providers was associated with decreased initiation. This underscores a need for the continued implementation and scale-up of evidence-based maternity care practices and education of providers and the public to support breastfeeding.

To compare two data sources from Wisconsin—Medicaid claims and Pregnancy Risk Assessment Monitoring System (PRAMS) surveys—for measuring postpartum care utilization and to better understand the incongruence between the sources. We used linked Medicaid claims and PRAMS surveys of Wisconsin residents who delivered a live birth during 2011–2015 to assess women’s postpartum care utilization. Three different definitions of postpartum care from Medicaid claims were employed to better examine bundled service codes and timing of care. We used one question from the PRAMS survey that asks women if they have had a postpartum checkup. Concordance between the two data sources was examined using Cohen’s Kappa value. For women who reported having a postpartum checkup on PRAMS but did not have a Medicaid claim for a traditional postpartum visit, we determined the other types of health care visits these women had after delivery documented in the Medicaid claims. Among the 2313 women with a Medicaid-paid delivery and who completed a PRAMS survey, 86.6% had claims for a postpartum visit during the first 12 weeks postpartum and 90.5% self-reported a postpartum checkup on PRAMS (percent agreement = 79.9%, Kappa = 0.015). The percent agreement and Kappa values varied based on the definition of postpartum care derived from the Medicaid claims data. There was slight agreement between Medicaid claims and PRAMS data. Most women had Medicaid claims for postpartum care at some point in the first 12 weeks postpartum, although the timing of these visits was somewhat unclear due to the use of bundled service codes.

To ascertain the component of the excess preterm birth (

There is literature suggesting an intergenerational relationship between maternal and infant size for gestational age status and preterm birth, but much less is known about the contribution of paternal birth outcome to infant birth outcome. This study seeks to determine the association between paternal and infant small-for-gestational-age status (weight for gestational age

To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011–2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics. Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82). Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

Background Unintended pregnancy among women with short interpregnancy intervals remains common. Women's attendance at the 4- to 6-week postpartum visit, when contraception provision often occurs, is low, whereas their attendance at well-baby visits is high. We aimed to evaluate if offering co-located contraceptive services to mothers at well-baby visits increases use of long-acting reversible contraception (LARC) at 5 months postpartum compared with usual care in a randomized, controlled trial. Methods Women with infants aged 4.5 months or younger who were not using a LARC method and had not undergone sterilization were eligible. Generalized linear models were used to estimate risk ratios. Likability and satisfaction of the contraception visit were assessed. Results Between January 2015 and January 2017, 446 women were randomized. LARC use at 5 months was 19.1% and 20.9% for the intervention and control groups, respectively, and was not significantly different after controlling for weeks postpartum (risk ratio, 0.85; 95% confidence interval, 0.59–1.23). Uptake of the co-located visit was low (17.7%), but the concept was liked; insufficient time to stay for the visit was the biggest barrier to uptake. Women who accepted the visit were more likely to use a LARC method at 5 months compared with women in the control group (risk ratio, 1.97; 95% confidence interval, 1.26–3.07). Conclusions Women perceived co-located care favorably and LARC use was higher among those who completed a visit; however, uptake was low for reasons including inability to stay after the infant visit. Intervention effects were possibly diluted. Future research should test a version of this intervention designed to overcome barriers that participants reported.

To examine the extent to which lifelong neighborhood income modifies the generational association of teen birth among White and AA women in Cook County, IL.Stratified and multilevel logistic regression analyses were conducted on the Illinois transgenerational dataset of singleton births (1989-1991) to non-Latina White and AA mothers (born 1956-1976) with appended U.S. census income information. We calculated rates and risks of teen births according to race, maternal age, and lifelong neighborhood economic environment.Teen birth occurred at a rate of 9.5% and 52.9% for White and AA women, respectively. White women whose mothers were teens when they were born had an over five-fold increased risk of becoming teen mothers themselves. For AA women, the risk was smaller, but statistically significant. For both races, women who experienced downward economic mobility had the highest risk of teen birth, while women with upward mobility had the lowest risk, even compared to women in lifelong high income neighborhoods. While White women exposed to lifelong low income had almost threefold increased risk of teen birth compared to those in lifelong high income neighborhoods, AA women in lifelong high and lifelong low income neighborhoods had similar risk of teen birth.Understanding the racial differences in intergenerational patterns of teen birth is important for effective program planning and policy making, given that interventions targeted at daughters of teen mothers may differ in effectiveness for White and AA teens.

Child maltreatment is an important societal and public health problem. However, there are limited data on the epidemiology of maltreatment related hospitalizations.The objective of this study was to describe maltreatment related hospitalizations among children ages 17 and younger in New York State (NYS).Using 2011-2013 statewide planning and research cooperative system (SPARCS) inpatient hospital discharge data, maltreatment related hospitalizations among children ages 17 years and younger were identified using international classification of diseases, ninth revision, clinical modification codes for diagnoses and external cause of injury. Distributions of demographic and inpatient care characteristics were compared between hospitalizations for maltreatment and those for other causes, and between different types of maltreatment, using chi-square tests (for categorical variables) and t-tests (for continuous variables).During 2011-2013, a total of 853 maltreatment related hospitalizations among 836 children ages 17 years and younger were documented in NYS SPARCS. Infants (children 1) had the highest rates of hospitalization. Overall, physical abuse was the most prevalent maltreatment type reported.This is the first study in NYS to describe the epidemiology of child maltreatment hospitalizations; it establishes a statewide baseline for this public health and societal issue.

