Achieving safe motherhood: Applying a life course and multiple determinants perinatal health framework in public health

Examining emotion regulation and inflammation as predictors of maternal mental health after fetal anomaly diagnosis

OBJECTIVE

Fetal anomalies occur in approximately 3% of pregnancies and receiving the diagnosis may be a potentially traumatic experience for families. The mental health of mothers receiving diagnoses and what predicts resilience or poor mental health is understudied. Emotion regulation is an important, modifiable, transdiagnostic factor of mental health, and may be protective post-diagnosis. Evaluating biomarkers of stress, including IL-6 and Allostatic Load (AL), can also serve as early indicators of risk, indicative of early intervention. This study assessed whether reappraisal, suppression, IL-6, and AL was associated with mental health outcomes and resilience in women after receiving a fetal anomaly diagnosis.

METHODS

Pregnant women (N=108) presenting to a fetal concerns clinic for initial consultation completed measures of emotion regulation (i.e., reappraisal and suppression), depression, anxiety, posttraumatic stress symptoms, and resilience between 2019-2022. A blood draw was used to assess IL-6 and create composite allostatic load measure including: IL-6, blood pressure, heart rate, glucose, cortisol, and body mass index.

RESULTS

Linear regressions controlling for age, gestational age, and perceived fetal diagnosis severity, demonstrated that IL-6 was negatively associated with resilience and positively associated with depression. Reappraisal was positively associated to resilience and negatively associated with depression, anxiety, and PTSD, whereas state insurance status was positively associated to anxiety and PTS symptoms. Suppression and allostatic load were not significant.

CONCLUSIONS

Women experiencing fetal anomaly diagnosis represent an understudied population with unaddressed mental health needs. Reappraisal serves as not only a protective factor, but one that can be enhanced to promote maternal resilience and mental health. Furthermore, elevated IL-6 may be a critical early indicator of potential intervention needs among women who are pregnant, to mitigate negative psychological states and enhance resilience.

Prognostic prediction models for adverse birth outcomes: A systematic review

Background

Despite progress in reducing maternal and child mortality worldwide, adverse birth outcomes such as preterm birth, low birth weight (LBW), small for gestational age (SGA), and stillbirth continue to be a major global health challenge. Developing a prediction model for adverse birth outcomes allows for early risk detection and prevention strategies. In this systematic review, we aimed to assess the performance of existing prediction models for adverse birth outcomes and provide a comprehensive summary of their findings.

Methods

We used the Population, Index prediction model, Comparator, Outcome, Timing, and Setting (PICOTS) approach to retrieve published studies from PubMed/MEDLINE, Scopus, CINAHL, Web of Science, African Journals Online, EMBASE, and Cochrane Library. We used WorldCat, Google, and Google Scholar to find the grey literature. We retrieved data before 1 March 2022. Data were extracted using CHecklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies. We assessed the risk of bias with the Prediction Model Risk of Bias Assessment tool. We descriptively reported the results in tables and graphs.

Results

We included 115 prediction models with the following outcomes: composite adverse birth outcomes (n = 6), LBW (n = 17), SGA (n = 23), preterm birth (n = 71), and stillbirth (n = 9). The sample sizes ranged from composite adverse birth outcomes (n = 32-549), LBW (n = 97-27 233), SGA (n = 41-116 070), preterm birth (n = 31-15 883 784), and stillbirth (n = 180-76 629). Only nine studies were conducted on low- and middle-income countries. 10 studies were externally validated. Risk of bias varied across studies, in which high risk of bias was reported on prediction models for SGA (26.1%), stillbirth (77.8%), preterm birth (31%), LBW (23.5%), and composite adverse birth outcome (33.3%). The area under the receiver operating characteristics curve (AUROC) was the most used metric to describe model performance. The AUROC ranged from 0.51 to 0.83 in studies that reported predictive performance for preterm birth. The AUROC for predicting SGA, LBW, and stillbirth varied from 0.54 to 0.81, 0.60 to 0.84, and 0.65 to 0.72, respectively. Maternal clinical features were the most utilised prognostic markers for preterm and LBW prediction, while uterine artery pulsatility index was used for stillbirth and SGA prediction.

Conclusions

A varied prognostic factors and heterogeneity between studies were found to predict adverse birth outcomes. Prediction models using consistent prognostic factors, external validation, and adaptation of future risk prediction models for adverse birth outcomes was recommended at different settings.

Registration

PROSPERO CRD42021281725.

The importance of community support for women in a Gulf Coast Indigenous tribe

Purpose –

Community support is an integral aspect of health and well-being for Indigenous peoples. The purpose of this paper is to demonstrate the valuable role of community support for Indigenous women specifically, who experience reproductive health disparities at alarming rates. This study helps fill an important gap in Indigenous scholarship by centering the resilience of women and Indigenous tribes and by using a framework that is consistent with Indigenous holistic views of health.

