Smoking Behaviors Among Urban and Rural Pregnant Women Enrolled in the Kansas WIC Program

Prevalence of Cigarette Smoking, E-cigarette Use, and Dual Use Among Urban and Rural Women During the Peripartum Period, PRAMS 2015-2020

OBJECTIVES

Evidence has emerged on the health dangers of electronic cigarette (e-cigarette) use among pregnant women and neonates. We examined whether rural residence is a risk factor for smoking and e-cigarette use among women during the peripartum period in the United States.

METHODS

This study was based on pooled cross-sectional 2015-2020 data from the Pregnancy Risk Assessment Monitoring System. The outcome was exclusive smoking, exclusive e-cigarette use, and use of both products (ie, dual use) versus use of neither tobacco product by women with live infants aged 2 to 6 months. We examined rural-urban differences in outcome by using univariate and multivariable multinomial logistic regressions with post hoc contrasts and marginal analyses, adjusting for complex survey design and nonresponse.

RESULTS

During the peripartum period, 5.0% of women were smoking combustible cigarettes, 5.0% were using e-cigarettes, and 1.9% were using both tobacco products. The crude prevalence of e-cigarette use was 1.1 percentage point higher, and the adjusted prevalence was 0.8 percentage points lower for rural versus urban women (P < .001 for both). Among rural women, 6.7% (95% CI, 6.3%-7.1%) smoked combustible cigarettes exclusively and 2.6% (95% CI, 2.3%-2.8%) used both products, as compared with 4.5% (95% CI, 4.4%-4.8%) and 1.7% (95% CI, 1.6%-1.8%) of urban women, respectively, adjusting for sociodemographic and health-related characteristics.

CONCLUSIONS

Maternal sociodemographic and health-related characteristics differed by combustible smoking versus e-cigarette use during the peripartum period. The effect of residence on e-cigarette use was significantly confounded by sociodemographic and health-related characteristics, resulting in clinically comparable prevalence of e-cigarette use in rural and urban mothers with live infants aged 2 to 6 months.

Gestational Weight Gain Among Urban and Rural Pregnant Individuals Who Smoke or Quit Smoking

INTRODUCTION

Approximately 7.2% of individuals in the U.S. smoke during pregnancy, and cessation is associated with excessive gestational weight gain (GWG). Weight gain is a common reason for not quitting smoking or relapsing. The current study aimed to characterize who is at risk for excessive GWG and determine the moderating effect of rurality given the higher smoking rates and lower access to healthcare services in these areas.

METHODS

Data from the Virginia Pregnancy Risk Assessment Monitoring System (PRAMS; years 2009-2020) were used to assess the association between participant characteristics, smoking behaviors, and rurality by excessive GWG status in 2023.

RESULTS

Almost half (44.0%) of participants experienced excessive GWG; 9.8% of participants quit smoking while 6.9% continued smoking. Respondents who quit during pregnancy had higher odds of excessive GWG than non-smoking respondents (OR=1.83, 95% CI: [1.24, 2.71]). Among those who were non-smoking, respondents in rural areas, compared to urban areas, had a higher probability of experiencing excessive GWG (0.46 vs 0.44, p<0.001). For those who quit smoking (0.60 vs 0.41, p<0.001) or continued to smoke during pregnancy (0.46 vs 0.33, p<0.001), urban residence was associated with a higher likelihood of excessive GWG compared to rural residence.

CONCLUSIONS

Smoking cessation and weight management during pregnancy are critical to promoting infant and maternal health. Targeted interventions combining weight management and smoking cessation have been successful among the general population and could be adapted for pregnant individuals who smoke to facilitate cessation and healthy GWG in both urban and rural areas.

Assessing the relationship between census tract rurality and severe maternal morbidity in California (1997-2018)

PURPOSE

Recent studies have demonstrated an increased risk of severe maternal morbidity (SMM) for people living in rural versus urban counties. Studies have not considered rurality at the more nuanced subcounty census-tract level. This study assessed the relationship between census-tract-level rurality and SMM for birthing people in California.

METHODS

We used linked vital statistics and hospital discharge records for births between 1997 and 2018 in California. SMM was defined by at least 1 of 21 potentially fatal conditions and lifesaving procedures. Rural-Urban Commuting Area codes were used to characterize census tract rurality dichotomously (2-category) and at 4 levels (4-category). Covariates included sociocultural-demographic, pregnancy-related, and neighborhood-level factors. We ran a series of mixed-effects logistic regression models with tract-level clustering, reporting risk ratios and 95% confidence intervals (CIs). We used the STROBE reporting guidelines.

FINDINGS

Of 10,091,415 births, 1.1% had SMM. Overall, 94.3% of participants resided in urban/metropolitan and 5.7% in rural tracts (3.9% micropolitan, 0.9% small town, 0.8% rural). In 2-category models, the risk of SMM was 10% higher for birthing people in rural versus urban tracts (95% CI: 6%, 13%). In 4-category models, the risk of SMM was 16% higher in micropolitan versus metropolitan tracts (95% CI: 12%, 21%).