To determine the proportion of the excess early preterm birth (

Objective To examine whether the H-HOPE (Hospital to Home: Optimizing the Preterm Infant’s Environment) intervention reduced birth hospitalization charges yielding net savings after adjusting for intervention costs. Study design One hundred and twenty-one mother-preterm infant dyads randomized to H-HOPE or a control group had birth hospitalization data. Neonatal intensive care unit costs were based on billing charges. Linear regression, propensity scoring and regression analyses were used to describe charge differences. Results Mean H-HOPE charges were $10,185 lower than controls (p = 0.012). Propensity score matching showed the largest savings of $14,656 (p = 0.003) for H-HOPE infants, and quantile regression showed a savings of $13,222 at the 75th percentile (p = 0.015) for H-HOPE infants. Cost savings increased as hospital charges increased. The mean intervention cost was $680 per infant. Conclusions Lower birth hospitalization charges and the net cost savings of H-HOPE infants support implementation of H-HOPE as the standard of care for preterm infants.

Objectives: Before implementation of the Affordable Care Act, many uninsured women in Illinois received care through safety-net programs. The new law allowed them to acquire health insurance through Medicaid or the Illinois Health Exchange. We examined (1) the health care experiences of such women who previously used a safety-net program and acquired this new coverage and (2) persisting gaps in coverage for breast and cervical cancer services and other health care services. Methods: We interviewed a stratified random sample of 400 women aged 34-64 in Illinois each year during 2015-2017 (total N = 1200). We used multivariable logistic regression models to determine the association between health insurance status (Illinois Health Exchange vs Medicaid) and past 12-month gaps in coverage (ie, delaying care, not having a recent mammogram, having a medical cost, and having a medical cost not covered) for the 360 women who were former participants of the Illinois Breast and Cervical Cancer Program. We calculated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for race/ethnicity, age, income, and education. Results: We found no significant differences by health insurance status in the prevalence of delaying preventive, chronic, or sick care; timeliness of the most recent mammogram; and having a major medical cost. However, of women who reported a major medical cost, women with health insurance through the Illinois Health Exchange had a higher prevalence of not having a cost covered than women with Medicaid (adjusted OR = 4.86; 95% CI, 1.48-16.03). Conclusions: The results of this study suggest that many women who gained health insurance lacked adequate coverage and services. Safety-net programs will likely continue to play an essential role in supporting women as they navigate a complex system.

PURPOSE: Describe how Ohio and Massachusetts explored severe maternal morbidity (SMM) data, and used these data for increasing awareness and driving practice changes to reduce maternal morbidity and mortality. DESCRIPTION: For 2008–2013, Ohio used de-identified hospital discharge records and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to identify delivery hospitalizations. Massachusetts used existing linked data system infrastructure to identify delivery hospitalizations from birth certificates linked to hospital discharge records. To identify delivery hospitalizations complicated by one or more of 25 SMMs, both states applied an algorithm of ICD-9-CM diagnosis and procedure codes. Ohio calculated a 2013 SMM rate of 144 per 10,000 delivery hospitalizations; Massachusetts calculated a rate of 162. Ohio observed no increase in the SMM rate from 2008 to 2013; Massachusetts observed a 33% increase. Both identified disparities in SMM rates by maternal race, age, and insurance type. ASSESSMENT: Ohio and Massachusetts engaged stakeholders, including perinatal quality collaboratives and maternal mortality review committees, to share results and raise awareness about the SMM rates and identified high-risk populations. Both states are applying findings to inform strategies for improving perinatal outcomes, such as simulation training for obstetrical emergencies, licensure rules for maternity units, and a focus on health equity. CONCLUSION: Despite data access differences, examination of SMM data informed public health practice in both states. Ohio and Massachusetts maximized available state data for SMM investigation, which other states might similarly use to understand trends, identify high risk populations, and suggest clinical or population level interventions to improve maternal morbidity and mortality.

In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation.Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified.The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities.Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.

To ascertain the component of the excess preterm birth ( 37 weeks, PTB) rate among US-born (compared to foreign-born) Black women attributable to differences in acknowledged father's education attainment.Stratified analyses and Oaxaca-Blinder decomposition methods were performed on the 2013 National Center for Health Statistics birth certificate files of singleton infants with acknowledged fathers.US-born Black women (N = 196,472) had a PTB rate of 13.3%, compared to 10.8% for foreign-born Black women (N = 51,334; Risk Difference (95% confidence interval) = 2.5 (2.3, 2.8). Infants of US-born black women had a greater a percentage of fathers with a high school diploma or less and a lower percentage of fathers with bachelor's degrees or higher than their counterparts of foreign-born women. In both subgroups, PTB rates tended to decline as the level of paternal education attainment rose. In an Oaxaca model (controlling for maternal age, education, marital status, parity, adequacy of prenatal care utilization, and chronic medical conditions), differences in paternal education attainment explained 15% of the maternal nativity disparity in PTB rates. In contrast, maternal education attainment accounted for approximately 4% of the disparity in PTB rates.Acknowledged father's low level of education attainment, or something closely related to it, explains a notable proportion of the disparity in PTB rates between US-born and foreign-born Black women.

Background The term "oral feeding success" (OFS) is frequently used in clinical practice and research. However, OFS is inconsistently defined, which impacts the ability to adequately evaluate OFS, identify risk factors, and implement interventions in clinical practice and research. Purpose To develop the defining attributes, antecedents, and consequences for the concept of OFS in preterm infants during their initial hospitalization. Methods PubMed, CINAHL, and PsycINFO databases were searched for English articles containing the key words "oral feeding success" and "preterm infants." The Walker and Avant method for concept analysis was employed. Results Sixteen articles revealed the defining attributes, antecedents, and consequences. Defining attributes included (1) physiologic stability; (2) full oral feeding; and (3) combined criteria of feeding proficiency (≥30% of the prescribed volume during the first 5 minutes), feeding efficiency (≥1.5 mL/min over the entire feeding), and intake quantity (≥80% of the prescribed volume). Implications for practice The 3 defining attributes may be used in clinical practice to consistently evaluate OFS. The antecedents of OFS provide clinicians with a frame of reference to assess oral feeding readiness, identify risk factors, and implement effective interventions. The consequences of OFS allow clinicians to anticipate challenges when OFS is not achieved and create a care plan to support the infants. Implications for research The empirical referents of OFS provide consistent and clear operational definitions of OFS for use in research. The antecedents and consequences may guide researchers to select specific measures or covariates to evaluate valid measures of OFS.