Design/methodology/approach –

The data for this paper was collected as part of a larger study exploring the reproductive health experiences of a state-recognized Gulf Coast tribe. A total of 31 semi-structured interviews were conducted with individuals who identify as women and as members of this tribe using qualitative descriptive methodology. This method is recommended for research with Indigenous communities. A community advisory board with representatives from this tribe provided feedback throughout the project.

Findings –

Themes expressed by participants included Community Closeness and Support; Community Support in Raising Children; Informal Adoption Common; and Community Values of Mutual Aid and Self-Sufficiency. The findings support current literature noting the value of generational and communal ties for Indigenous peoples. Implications of this research include the need to value and support community networks in programs serving tribes, in addition to meaningfully including Indigenous communities in developing interventions.

Originality/value –

This paper centers Indigenous women's resilience, approaches the health and well-being of Indigenous tribes holistically and helps to fill an important gap in literature describing informal adoption (outside the legal system) in state-recognized Indigenous communities.

Healthcare needs and infrastructure obstacles for a state-recognised Indigenous tribe in the United States

Although Indigenous groups continue to experience extensive health disparities, little research explores the role of structural barriers in contributing to health disparities for state-recognised tribes, who do not receive healthcare services from the Indian Health Service. In addition, much research focuses on discrete physical health outcomes, without utilising community-based approaches to allow participants to identify healthcare priorities and needs in their own voices. In partnership with a community advisory board, a qualitative descriptive methodology was used to conduct 31 life-course interviews with participants of a state-recognised tribe in the Gulf South region of the United States to explore healthcare experiences. Participants identified unmet healthcare needs and healthcare infrastructure barriers. Some of the most common barriers and unmet healthcare needs included: Long Distance to Healthcare Services and Difficulty in Accessing Specialists, Need for Increased Communication, Long Hospital or Appointment Wait Times, Unmet Mental Health Needs, Need for Substance Use or Abuse Prevention Programs and Need for Health Education. These findings highlight some of the structural barriers that exacerbate existing health disparities and suggest important areas of intervention, such as including a focus on mental health needs. Increased healthcare resources and recognition of sovereignty for this state-recognised tribe are also needed to begin to address these barriers. In addition, because of the long history of exploitation of Indigenous communities, healthcare interventions should meaningfully include Indigenous tribes in the development and implementation of any healthcare programs.

The Development of the Framework of Integrated Reproductive and Sexual Health Theories (FIRSHT) to Contextualize Indigenous Women's Health Experiences

Introduction

Indigenous women experience extensive reproductive health disparities and reproductive oppression. Theoretical frameworks for understanding the complex intersection of factors that contribute to these experiences are needed, especially those that highlight the resilience of Indigenous peoples throughout settler colonialism. The purpose of this article is to explore the empirical development of the Framework of Integrated Reproductive and Sexual Health Theories (FIRSHT) to contextualize and understand the reproductive and sexual health experiences of Indigenous women.

Methods

The FIRSHT was developed through a qualitative descriptive research study with 31 Indigenous women from a Gulf Coast tribe. Interviews were conducted in 2018 and 2019. The first author partnered with a community-advisory board throughout the research project, and in the dissemination of results to tribal members.

Results

After presenting a snapshot of the overarching results, we discuss how the FIRSHT incorporates key components of the reproductive justice, resilience, Indigenous critical theory, life course and eco-systemic theoretical frameworks. The proposed framework conceptualizes the interrelationship of factors that impact women's reproductive and sexual health experiences.

Discussion

This research fills a gap in the need for holistic understandings of Indigenous women's reproductive and sexual healthcare required for the development of interventions that not only address social justice issues and weaknesses in the healthcare system but also promote the existing strengths and resources in Indigenous communities.

Policy Implications

This theoretical framework may be useful for researchers interested in studying the reproductive and sexual health experiences of Indigenous women, who desire a holistic and strengths-based framework.

Systematic Review of Health Promotion Frameworks Focused on Health in the Postpartum Period

OBJECTIVE

To systematically review the scope and development of frameworks to promote health during the postpartum period.

DATA SOURCES

We searched PubMed, CINAHL, and American Psychological Association PsycInfo during May 2021.

STUDY SELECTION

We included English-language, peer-reviewed articles focused on frameworks for health promotion in the postpartum period. We placed no time limit on publication date. Our search resulted in 2,355 articles after we removed duplicates. After excluding articles based on titles and abstracts, we conducted full-text reviews of 23 articles. Three articles met inclusion criteria and addressed the following frameworks: Integrated Perinatal Health Framework, Perinatal Maternal Health Promotion Model, and Maternal Self-Care Framework.

DATA EXTRACTION

We extracted data into analytic tables that included categories for the scope, such as time frame, and criteria for the level of development of the frameworks, including the origins, concept definitions and theoretical linkages among concepts, and evidence of application in research or practice.