CONCLUSION

The observed rurality and SMM relationship was driven by living in a micropolitan versus metropolitan tract. Increased risk may result from resource access inequities within suburban areas. Our findings demonstrate the importance of considering rurality at a subcounty level to understand locality-related inequities in the risk of SMM.

Characteristics Associated with Sudden Unexpected Infant Death in a Rural Hispanic Population: A Case-Control Study

INTRODUCTION

Sudden unexpected infant death (SUID) is the leading cause of death among U.S. infants aged 28 days to 1 year. In Kansas, Hispanic infant mortality is nearly 50% higher than non-Hispanic White. Further, the SUID rate did not change between 2005-2018, while rates for non-Hispanic Black and White infants decreased significantly. This study sought to identify characteristics and behaviors of Hispanic birthing persons related to SUID.

METHODS

Linked Kansas birth/death vital statistics data (2005-2018) identified Hispanic birthing persons with a singleton birth who experienced SUID. To reduce confounding effects, greedy nearest neighbor matching paired each SUID case sequentially with the four nearest controls based on age, race, payor source and parity. Matching procedures, likelihood-ratio χ2, Fisher exact test and multiple logistic regression model with Firth's penalized maximum likelihood estimation were computed.

RESULTS

Of 86,052 Hispanic singleton births, 66 involved SUID and were matched with 264 controls. No differences were related to marital status, population density of residence, education level, language spoken, prenatal BMI, weight gained during pregnancy, adequacy of prenatal care, enrollment in WIC, or state immunization registry participation (all p>0.05). However, tobacco use during pregnancy contributed to a three times greater risk of SUID (OR=3.208; 95% CI=1.438 to 7.154). Multivariable models for behavioral variables revealed low predictive accuracy with area under the ROC curve=0.6303.

CONCLUSION

This study suggests SUID deaths to rural Hispanic families are likely multifaceted. Study results inform educational programs on the importance of addressing tobacco cessation in SUID risk reduction interventions for Hispanic families.

Preconception health status and associated disparities among rural, Midwestern women in the United States

BACKGROUND

Little is known about the preconception/interconception health and behaviors of reproductive-age women in the rural Midwest of the United States. The purpose of this study was to quantify preconception/interconception health status and to identify disparities compared with statewide estimates.

METHODS

In this cross-sectional study, we collected data on 12 health conditions and behaviors that are risk factors for adverse maternal and infant health outcomes from nonpregnant women ages 18-45 years in rural northwestern Ohio. Statistical tests were used to identify associations between selected demographic characteristics and a subset of eight high-priority health measures (smoking, diabetes, heavy alcohol use, folic acid intake, normal weight, sufficient physical activity, and effective contraception use); all but physical activity could be compared with Ohio estimates derived from the Behavioral Risk Factor Surveillance System and Ohio Pregnancy Assessment Survey.

RESULTS

Three hundred-fifteen women participated, with 98.4% reporting at least one high-priority risk factor. Statistically significant differences were identified among subpopulations related to smoking, folic acid, normal weight, sufficient physical activity, and effective contraception use. In addition, the proportion of participants reporting hypertension (P < 0.001), smoking (P < 0.001), abnormal weight (P = 0.002), and lack of daily folic acid intake (P = 0.006) were statistically significantly higher than expected based on statewide estimates.

CONCLUSIONS

Women in the rural Midwest of the United States are at risk for poor health and pregnancy outcomes. Statewide estimates tracking preconception/interconception health status may obscure variation for at-risk groups, particularly in rural or underserved areas. These findings illustrate the need for interventions to advance preconception/interconception health and improve methods to capture and analyze data for rural women.

Challenges Experienced by Women Who Smoke During Pregnancy or Postnatally

Maternal smoking during pregnancy and maternal smoking postnatally are important public health concerns worldwide. Smoking adversely affects the woman's general health and is causally related to pregnancy complications and serious health outcomes for the child, such as stillbirth, preterm delivery, low birth weight, and sudden infant death. The purpose of this research was to examine maternal smoking through a quantitative descriptive survey of 164 women, 120 who were pregnant and 44 who were postnatal. Women experienced barriers to quitting smoking, including dealing with stress, being exposed to smokers, not being ready to quit, not knowing how to quit, not looking for or not being able to find information about smoking or quitting smoking, and lacking adequate social and healthcare provider support. On the other hand, women revealed characteristics that suggest they might have had improved potential for quitting smoking, including having negative feelings about smoking, having cut down on smoking, smoking at a low level, having made quit attempts, thinking it would not be hard to quit smoking, being in the preparation stage of behavioral change, and thinking their healthcare providers (HCPs) would help them if they decided to quit. Taken together, those findings suggest that HCPs could offer important assistance to help women achieve smoking cessation. However, more research needs to be conducted to clarify the role and effectiveness of various HCPs in smoking cessation interventions and to identify measures to strengthen their provision of such interventions.