There is literature suggesting an intergenerational relationship between maternal and infant size for gestational age status and preterm birth, but much less is known about the contribution of paternal birth outcome to infant birth outcome. This study seeks to determine the association between paternal and infant small-for-gestational-age status (weight for gestational age 10th percentile, SGA) and preterm birth ( 37 weeks gestation, PTB) in a large, diverse population-based sample in the United States.Stratified and log-binomial multivariable regression analyses were computed on the vital records of Illinois-born infants (1989-1991) and their Illinois-born parents (born 1956-1976).Among non-Hispanic Whites (n = 83,218), the adjusted (controlling for maternal SGA or PTB, age, parity, education, marital status, prenatal care, and cigarette smoking) relative risk (95% confidence interval) of infant SGA and PTB for former SGA (compared to non-SGA) and preterm (compared to term) fathers equaled 1.65 (1.53, 1.77) and 1.07 (0.92, 1.24), respectively. Among African-Americans (n = 8401), the adjusted relative risk (95% confidence interval) of infant SGA and PTB for former SGA (compared to non-SGA) and preterm (compared to term) fathers equaled 1.32 (1.14, 1.52) and 1.19 (0.98, 1.45), respectively.Paternal adverse birth outcome, particularly SGA, is a modest risk factor for corresponding adverse infant outcome, independent of maternal risk status. This phenomenon appears to occur similarly among non-Hispanic White and African-American women.

To compare patterns of routine postpartum health care utilization for women in Wisconsin with continuous Medicaid eligibility versus pregnancy-only Medicaid METHODS: This analysis used Medicaid records and linked infant birth certificates for Medicaid paid births in Wisconsin during 2011-2015 (n = 105,718). We determined if women had continuous or pregnancy-only eligibility from the Medicaid eligibility file. We used a standard list of billing codes to identify if women received routine postpartum care. We examined maternal characteristics and receipt of postpartum care overall and by Medicaid eligibility category. Finally, we used a binomial model to calculate the relationship between Medicaid eligibility category and receipt of postpartum care, adjusted for maternal characteristics.Women with continuous Medicaid had profiles more consistent with low postpartum visit attendance rates (e.g., younger, more likely to use tobacco) than women with pregnancy-only Medicaid. However, after adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid (RD: 6.27, 95% CI 5.72, 6.82).Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

The relationship between non-Hispanic White (NHW) women's decreased neighborhood income between early-life and adulthood, individual risk-status at delivery, and small for gestational age (weight for gestation 10th percentile, SGA) rates is unknown.To determine the extent to which NHW women's exposure to decreased neighborhood income is a risk factor for SGA births, and whether their own birth weight modifies this relationship.Stratified and multilevel logistic regression analyses were executed on the Illinois transgenerational dataset of mothers (born 1956-1976) and their infants (born 1989-1991) with appended U.S. census income information. Only NHW women with an early-life residence in top income quartile Chicago neighborhoods were studied.NHW women (n = 4889) unexposed to decreased neighborhood income between early-life and adulthood had an SGA rate of 7.1%. In contrast, NHW women exposed to slightly (n = 5112), modestly (n = 2158), or severely (n = 339) decreased neighborhood income by the time of delivery had SGA rates of 8.2%, 10.8%, and 10.8%, respectively; RR (95% CI) equaled 1.2 (1.0-1.3), 1.5 (1.3-1.8) and 1.5 (1.1-2.1), respectively. The relationship between maternal exposure to modestly decreased neighborhood income and SGA rates was present only among former non-low birth weight ( 2500 g, non-LBW) mothers. In multilevel logistic regression models, the adjusted (controlling for age, parity, prenatal care usage, and cigarette smoking) OR of SGA birth for former low birth weight ( 2500 g, LBW) and non-LBW NHW women exposed to modestly (compared to no) decreased neighborhood income equaled 0.7 (0.4, 1.4) and 1.3 (1.1-1.6), respectively.NHW women's exposure to modestly decreased neighborhood income is associated with an increased risk of SGA birth; this phenomenon is absent among former low birth weight women.

Objective Primary: to identify the potential relationship between duration of tube feeding and success of oral feeding in preterm infants; secondary: to identify the potential relationships among duration of tube feeding and alert behavioral states, orally directed behaviors, and nutritive sucking. Design A descriptive correlational study. Setting A Level III NICU at an inner-city hospital. Participants Twenty-eight preterm infants who were born between 28 and 32 weeks gestational age, were clinically stable, and were expected to have at least 1 week of tube feeding during their initial hospitalizations. Methods Data were collected daily from participants' electronic medical records and at one-time oral feeding evaluations within 48 hours after the removal of the feeding tube. Results We found a significant negative correlation between duration of tube feeding and oral feeding success (p = .000). We found no correlations between duration of tube feeding and alert behavioral states, orally directed behaviors, or nutritive sucking. Conclusion Although the duration of tube feeding is a nonmodifiable factor, preterm infants who are anticipated to have extended durations of tube feeding may be at risk for delayed oral feeding success.