DATA SYNTHESIS

The three frameworks described in the articles included in our review covered various periods, including the reproductive life span, the first year after birth, and the first 6 weeks after birth. Overall, the frameworks were comprehensive. Most key concepts in the frameworks were defined, and some degree of relationships linking concepts was specified. Empirical referents were provided for most but not all concepts in the frameworks. Developers of the three frameworks elaborated on application in practice or health services, but only the developers of the Maternal Self-Care Framework indicated how their framework might be used in research. The Integrated Perinatal Health Framework and Maternal Self-Care Framework were partially derived from existing general theories; the methods used to develop the Perinatal Maternal Health Promotion Model were less clear.

CONCLUSION

The frameworks met most criteria and together provided a comprehensive strategy for health promotion during the postpartum period. Elaboration of the frameworks for application in research is needed.

Adolescent Obesity Modeling: A Framework of Socio-Economic Analysis on Public Health

Bayesian Structural Equation Modeling (SEM-Bayesian) was applied across different research areas to model the correlation between manifest and latent variables. The primary purpose of this study is to introduce a new framework of complexity to adolescent obesity modeling based on adolescent lifestyle through the application of SEM-Bayesian. The introduced model was designed based on the relationships among several factors: household socioeconomic status, healthy food intake, unhealthy food intake, lifestyle, body mass index (BMI) and body fat. One of the main contributions of this study is from considering both BMI and body fat as dependent variables. To demonstrate the reliability of the model, especially in terms of its fitting and accuracy, real-time data were extracted and analyzed across 881 adolescents from secondary schools in Tehran, Iran. The output of this study may be helpful for researchers who are interested in adolescent obesity modeling based on the lifestyle and household socioeconomic status of adolescents.

Pregnancy and Parenthood Among Autistic Adults: Implications for Advancing Maternal Health and Parental Well-Being

Background

Strikingly little research has considered how autistic adults experience pregnancy and parenthood, two key transition periods in adult development with potentially far-reaching implications for physical and psychosocial health outcomes across the lifespan. This article reviews the research on pregnancy and parenthood among autistic adults, to summarize existing research and identify future directions to advance this critical area of study.

Methods

We conducted a systematic review of the literature on pregnancy and parenthood among autistic adults. Researchers extracted selected articles for key information, including methodology and sample size, study location, demographic characteristics of participants, measurement approaches, and key study findings.

Results

Overall, we identified 13 studies that used a range of quantitative and qualitative approaches to study pregnancy experiences and outcomes and parenthood among autistic adults. The findings show that autistic adults (1) experience difficulties and dissatisfaction communicating with health care providers throughout pregnancy and birth, (2) are more likely to experience depression during and after pregnancy, and (3) experience higher rates of pregnancy complications, including preterm birth, cesarean delivery, and pre-eclampsia. During parenthood, autistic adults report lower parenting competence, experience parenthood as isolating, have difficulty communicating with professionals about their child and are questioned by providers about their ability to parent, experience high rates of involvement with child protective services, and express a desire for increased parenting support. Autistic adults also reported parenting strengths, including high levels of finding parenthood rewarding and putting their children's needs ahead of their own.

Conclusions

A key limitation of the literature is the significant lack of sociodemographic diversity among participants, the small number of existing studies, and reliance on cross-sectional mono-method designs. Future research should be conducted in partnership with autistic adults to develop assessment and intervention approaches for supporting pregnancy health and parental well-being among diverse and underserved communities.

Lay summary

Why is this topic important?: Very little is known about how autistic adults experience pregnancy and parenthood. Better understanding these experiences is important, because pregnancy and parenthood are key transition periods in adult development that are associated with a range of health outcomes later in life.What is the purpose of this article?: This article reviews the existing research on pregnancy and parenthood among autistic adults. We wanted to summarize what is already known, evaluate how that knowledge was created, and consider who has and who has not been included in this research to inform future research. We summarized 13 studies that considered pregnancy or parenthood among autistic adults.What did the authors find about pregnancy among autistic adults?: One study used data from hospital and birth records in Sweden, and showed that autistic women experience higher rates of pregnancy complications, such as preterm birth (early delivery before 37 weeks), cesarean delivery, and pre-eclampsia (a condition defined by high blood pressure during pregnancy). Two studies had autistic and nonautistic adults fill out online surveys about their experiences, and found that autistic adults are more likely to have depression during and after pregnancy, have more difficulty interacting with health care professionals at pregnancy appointments and during the birth process, and feel that information and support services for pregnancy do not always meet their needs. Autistic women also reported that sensory differences can make health care visits during pregnancy especially difficult, and described that they may experience anxiety and confusion when interacting with health care staff.What did the authors find about parenthood among autistic adults?: The research we reviewed showed that autistic adults experience strengths and difficulties in parenting. Many autistic adults found parenthood rewarding, but also felt isolated as parents and had difficulty communicating with health care professionals about their children. Autistic adults also had high rates of interacting with child protective services (CPS). Some research also found that autistic adults had lower self-confidence in parenting, although findings are mixed.What are the recommendations for future research and practice?: We need to develop support strategies to promote pregnancy health and parenting satisfaction in partnership with autistic adults. For example, it may be helpful to develop communication tools that can support autistic adults during pregnancy, labor, and birth. We also recommend that future research develop questionnaires to ask autistic adults about their pregnancy and parenting experiences in sensitive ways, so that in the future providers can regularly ask autistic adults about their support needs. Most importantly, it is critical that future research also include more diverse autistic participants in their research, including racial/ethnic and sexual and gender minorities.How will these findings help autistic adults now or in the future?: We hope that this article will help guide future research that strives to better understand how autistic adults experience pregnancy and parenthood. Ultimately, we believe this research can lead to supports and intervention strategies that can improve pregnancy health and parental well-being for autistic adults.