Prevalence and Correlates of Tobacco Smoking During the Perinatal Period Among Women Enrolled in a Midwestern WIC Program

BACKGROUND

Perinatal tobacco smoking remains a public health concern and is associated with smoking related morbidity and mortality. This study aims to report the prevalence and correlates of smoking during pregnancy among low-income women.

METHODS

The study sample comprised 729 pregnant women who were enrolled in a perinatal depression registry in a public health WIC program between 2013 and 2015. Smoking risks were obtained from the clinical USDA Risk Assessment. STATA 14.2 was used for analyses.

RESULTS

15.1% of women reported smoking during pregnancy. Compared to White women, Black women were less likely to smoke odds ratio (OR 0.45 [95% CI 0.25-0.81]). Foreign-born women and women living in non-smoking homes remained at a lower risk for smoking during pregnancy.

IMPLICATIONS

Smoking during pregnancy is prevalent among low-income women. In addition to prenatal education on smoking cessation, supportive measures to help deliver smoking cessation interventions should be provided to household members.

Electronic Monitoring Of Mom's Schedule (eMOMS™): Protocol for a feasibility randomized controlled trial to improve postpartum weight, blood sugars, and breastfeeding among high BMI women

Background

Overweight and obesity are major risk factors for gestational diabetes among U.S. women. Evidence suggests that longer duration of breastfeeding among women with a history of gestational diabetes is associated with lower incidence of developing type 2 diabetes after pregnancy. Women may potentially benefit from a lifestyle change program that includes breastfeeding education and support.

Purpose

To describe the design and justification of a combined breastfeeding, national Diabetes Prevention Program (DPP)-based feasibility randomized controlled trial, the electronic Monitoring Of Mom's Schedule (eMOMS^TM) study. eMOMS^TM compares the feasibility and efficacy of three interventions on six-month postpartum weight loss among women with a BMI ≥25.

Methods

The intervention is delivered via Facebook and includes three groups: DPP and breastfeeding (eMOMS1); DPP only (eMOMS2); and Usual Care (eMOMS3). Recruitment is ongoing at two clinical sites (rural and urban). A total of 72 women, 24 per group, will be randomly assigned to one of the three groups. It is anticipated that women in eMOMS1 will have greater weight loss and increased length of breastfeeding at three and six months postpartum compared to women in eMOMS2 and eMOMS3. Additional data will be collected on metabolic markers, anthropometrics, physical activity, nutrition, breastfeeding, and depression. Program cost will be compared to that of traditionally scheduled group meetings. Expected study completion date: October 2021.

Conclusions

This study has the potential to define a high impact, cost effective intervention that can improve public health by reducing negative health outcomes associated with gestational diabetes among an at-risk population.

The Role of Maternal Adverse Childhood Experiences and Race in Intergenerational High-Risk Smoking Behaviors

INTRODUCTION

A history of adversity in childhood is associated with cigarette smoking in adulthood, but there is less evidence for prenatal and next-generation offspring smoking. We investigated the association between maternal history of childhood adversity, pregnancy smoking, and early initiation of smoking in offspring, overall and by maternal race/ethnicity.

METHODS

Data on maternal childhood exposure to physical abuse, household alcohol abuse, and household mental illness, prenatal smoking behaviors, and offspring age of smoking initiation were analyzed from the US National Longitudinal Survey of Youth 1979 (NLSY79, n = 2999 mothers) and the NLSY79 Children and Young Adults Survey (NLSYCYA, n = 6596 children). Adjusted risk ratios were estimated using log-linear regression models. We assessed multiplicative interaction by race/ethnicity for all associations and a three-way interaction by maternal exposure to adversity and race/ethnicity for the association between prenatal and child smoking.

RESULTS

Maternal exposure to childhood physical abuse was significantly associated with 39% and 20% increased risks of prenatal smoking and child smoking, respectively. Household alcohol abuse was associated with significantly increased risks of 20% for prenatal smoking and 17% for child smoking. The prenatal smoking-child smoking relationship was modified by maternal exposure to household alcohol abuse and race. There were increased risks for Hispanic and white/other mothers as compared to the lowest risk group: black mothers who did not experience childhood household alcohol abuse.

CONCLUSIONS

Mothers in this national sample who experienced adversity in childhood are more likely to smoke during pregnancy and their offspring are more likely to initiate smoking before age 18. Findings varied by type of adversity and race/ethnicity.

IMPLICATIONS

These findings support the importance of a life-course approach to understanding prenatal and intergenerational smoking, and suggest that maternal early-life history is a potentially important risk factor that could be targeted with screening and interventions to reduce smoking in pregnant women and their children.