Few studies have examined contributions of paternal factors to birth outcomes. Weathering is a pattern of increasing rates of adverse birth outcome with increasing maternal age. This study evaluates for an association between paternal involvement and weathering in the context of preterm birth (PTB,37 weeks) among non-Hispanic African-American and non-Hispanic White women with and without lifelong exposure to neighborhood poverty. Using the Illinois transgenerational dataset with appended US census income information of infants (1989-1991) and their mothers (1956-1976), we compared infants of women by degree of paternal involvement: married, unmarried with father named on birth certificate, and unnamed father. Data were stratified by maternal residence in higher or lower income neighborhoods at both the time of mothers' birth and infants' birth, estimating maternal lifelong economic context. We computed race-specific PTB rates according to maternal age, lifelong neighborhood income, and paternal involvement. We calculated Mantel-Haenszel chi-square tests of linear trend from contingency tables to evaluate weathering. Among African-Americans (n = 39,991) with unnamed fathers and lifelong residence in lower income neighborhoods, PTB rate was lowest among teens at 18.8%, compared to 21.5% for 30-35 year-old mothers (p for linear trend0.05). Among African-Americans with unnamed fathers and lifelong residence in higher income neighborhoods, PTB rate among teens was 16%, compared to 25% for 30-35 year-old mothers (p = 0.21). Among married African-Americans with lifelong residence in lower income neighborhoods, PTB rate among teens was 16.4%, compared to 12.5% for 30-35 year-old mothers (p = 0.79). Among married African-Americans with lifelong residence in higher income neighborhoods, PTB rate among teens was 20%, compared to 11.4% for 30-35 year-old mothers (p = 0.40). White mothers (n = 31,981) did not demonstrate weathering, regardless of paternal involvement and neighborhood poverty. We conclude that weathering was not seen among married African-Americans, independent of neighborhood income, suggesting a potentially protective mechanism associated with paternal involvement.

Background The quality of mother-preterm infant interaction has been identified as a key factor in influencing the infant's later development and language acquisition. The relationship between mother-infant responsiveness and later development may be evident early in infancy, a time period which has been understudied. Aim Describe the relationship between mother-infant mutual dyadic responsiveness and premature infant development. Design This study employed a secondary analysis of data from the 6-week corrected age (CA) follow-up visit of the Hospital-Home Transition: Optimizing Prematures' Environment (H-HOPE) study, a randomized clinical trial testing the efficacy of a mother- and infant- focused intervention for improving outcomes among premature infants. Subjects Premature infants born between 29 and 34 weeks gestational age and their mothers who had social-environmental risks. Outcome measures At 6-weeks corrected age, a play session was coded for the quality of mutual responsiveness (Dyadic Mutuality Code). Development was assessed via the Bayley Scales of Infant and Toddler Development, 3rd edition. Results Of 137 mother-infant dyads, high, medium and low mutual responsiveness was observed for 35.8%, 34.3% and 29.9%, respectively. Overall motor, language and cognitive scores were 115.8 (SD = 8.2), 108.0 (7.7) and 109.3 (7.9). Multivariable linear models showed infants in dyads with high versus low mutual responsiveness had higher scores on the motor (β = 3.07, p = 0.06) and language (β = 4.47, p = 0.006) scales. Conclusion High mutual responsiveness in mother-premature infant dyads is associated with significantly better language development and marginally better motor development.

Understanding how safety net programs adapt to systemic health care changes is pivotal for creating feasible recommendations for policy implementation. This study characterizes perspectives of Lead Agency (LA) coordinators of the Illinois Breast and Cervical Cancer Program (IBCCP) in response to sociopolitical changes at state and national levels. Our cross-sectional study included 29 semistructured telephone interviews between December 2015 and January 2016. Respondents indicated some changes in the priority population served, changes in referrals and clinical services, and, a continued commitment to IBCCP. Our findings suggest that IBCCP and other safety net programs will need to be flexible to meet the ongoing needs of historically vulnerable populations in a complex, shifting environment. Implications for public health practice and policy include the need to ensure that program personnel are aware of evidence-based strategies to reach different priority populations and are kept abreast of organizational and system changes that may affect referral patterns as well as the need to educate health care providers working with safety net programs about changes in the delivery and coordination of services.

Background The relationship between African-American women’s upward economic mobility and small for gestational age (weight for gestational

Objective To identify maternal characteristics associated with social support among new mothers of premature infants who are at social–environmental risk. Design Cross-sectional analysis of intake interview data from a larger randomized controlled trial of a mother–premature infant developmentally based intervention. Setting Two urban community-based hospitals. Participants One hundred ninety-four women (50% Black, 50% Hispanic) who recently gave birth to otherwise healthy, premature (29–34 weeks gestational age) infants. Participants had at least 2 of 10 social–environmental risks (e.g., poverty). Methods In-hospital interviews were conducted to obtain data on sociodemographic characteristics, prior mental health problems, and social support through the use of the Personal Resources Questionnaire 2000. Bivariate and multivariable linear regression analyses were performed to identify factors associated with social support. Results Mean Personal Resources Questionnaire 2000 scores were significantly lower for Hispanic than Black participants (92.0 vs. 96.0, respectively), those interviewed in Spanish versus English (89.8 vs. 96.1), those with low versus age-appropriate education levels (89.7 vs. 95.3), multiparous versus primiparous women (92.7 vs. 96.0), and those reporting versus not reporting histories of mental health problems (84.7 vs. 94.8). After multivariable adjustment, only younger age, Spanish language preference, multiparity, and a history of mental health problems were associated with significantly lower levels of social support ( R 2 = 0.18). Conclusion More programs should be made available to provide social support to at-risk mothers, especially younger mothers, and those with limited English ability, other children at home, or histories of mental health problems. Nurses should target these mothers for additional support during their premature infants' NICU stay.