The Victorian Intergenerational Health Cohort Study (VIHCS): Study design of a preconception cohort from parent adolescence to offspring childhood

BACKGROUND

There is increasing evidence that parental determinants of offspring early life development begin well before pregnancy.

OBJECTIVES

We established the Victorian Intergenerational Health Cohort Study (VIHCS) to examine the contributions of parental mental health, substance use, and socio-economic characteristics before pregnancy to child emotional, physical, social, and cognitive development.

POPULATION

Men and women were recruited from the Victorian Adolescent Health Cohort (VAHCS), an existing cohort study beginning in 1992 that assessed a representative sample of 1943 secondary school students in Victoria, Australia, repeatedly from adolescence (wave 1, mean age 14 years) to adulthood (wave 10, mean age 35 years).

METHODS

Victorian Adolescent Health Cohort participants with children born between 2006 and 2013 were recruited to VIHCS and invited to participate during trimester three, at 2 months postpartum, and 1 year postpartum. Parental mental health, substance use and socio-economic characteristics were assessed repeatedly throughout; infant characteristics were assessed postnatally and in infancy. Data will be supplemented by linkage to routine datasets. A further follow-up is underway as children reach 8 years of age.

PRELIMINARY RESULTS

Of the 1307 infants born to VAHCS participants between 2006 and 2013, 1030 were recruited to VIHCS. At VIHCS study entry, 18% of recruited parents had preconception common mental disorder in adolescence and young adulthood, 18% smoked daily in adolescence and young adulthood, and 6% had not completed high school. Half of VIHCS infants were female (48%), 4% were from multiple births, and 7% were preterm (<37 weeks' gestation).

CONCLUSIONS

Victorian Intergenerational Health Cohort Study is a prospective cohort of 1030 children with up to nine waves of preconception parental data and three waves of perinatal parental and infant data. These will allow examination of continuities of parental health and health risks from the decades before pregnancy to offspring childhood, and the contributions of exposures before pregnancy to offspring outcomes in childhood.

Results of a Dutch national and subsequent international expert meeting on interconception care

Introduction: The potential value of preconception care and interconception care is increasingly acknowledged, but delivery is generally uncommon. Reaching women for interconception care is potentially easier than for preconception care, however the concept is still unfamiliar. Expert consensus could facilitate guidelines, policies and subsequent implementation. A national and subsequent international expert meeting were organized to discuss the term, definition, content, relevant target groups, and ways to reach target groups for interconception care.Methods: We performed a literature study to develop propositions for discussion in a national expert meeting in the Netherlands in October 2015. The outcomes of this meeting were discussed during an international congress on preconception care in Sweden in February 2016. Both meetings were recorded, transcribed and subsequently reviewed by participants.Results: The experts argued that the term, definition, and content for interconception care should be in line with preconception care. They discussed that the target group for interconception care should be "all women who have been pregnant and could be pregnant in the future and their (possible) partners". In addition, they opted that any healthcare provider having contact with the target group should reach out and make every encounter a potential opportunity to promote interconception care.Discussion: Expert discussions led to a description of the term, definition, content, and relevant target groups for interconception care. Opportunities to reach the target group were identified, but should be further developed and evaluated in policies and guidelines to determine the optimal way to deliver interconception care.

Healthcare barriers and supports for American Indian women with cancer

Although American Indian (AI) women continue to experience cancer at higher rates and have not seen the same decline in cancer prevalence as the general U.S. population, little research examines how interactions with health care providers may influence and exacerbate these health disparities. The purpose of the study was to understand the experiences of AI women who receive cancer treatment, which is integral for eradication of AI cancer disparities among women. A qualitative descriptive methodology was used with a sample of 43 AI women with breast, cervical, colon, and other types of cancer from the Northern Plains region of South Dakota. Interviews were conducted from June 2014 to February 2015. Qualitative content analysis revealed that women experienced: (a) health concerns being ignored or overlooked; (b) lack of consistent and qualified providers; (c) inadequate healthcare infrastructure; (d) sub-optimal patient-healthcare provider relationships; (e) positive experiences with healthcare providers; and (f) pressure and misinformation about treatment. Results indicate the types of support AI women may need when accessing healthcare. Culturally informed trainings for healthcare professionals may be needed to provide high-quality and sensitive care for AI women who have cancer, and to support those providers already providing proper care.