Objectives To describe statewide SMM trends in Iowa from 2009 to 2014 and identify maternal characteristics associated with SMM, overall and by age group. Methods We used 2009-2014 linked Iowa birth certificate and hospital discharge data to calculate SMM based on a 25-condition definition and 24-condition definition. The 24-condition definition parallels the 25-condition definition, but excludes blood transfusions. We calculated SMM rates for all delivery hospitalizations (N = 196,788) using ICD-9-CM diagnosis and procedure codes. We used log-binomial regression to assess the association of SMM with maternal characteristics, overall and stratified by age groupings. Results In contrast to national rates, Iowa's 25-condition SMM rate decreased from 2009 to 2014. Based on the 25-condition definition, SMM rates were significantly higher among women20 years and34 years compared to women 25-34 years. Blood transfusion was the most prevalent indicator, with hysterectomy and disseminated intravascular coagulation (DIC) among the top five conditions. Based on the 24-condition definition, younger women had the lowest SMM rates and older women had the highest SMM rates. SMM rates were also significantly higher among racial/ethnic minorities compared to non-Hispanic white women. Payer was the only risk factor differentially associated with SMM across age groups. First trimester prenatal care initiation was protective for SMM in all models. Conclusions High rates of blood transfusion, hysterectomy, and DIC indicate a need to focus on reducing hemorrhage in Iowa. Both younger and older women and racial/ethnic minorities are identified as high risk groups for SMM that may benefit from special consideration and focus.

Parental obesity is highly predictive of child obesity, and preterm infants are at greater risk of obesity, but little is known about obese and non-obese mothers’ responsiveness to preterm infant cues during feeding. The relationship between maternal weight status and response to preterm infant behavioral cues during feeding at 6-weeks corrected age was examined. This secondary analysis used data from a randomized clinical trial. Maternal weight was coded during a play session. Mother-infant interaction during feeding was coded using the Nursing Child Assessment Satellite Training Feeding Scale (NCAST). We used multivariate linear regressions to examine NCAST scores and multivariate logistic regressions for the two individual items, satiation cues and termination of feeding. Of the 139 mothers, 56 (40.3%) were obese, two underweight women were excluded. Obese mothers did not differ from overweight/normal weight mothers for overall NCAST scores, but they had higher scores on response to infant’s distress subscale (mean = 10.2 vs. 9.6, p = 0.01). The proportion of infants who exhibited satiation cues did not differ by maternal weight. Obese mothers were more likely than overweight/normal weight mothers to terminate the feeding when the infant showed satiation cues (82.1% vs. 66.3%, p = 0.04, adjusted OR = 2.31, 95% CI = 0.97, 5.48). Limitations include lack of BMI measures and small sample size. Additional research is needed about maternal weight status and whether it influences responsiveness to preterm infant satiation cues. Results highlight the need for educating all mothers of preterm infants regarding preterm infant cues. NCT02041923 . Feeding and Transition to Home for Preterms at Social Risk (H-HOPE). Registered 15 January 2014.

To ascertain the relation of men’s lifelong class status (as measured by neighborhood income) to the rates of early (

To determine the importance of infant factors, maternal prenatal care use, and demographic characteristics in explaining the racial disparity in infant (age365 days) mortality due to congenital heart defects (CHD).In this cross-sectional population-based study, stratified and multivariable logistic regression analyses were performed on the 2003-2004 National Center for Health Statistics linked live birth-infant death cohort files of term infants with non-Hispanic white (n = 3 684 569) and African-American (n = 782 452) US-born mothers. Infant mortality rate, including its neonatal (28 day) and postneonatal (28-364 day) components, due to CHD was the outcome measured.The infant mortality rate due to CHD for African-American infants (296 deaths; 3.78 per 10 000 live births) exceeded that of white infants (1025 deaths; 2.78 per 10 000 live births) (relative risk [RR], 1.36; 95% CI, 1.20-1.55). The racial disparity was wider in the postneonatal period (2.08 per 10 000 vs 1.42 per 10 000; RR, 1.53; 95% CI, 1.29-1.83) compared with the neonatal period (1.70 per 10 000 vs 1.44 per 10 000; RR, 1.20; 95% CI, 0.99-1.45). Compared with white mothers, African-American mothers had a higher percentage of high-risk characteristics. In multivariable logistic regression models, the adjusted OR of postneonatal and neonatal mortality due to CHD for African-American mothers compared with white mothers was 1.20 (95% CI, 0.98-1.48) and 0.95 (95% CI, 0.77-1.19), respectively.The racial disparity in infant mortality rate due to CHD among term infants with US-born mothers is driven predominately by the postneonatal survival disadvantage of African-American infants. Commonly cited individual-level risk factors partly explain this phenomenon. The study is limited by the lack of information on neighborhood factors.

Objectives The authors investigated the association between maternal birth weight and adverse birth outcome as measured by rates of low birth weight (

Purpose In recognition of the importance of performance measurement and MCH epidemiology leadership to quality improvement (QI) efforts, a plenary session dedicated to this topic was presented at the 2014 CityMatCH Leadership and MCH Epidemiology Conference. This paper summarizes the session and provides two applications of performance measurement to QI in MCH. Description Performance measures addressing processes of care are ubiquitous in the current health system landscape and the MCH community is increasingly applying QI processes, such as Plan-Do-Study-Act (PDSA) cycles, to improve the effectiveness and efficiency of systems impacting MCH populations. QI is maximally effective when well-defined performance measures are used to monitor change. Assessment MCH epidemiologists provide leadership to QI initiatives by identifying population-based outcomes that would benefit from QI, defining and implementing performance measures, assessing and improving data quality and timeliness, reporting variability in measures throughout PDSA cycles, evaluating QI initiative impact, and translating findings to stakeholders. MCH epidemiologists can also ensure that QI initiatives are aligned with MCH priorities at the local, state and federal levels. Two examples of this work, one highlighting use of a contraceptive service performance measure and another describing QI for peripartum hemorrhage prevention, demonstrate MCH epidemiologists' contributions throughout. Challenges remain in applying QI to complex community and systems-level interventions, including those aimed at improving access to quality care. Conclusion MCH epidemiologists provide leadership to QI initiatives by ensuring they are data-informed and supportive of a common MCH agenda, thereby optimizing the potential to improve MCH outcomes.