Maternal body weight trajectories across the life course and risk of preterm delivery

We examined the association between life course body weight percentile trajectories and risk for preterm delivery (PTD). Data about women's weight at birth, age 18, and before pregnancy were obtained by retrospective self-report in a cohort of 1410 black women in metropolitan Detroit. Growth mixture models were used to categorize women with similar weight percentile trajectories across these time points. Log-Poisson models were used to examine the association between the trajectory groups and PTD. Four trajectory groups with different beginning and endpoints of their weight percentiles (high-high, high-low, low-high and low-low) best fit the data. The groups with the highest prevalence of PTD were those that started low (low-high, 21%; low-low, 18%). The low-high group had a higher prevalence of PTD than the high-high trajectory group in unadjusted models (prevalence ratio=1.49 [95% confidence interval (CI) 1.11, 2.00]). The association became not significant after adjusting for maternal age at delivery, income, diabetes and hypertension. When compared with the high-high trajectory group, the low-low trajectory seemed to also have a higher prevalence of PTD after adjusting for maternal age at delivery, income, diabetes and hypertension (prevalence ratio=1.35 [95% CI 1.00, 1.83]). Results suggest that a woman's risk for PTD is influenced by her body weight trajectory across the life course.

Teaching University Students About Evidence-Based Perinatal Care: Effects on Learning and Future Care Preferences

U.S. university students hold generally medicalized views on childbirth, which contrast with evidence indicating that low-intervention birth is safest for most. Therefore, intentional efforts are needed to educate childbearing populations on perinatal care evidence. Toward that aim, this study involved teaching university students in an introductory class (N = 50) about evidence-based perinatal care. Students completed a "future birth plan" and an essay on how their learning affected care preferences. Analyses revealed that students selected evidence-based care components up to 100 times more frequently than what the national data indicate they are used. Students based care selections on evidence, costs, and personal views. Their interest in physiologic birth has important implications for advancing education on perinatal care, practice, and policy.

Understanding Women's Awareness and Access to Preconception Health Care in a Rural Population: A Cross Sectional Study

Despite evidence of the benefits of preconception health care (PCHC), little is known about awareness and access to PCHC for rural, reproductive-aged women. This study aimed to assess the prevalence of PCHC conversations between rural reproductive-age women and health care providers, PCHC interventions received in the past year, and ascertain predictors of PCHC conversations and interventions. Women (n = 868; 18-45 years) completed a questionnaire including reproductive history, health care services utilization, and interest in PCHC. The prevalence of health care providers' PCHC conversations was 53.9 %, and the mean number of interventions reported was 2.6 ± 2.7 (±SD). Significant predictors of PCHC conversation based on adjusted odds ratios from logistic regression were race (Native American 76 % greater than White), health care provider type (non-physician 63 % greater than physician), visits to a health care provider (3+ times 32 % greater than 1-2 times), and pregnancy planning (considering in next 1-5 years 51 % greater than no plans). Significant predictors of PCHC interventions received in the past 12 months based on adjusted risk ratios from negative binomial regression were race (Native American 22 % greater than White), PCHC conversation with a health care provider (yes 52 % lower than no), reporting PCHC as beneficial (yes 32 % greater than don't know), and visits to a health care provider in the past year (3+ times 90 % greater than 1-2 times). Increasing conversations about PCHC between health care providers and their reproductive-aged patients can improve awareness and increase their likelihood of receiving all of the recommended interventions.

Maternal morbidities and postpartum depression: an analysis using the 2007 and 2008 Pregnancy Risk Assessment Monitoring System

PURPOSE

Postpartum depression (PPD) is common and associated with significant health outcomes and other consequences. Identifying persons at risk may improve screening and detection of PPD. This exploratory study sought to identify the morbidities that associate with 1) PPD symptoms and 2) PPD diagnosis.

METHODS

Data from the 2007 and 2008 Pregnancy Risk Assessment Monitoring System were analyzed from 23 states and 1 city (n = 61,733 pregnancies); 13 antenatal morbidities were included. To determine whether antenatal morbidity predictors of PPD would differ based on PPD symptoms versus a diagnosis, each of the 13 antenatal morbidities were examined in separate logistic regression models with each PPD outcome. For each objective, two samples were examined: 1) Women from all states and 2) women from Alaska and Maine, the two states that included both PPD symptoms and PPD diagnosis measures in their questionnaires. Control variables included demographic and sociodemographic variables, pregnancy variables, antenatal and postpartum health behaviors, and birth outcomes.