Background While there is considerable variability with respect to attendance at the postpartum visit, not much is known about women’s preferences with respect to postpartum care. Likewise, there is also limited information on providers’ practices regarding the postpartum visit and care including the delivery of contraception. To understand and address deficits in the delivery and utilization of postpartum care, we examined the perceptions of low-income postpartum women with respect to barriers to and preferences for the timing and location of the postpartum visit and receipt of contraception. We also examined providers’ current prenatal and postnatal care practices for promoting the use of postpartum care and their attitudes toward alternative approaches for delivering contraceptive services in the postpartum period. Methods Qualitative face-to-face interviews were completed with 20 postpartum women and in-depth qualitative phone interviews were completed with 12 health care providers who had regular contact with postpartum women. Interviews were coded using Atlas.ti software and themes were identified. Results Women believed that receiving care during the postpartum period was an important resource for monitoring physical and mental health and also strongly supported the provision of contraception earlier than the 6-week postpartum visit. Providers reported barriers to women’s use of postpartum care on the patient, provider, and system levels. However, providers were receptive to exploring new clinical practices that may widen the reach of postpartum care and increase access to postpartum contraception. Conclusion Approaches that increase the flexibility and convenience of postpartum care and the delivery of postpartum contraception may increase the likelihood that women will take advantage of essential postpartum services.

Purpose Although previous studies demonstrate associations between adverse perinatal outcomes and developmental disabilities (DDs), study of population impacts is limited. Methods We computed relative risks adjusted (aRRs) for sociodemographic factors and component and summary population attributable fractions (PAFs) for associations between very low birth weight (VLBW, all preterm births), moderately low birth weight (MLBW) + Preterm, MLBW at term, and normal birth weight (NBW) + Preterm and seven DDs (cerebral palsy [CP], autism spectrum disorder [ASD], intellectual disability [ID], behavioral-conduct disorders, attention-deficit-hyperactivity disorder [ADHD], learning disability [LD], and other developmental delay) among children aged 3–17 years in the 2011–2012 National Survey of Children's Health. Results VLBW-Preterm, MLBW-Preterm and NBW-Preterm were strongly to moderately associated with CP (aRRs: 43.5, 10.1, and 2.2, respectively; all significant) and also associated with ID, ASD, LD, and other developmental delay (aRR ranges: VLBW-Preterm 2.8–5.3; MLBW-Preterm 1.9–2.8; and NBW-Preterm 1.6–2.3). Summary PAFs for preterm birth and/or LBW were 55% for CP, 10%–20% for ASD, ID, LD, and other developmental delay, and less than 5% for ADHD and behavioral-conduct disorders. Findings were similar whether we assessed DDs as independent outcomes or within mutually exclusive categories accounting for DD co-occurrence. Conclusions Preterm birth has a sizable impact on child neurodevelopment. However, relative associations and population impacts vary widely by DD type.

Objectives To determine the relation of paternal lifelong socioeconomic position (SEP) to the racial disparity in low birth weight (

Objective To examine whether mortgage discrimination, or redlining, is a risk factor for preterm birth among African American women in Chicago, and how it is related to racial residential segregation. Methods This was a retrospective cross-sectional study in Chicago, Illinois, 1989–1991. African American mothers (n = 33,586) in the Illinois Transgenerational Birth File were linked to the 1990 census and the 1990–1995 Home Mortgage Disclosure Act database. Logistic regression models assessed the relationship between redlining and preterm birth rates. Results Preterm birth rates were higher among African American women in redlined areas (18.5%) vs. non-redlined areas (17.1%). Unadjusted and adjusted odds ratio for preterm birth among African American women in redlined neighborhoods, compared to non-redlined neighborhoods, were 1.08 (95% CI 1.03-1.14) and 1.12 (1.04-1.20), respectively. By level of racial residential segregation, preterm birth rate was elevated (18.2%) in redlined, high-proportion African American areas compared to non-redlined high-proportion African American areas (16.7%), redlined low- (16.2%) and mid-proportion (16.1%) African American areas. Conclusions Mortgage discrimination may be an important measure of institutional racism to be used in understanding racial disparities in preterm birth.

Objectives: Implementation science provides useful tools for guiding and evaluating the integration of evidence-based interventions with standard practice. The objective of our study was to demonstrate the usefulness of applying an implementation science framework—the Consolidated Framework for Implementation Research (CFIR)—to increase understanding of implementation of complex statewide public health initiatives, using the example of Medicaid immediate postpartum long-acting reversible contraception (LARC) policies. Methods: We conducted semistructured telephone interviews with the 13 state teams participating in the Immediate Postpartum LARC Learning Community. We asked teams to describe the implementation facilitators, barriers, and strategies in 8 focus areas of the Learning Community. We audio-recorded and transcribed interviews and then coded each interview according to the domains and constructs (ie, theoretical concepts) of the CFIR. Results: Cosmopolitanism (ie, networking with external organizations) was the most frequently coded construct of the framework. A related construct was networks and communications (ie, the nature and quality of social networks and formal and informal communications in an organization). Within the construct of cost, state teams identified barriers that were often unable to be overcome. Trialability (ie, ability to test the intervention on a small scale) and engaging champions (ie, attracting and involving persons who dedicate themselves to supporting the intervention in an organization) were among the most salient constructs of the framework and were the sources of many implementation strategies. Conclusions: State leaders and program staff members may benefit from considering the CFIR domains and constructs in the planning, implementation, and evaluation of complex statewide public health initiatives.