MAIN FINDINGS

Having vaginal bleeding (odds ratio [OR], 1.42; OR, 1.76), kidney/bladder infection (OR, 1.59; OR, 1.63), nausea (OR, 1.50; OR, 1.80), preterm labor (OR, 1.54; OR, 1.51), or being on bed rest (OR, 1.34; OR, 1.56) associated with both PPD symptoms and PPD diagnosis, respectively. Being in a car accident associated with PPD symptoms only (OR, 1.65), whereas having hypertension (OR, 1.94) or a blood transfusion (OR, 2.98) was associated with PPD diagnosis only. Among women from Alaska or Maine, having preterm labor (OR, 2.54, 2.11) or nausea (OR, 2.15, 1.60) was associated with both PPD symptoms and PPD diagnosis, respectively. Having vaginal bleeding (OR, 1.65), kidney/bladder infection (OR, 1.74), a blood transfusion (OR, 3.30), or being on bed rest (OR, 1.87) was associated with PPD symptoms only, whereas having diabetes before pregnancy (OR, 5.65) was associated with PPD diagnosis only.

CONCLUSIONS

The findings of this exploratory study revealed differences in the antenatal morbidities that were associated with PPD symptoms versus diagnosis in both samples, and can assist prenatal care providers in prioritizing and screening for these morbidities that are associated with PPD during pregnancy. Additional research is warranted to confirm the results of this study in other samples and populations. Developing strategies to 1) improve general awareness of PPD and the appropriate antenatal morbidity risk factors to focus on in clinical settings, and 2) increase screening for the antenatal morbidities determined to be predictors of PPD in this study are warranted in preventing PPD.

A review of national health policies and professional guidelines on maternal obesity and weight gain in pregnancy

Maternal obesity creates an additional demand for health-care services, as the routine obstetric care pathway requires alterations to ensure the most optimal care for obese women of childbearing age. This review examines the extent to which relevant national health documents reflect and respond to the health implications of maternal obesity and excessive gestational weight gain. A targeted search of peer-reviewed publications and grey literature was conducted for each country to identify national health documents, which were subsequently content analyzed according to an adapted framework. A total of 37 documents were identified, including one policy, 10 strategies and 26 guidelines, published within the last 10 years. Out of the 31 countries investigated, only 13 countries address maternal obesity while none address excessive gestational weight gain. We found inconsistencies and gaps in the recommendations to health-care service providers for the management of maternal obesity and weight gain in pregnancy. The findings show that only limited guidance on maternal obesity and gestational weight gain exists. The authors recommend that international, evidence-based guidelines on the management of maternal obesity and excessive gestational weight gain should be developed to reduce the associated health-care and economic costs.

La Compleja Relación Entre Posición Socioeconómica, Estatus Migratorio y Resultados de Salud

INTRODUCTION

The relationship between socioeconomic position (SEP), migration and health is dynamic, difficult to predict, multifactorial and poorly studied in the Latin American region. Moreover, there are high levels of uncertainty about reasons, types, and consequences of migration to an individual, family, community, country of origin and the receiving country.

OBJECTIVE

To discuss the evidence about the complex relationship between SEP, migration and health outcomes.

RESULTS

According to international evidence available, migration has a direct impact on health outcomes in a population and, in turn, on public health policy decisions in each locality. The available evidence on this issue affects multiple parts of the social sciences. The "healthy migrant" effect is not consistently observed among immigrant populations, particularly after adjusting for PSE. Moreover, the immigrant population tends to assimilate in terms of risk factors and morbidity to the local population after about 10 years of stay in the foreign country. Migration has consequences for international relations, economic productive capacity of a country, inequality, demographic changes and health outcomes, to mention a few.

CONCLUSION

There is now the opportunity to generate better and more evidence longitudinal population-based around the relationship between SEP, migration status and health. This will contribute to reduce uncertainty about the health status of immigrants that is required for decision- making in public health in Chile and the region.

Selected preconception health indicators and birth weight disparities in a national study

BACKGROUND

This analysis explored the effect of timing, sequencing, and change in preconception health across adolescence and young adulthood on racial/ethnic disparities in birth weight in a diverse national cohort of young adult women.

METHODS

Data came from Waves I (1994-1995), III (2001-2002), and IV (2007-2008) of the National Longitudinal Study of Adolescent Health. Eligibility was restricted to all singleton live births to female non-Hispanic White, non-Hispanic Black, Mexican-origin Latina, or Asian/Pacific Islander participants (n = 3,014) occurring between the Wave III (ages 18-26 years) and IV (ages 24-32 years) interviews. Birth weight was categorized into low (<2,500 g), normal (2,500-4,000 g), and macrosomic (>4,000 g). Preconception health indicators were cigarette smoking, heavy alcohol consumption, overweight or obesity, and inadequate physical activity, measured in adolescence (Wave I, ages 11-19 years) and early adulthood (Wave III) and combined into four-category variables to capture the timing and sequencing of exposure.

FINDINGS

Measures of preconception health did not explain the Black-White disparity in low birth weight, which increased after adjustment for confounders (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.33-3.53) and effect modification by overweight/obesity (OR, 3.58; 95% CI, 1.65-7.78). A positive association between adult-onset overweight/obesity and macrosomia was modified by race (OR, 3.83; 95% CI, 1.02-14.36 for Black women).

CONCLUSIONS

This longitudinal analysis provides new evidence on preconception health and racial/ethnic disparities in birth weight. Specifically, it indicates that interventions focused on prevention of overweight/obesity and maintenance of healthy weight during the transition to adulthood, especially among Black females, may be warranted.

Incorporating the life course model into MCH nutrition leadership education and training programs

Life course perspective, social determinants of health, and health equity have been combined into one comprehensive model, the life course model (LCM), for strategic planning by US Health Resources and Services Administration's Maternal and Child Health Bureau. The purpose of this project was to describe a faculty development process; identify strategies for incorporation of the LCM into nutrition leadership education and training at the graduate and professional levels; and suggest broader implications for training, research, and practice. Nineteen representatives from 6 MCHB-funded nutrition leadership education and training programs and 10 federal partners participated in a one-day session that began with an overview of the models and concluded with guided small group discussions on how to incorporate them into maternal and child health (MCH) leadership training using obesity as an example. Written notes from group discussions were compiled and coded emergently. Content analysis determined the most salient themes about incorporating the models into training. Four major LCM-related themes emerged, three of which were about training: (1) incorporation by training grants through LCM-framed coursework and experiences for trainees, and similarly framed continuing education and skills development for professionals; (2) incorporation through collaboration with other training programs and state and community partners, and through advocacy; and (3) incorporation by others at the federal and local levels through policy, political, and prevention efforts. The fourth theme focused on anticipated challenges of incorporating the model in training. Multiple methods for incorporating the LCM into MCH training and practice are warranted. Challenges to incorporating include the need for research and related policy development.

Integrating the life course perspective into a local maternal and child health program

For many decades, early access to prenatal care has been considered the gold standard for improving birth outcomes. In Contra Costa County, a diverse urban and suburban county of over one million people in the San Francisco Bay Area, the Family Maternal and Child Health Programs of Contra Costa Health Services (CCHS) have seen high rates of early entry into prenatal care since 2000. Yet despite our best efforts to increase access to quality prenatal care, our rates of low birth weight and infant mortality, especially among African Americans, continue to be high. When we were introduced to the Life Course Perspective in 2003 as an organizational framework for our programmatic activities, we recognized that emerging scientific evidence in the literature demonstrated the importance of social and environmental factors in determining health and health equity, and supported a general impression in the field that prenatal care was not enough to improve birth outcomes. The Life Course Perspective suggests that many of the risk and protective factors that influence health and wellbeing across the lifespan also play an important role in birth outcomes and in health and quality of life beyond the initial years. In this article, we describe the Life Course Perspective and how one local Maternal and Child Health Program adopted and adapted this paradigm by creating and launching a Life Course Initiative to guide our programs and services. The Life Course Initiative implemented by CCHS is designed to reduce inequities in birth outcomes, improve reproductive potential, and change the health of future generations by introducing a longitudinal, integrated, and ecological approach to implementing maternal and child health programs.

Self-efficacy scale for weight loss among multi-ethnic women of lower income: a psychometric evaluation

OBJECTIVE

This study examined test-retest reliability, internal consistency, and construct and predictive validity of the Physical Activity and Nutrition Self-Efficacy (PANSE) scale, an 11-item instrument to assess weight-loss self-efficacy among postpartum women of lower income.

METHODS

Seventy-one women completed the PANSE scale and psychosocial measures at baseline and at 7 and 13 weeks of a pilot study of weight loss.

RESULTS

Test-retest reliability of PANSE scores was r = 0.55 (P < .01). Cronbach α was r = 0.89. Construct validity was supported by correlations with less-healthful behaviors (r = -0.33, P = .005), perceived stress (r = -0.24, P = .04), and decisional balance (r = 0.25, P = .03). PANSE change scores correlated with intervention group weight changes (r = -0.54, P < .01), although baseline scores did not. One factor emerged (loadings .80 to .57).

CONCLUSIONS AND IMPLICATIONS

The PANSE scale demonstrated adequate reliability, internal consistency, construct validity, and moderate predictive validity. Replication is needed to confirm study findings.

Foundations for social justice-based actions in maternal/infant nursing

The purpose of this article is to discuss health disparities and inequities and their most significant effects on maternal/infant health. A literature background on the social context of justice and distinct ethical theories is provided. Different ethical approaches to guide interventions that can improve the health of mothers and infants are presented. By adopting an ethical framework of social justice, nurses can better understand and thus influence outcomes and ameliorate health disparities and inequalities.