Objective: To ascertain the association between father’s lifetime socioeconomic status (SES) and rates of small for gestational age (SGA, defined as weight for gestational age

Objectives To explore associations between race, nativity, and low birth weight (LBW) among Latina and non-Latina women, with special attention to the Black Latina subgroup. Methods Using US natality data from 2011 to 2013, we designed a population-based study to compare LBW (

Introduction: Mental health and substance use are growing public health concerns, but established surveillance methods do not measure the burden of these conditions among women of reproductive age. We developed a standardized indicator from administrative data to identify inpatient hospitalizations related to mental health or substance use (MHSU) among women of reproductive age, as well as co-occurrence of mental health and substance use conditions among those hospitalizations. Materials and Methods: We used inpatient hospital discharge data from 2012-2014 for women aged 15-44 residing in Illinois and Wisconsin. We identified MHSU-related hospitalizations through the principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and first-listed ICD-9-CM external cause of injury code (E code). We classified hospitalizations as related to 1 of 3 mutually exclusive categories: a mental disorder, a substance use disorder, or an acute MHSU-related event. We defined co-occurrence as the presence of both mental health and substance use codes in any available diagnosis or E-code field. Results: Of 1 173 758 hospitalizations of women of reproductive age, 150 318 (12.8%) were related to a mental disorder, a substance use disorder, or an acute MHSU-related event, for a rate of 135.6 hospitalizations per 10 000 women. Of MHSU-related hospitalizations, 115 163 (76.6%) were for a principal mental disorder, 22 466 (14.9%) were for a principal substance use disorder, and 12 709 (8.5%) were for an acute MHSU-related event; 42.4% had co-occurring mental health codes and substance use codes on the discharge record. Practice Implications: MHSU-related disorders and events are common causes of hospitalization for women of reproductive age, and nearly half of these hospitalizations involved co-occurring mental health and substance use diagnoses or events. This new indicator may improve public health surveillance by establishing a systematic and comprehensive method to measure the burden of MHSU-related hospitalizations among women of reproductive age.

Objectives To determine whether affluent-born White mother’s descending neighborhood income is associated with infant mortality rates (

Objectives The postpartum period is a high-risk time for unintended pregnancy, and additional opportunities to provide contraception are needed. Our objective was to evaluate the acceptability of providing postpartum contraceptive counseling at a pediatric well baby visit, and compare it to counseling at the routine postpartum visit. Methods Postpartum women (100 per group) were recruited for this cohort study at pediatric well baby visits and obstetric postpartum visits at an academic medical center. Well baby participants completed a baseline survey followed by contraceptive counseling by an obstetrician or midwife and a post-counseling survey. Postpartum participants were surveyed after their visit only. Results All well baby visit participants completed the intervention and were enrolled earlier in the postpartum period than postpartum visit participants (mean = 4.1 vs. 6.6 weeks, respectively, p

Objective We aimed to explore current practices regarding screening for rape and response to disclosure of rape-related pregnancy in the abortion care setting. Methods We performed a cross-sectional, nonprobability survey of U.S. abortion providers. Individuals were recruited in person and via emailed invitations to professional organization member lists. Questions in this web-based survey pertained to providers' practice setting, how they identify rape-related pregnancy, the availability of support services, and their experiences with law enforcement. Providers were asked their perceptions of barriers to care for women who report rape-related pregnancy. Results Surveys were completed by 279 providers (21% response rate). Most respondents were female (93.1%), and the majority were physicians in a clinical role (69.4%). One-half (49.8%) reported their practice screens for pregnancy resulting from rape, although fewer (34.8%) reported that screening is the method through which most patients with this history are identified. Most (80.6%) refer women with rape-related pregnancy to support services such as rape crisis centers. Relatively few (19.7%) have a specific protocol for care of women who report rape-related pregnancy. Clinics that screen were 79% more likely to have a protocol for care than centers that do not screen. Although the majority (67.4%) reported barriers to identification of women with rape-related pregnancy, fewer (33.3%) reported barriers to connecting them to support services. Conclusion Practices for identifying and providing care to women with rape-related pregnancy in the abortion care setting are variable. Further research should address barriers to care provision, as well as identifying protocols for care.

Objective The purpose of this study is to examine the association between sugar-sweetened beverage (SSB) consumption and caries experience among Georgia third graders. Methods The 2010-2011 Georgia Third Grade Oral Health Study provided a school-based sample for analysis. Data were weighted to be representative of the state of Georgia's third graders. Log-binomial regression was used to assess the association between SSB consumption and caries experience after adjusting for socio-demographic and maternal and child oral health characteristics. Results Georgia third graders consumed approximately two servings of SSB per day on average (1.7, 95% CI 1.6-1.8). Fifty-two percent of Georgia third graders had caries experience. Daily consumption of SSB and prevalence of caries experience differed significantly by demographic characteristics. After adjustment for socio-demographic and maternal oral health characteristics, caries experience increased 22 percent (adjusted PR = 1.2, 95% CI 1.1, 1.3) for every additional reported serving of SSB consumed per day. Conclusion Higher consumption of SSBs is associated with higher caries prevalence among Georgia third graders after adjustment for important covariates. Consequently, health messages about SSBs from dentists, physicians, and other healthcare providers as well as policy approaches at the school, state, and national levels to limit consumption of SSBs may collectively impact both the development of dental caries and obesity, leading to overall better health for children.

Rates of short-interval pregnancies that result in unintended pregnancies remain high in the United States and contribute to adverse reproductive health outcomes. Long-acting reversible contraception methods have annual failure rates of

A paucity of published data exists on the factors underlying the relatively poor birth outcome of non-Hispanic White women in the United States. To determine whether downward economic mobility is a risk factor for preterm birth (

Background Implementation strategies are imperative for the successful adoption and sustainability of complex evidence-based public health practices. Creating a learning collaborative is one strategy that was part of a recently published compilation of implementation strategy terms and definitions. In partnership with the Centers for Disease Control and Prevention and other partner agencies, the Association of State and Territorial Health Officials recently convened a multi-state Learning Community to support cross-state collaboration and provide technical assistance for improving state capacity to increase access to long-acting reversible contraception (LARC) in the immediate postpartum period, an evidence-based practice with the potential for reducing unintended pregnancy and improving maternal and child health outcomes. During 2015–2016, the Learning Community included multi-disciplinary, multi-agency teams of state health officials, payers, clinicians, and health department staff from 13 states. This qualitative study was conducted to better understand the successes, challenges, and strategies that the 13 US states in the Learning Community used for increasing access to immediate postpartum LARC. Methods We conducted telephone interviews with each team in the Learning Community. Interviews were semi-structured and organized by the eight domains of the Learning Community. We coded transcribed interviews for facilitators, barriers, and implementation strategies, using a recent compilation of expert-defined implementation strategies as a foundation for coding the latter. Results Data analysis showed three ways that the activities of the Learning Community helped in policy implementation work: structure and accountability, validity, and preparing for potential challenges and opportunities. Further, the qualitative data demonstrated that the Learning Community integrated six other implementation strategies from the literature: organize clinician implementation team meetings, conduct educational meetings, facilitation, promote network weaving, provide ongoing consultation, and distribute educational materials. Conclusions Convening a multi-state learning collaborative is a promising approach for facilitating the implementation of new reimbursement policies for evidence-based practices complicated by systems challenges. By integrating several implementation strategies, the Learning Community serves as a meta-strategy for supporting implementation.

Purpose To determine components of excess preterm birth (PTB) rates for U.S.-born black women relative to both foreign-born black women and U.S.-born white women attributable to differences in observed sociodemographic, behavioral, and medical risk factors. Methods Using the 2013 U.S. natality files, we used Oaxaca-Blinder decomposition on the absolute scale to estimate the contribution of the group differences in the prevalence of PTB predictors between U.S.- and foreign-born black women and U.S.-born black and U.S.-born white women. Results U.S.-born blacks had a 3.2 (95% confidence interval: 3.0–3.5) and 4.4 (95% confidence interval: 4.3–4.5) percentage point higher risk of PTB than foreign-born blacks and U.S.-born whites, respectively. The variables in the models explained between 18% and 27% of the PTB disparities. Differences in paternal acknowledgment (about 12%), maternal hypertension (about 7%–11%), and maternal education (about 6%–10%) explained the largest proportion of these disparities. Conclusions Programs and policies that address both distal and proximate factors, including the social determinants of health and the prevention and management of hypertension, may reduce the higher rates of PTB among U.S.-born black women compared to foreign-born black women and U.S.-born white women.

Objectives To determine the extent to which non-Latina White and African-American mother’s gestational age is associated with extremely early (

Preterm infants are challenged by immature infant behavioral organization which may negatively influence their ability to oral feed. The purpose of this study was to determine whether the integrated H-HOPE (Hospital to Home: Optimizing the Infant’s Environment) intervention would improve infant behavioral organization by increasing the frequency of orally directed behaviors and the proportion of time spent in an alert behavioral state when offered prior to oral feeding. Mother–infant dyads (n = 198) were randomly assigned to the H-HOPE intervention or the Attention Control groups. Infants were born at 29 to 34 weeks gestation and were clinically stable. Mothers had at least two social environmental risk factors such as minority status or less than high school education. H-HOPE is an integrated intervention that included (1) twice-daily infant directed stimulation using the ATVV intervention (auditory, tactile, visual, and vestibular stimuli) and (2) maternal participatory guidance sessions by a nurse-community advocate team. Orally directed behaviors and behavioral states were assessed weekly prior to feeding during hospitalization when infants were able to feed orally. There were no differences between the groups at baseline (Day 0, prior to the initiation of the integrated H-HOPE intervention). We observed a pattern of increased frequency of orally directed behaviors in the H-HOPE intervention group when compared to the Attention Control group, however, the proportion of time spent in an alert behavioral state remained stable in both groups over the course of the study. On Day 7, the H-HOPE intervention group exhibited a significantly higher mean frequency of orally directed behaviors than the Attention Control group (12.6 vs. 7.1 pre-intervention, 51.8 vs. 33.2 during intervention, 4.3 vs. 3.2 immediately after intervention, and 8.9 vs. 5.3 immediately prior to feeding). On Day 7, the H-HOPE intervention group exhibited a significantly higher proportion of time spent in an alert behavioral state only during intervention (0.26 vs. 0.11) and immediately after intervention (0.28 vs. 0.06). These findings are suggestive that the integrated H-HOPE intervention facilitated infant behavioral organization for clinically stable infants born between 29 and 34 weeks gestation. The orally directed behaviors appear to be an important indicator of the infant’s preparation for feeding, and when used in conjunction with assessment of behavioral states, are especially valuable to the clinician. Use of this combined assessment approach in practice would strengthen clinician assessment for initiation of (beginning the first oral feeding) and daily preparation for oral feeding in preterm infants.