What causes racial disparities in very preterm birth? A biosocial perspective

Very preterm birth (<32 weeks' gestation) occurs in approximately 2% of livebirths but is a leading cause of infant mortality and morbidity in the United States. African-American women have a 2-fold to 3-fold elevated risk compared with non-Hispanic white women for reasons that are incompletely understood. This paper reviews the evidence for the biologic and social patterning of very preterm birth, with attention to leading hypotheses regarding the etiology of the racial disparity. A systematic review of the literature in the MEDLINE, CINAHL, PsycInfo, and EMBASE indices was conducted. The literature to date suggests a complex, multifactorial causal framework for understanding racial disparities in very preterm birth, with maternal inflammatory, vascular, or neuroendocrine dysfunction as proximal pathways and maternal exposure to stress, racial differences in preconceptional health, and genetic, epigenetic, and gene-environment interactions as more distal mediators. Interpersonal and institutionalized racism are mechanisms that may drive racially patterned differences. Current literature is limited in that research on social determinants and biologic processes of prematurity has been generally disconnected. Improved etiologic understanding and the potential for effective intervention may come with better integration of these research approaches.

Preconception predictors of birth outcomes: prospective findings from the central Pennsylvania women's health study

OBJECTIVE

To examine maternal pre-pregnancy (preconception) predictors of birthweight and fetal growth for singleton live births occurring over a 2-year period in a prospective study.

METHODS

Data are from a population-based cohort study of 1,420 women who were interviewed at baseline and 2-years later; self-report data and birth records were obtained for incident live births during the followup period. The analytic sample includes 116 singleton births. Baseline preconception maternal health status and health-related behaviors were examined as predictors of birthweight and fetal growth, controlling for prenatal and sociodemographic variables, using multiple regression analysis.

RESULTS

Preconception BMI (overweight or obese) and vegetable consumption (at least one serving per day) had statistically significant independent and positive effects on birthweight and fetal growth. Maternal weight gain during pregnancy, a prenatal variable, was an additional independent predictor of birthweight and fetal growth. Sociodemographic variables were not significant predictors after controlling for preconception and prenatal maternal characteristics.

CONCLUSIONS

Findings confirm that preconception maternal health status and health-related behaviors can affect birthweight and fetal growth independent of prenatal and socioeconomic variables. Implications for preconception care are discussed.

Web-based education for postpartum depression: conceptual development and impact

Postpartum depression (PPD) is a major public health problem that occurs in one of every seven women in the first 3 months after birth. Left untreated, PPD can persist for months to years and lead to adverse consequences for both mother and child. Primary care providers have the most medical contact with postpartum women and are well positioned to screen for and identify PPD. However, PPD recognition and treatment is generally not included in physician training, and few continuing education programs on PPD are available. Developed with support from NIMH SBIR contract (# HHSN278200554096C), the Web site MedEdPPD was designed to provide professionals with the tools to successfully engage, screen, diagnose, treat, and refer women with PPD. Resources on the site include CME/CE modules; interactive case studies; classic papers and current literature; provider tools; a comprehensive slide library; events calendar; and resources. MedEdPPD also contains materials for women with PPD, their friends and family members. As of March 2008, the site had over 17,000 visitors who represented both consumers and a broad distribution of health care professional disciplines. The nine CME/CE learning modules on MedEdPPD have been particularly heavily utilized by nurses. The number of repeat and new visitors has increased steadily since the site's launch. User feedback has been consistently positive. Based upon theories of adult education, MedEdPPD offers diverse strategies to facilitate learning. The site promotes education and training in PPD treatment that is flexible, cost-effective, and meets the needs of health care professionals.

Engagement in paraprofessional home visitation: families' reasons for enrollment and program response to identified reasons

Home visitation programs have exhibited modest impact in promoting maternal and child health outcomes; therefore, formative research is necessary to examine whether home visiting program models or actual implementation need to be modified. In particular, client engagement and retention have been identified as areas in which program implementation can be enhanced. This study assessed home visiting clients' reasons for entering home visiting programs and their perception of programs' response to these identified needs. We asked newly enrolled home visiting clients (n = 123) to identify reasons for entering their home visiting program, including their first and second most important reasons. The most frequently cited reasons for enrolling were wanting information about job training, completing one's education, keeping in good health during pregnancy, and learning about infant growth and development. Home visiting programs' response to clients' identified needs varied. Needs more closely related to home visiting program goals of providing parenting education and promoting prenatal health were most often met, whereas needs less closely related to program goals (e.g., life course needs such as information about job training or education) were less often met. Our findings suggest that home visiting programs in urban contexts should consider modifying their program protocols to better respond to employment- and education-related issues facing their clients.