1. health and fitness

PREGNANCY PLANNING AND BIRTH OUTCOMES AMONG HIV POSITIVE
WOMEN IN BALTIMORE CITY
Meena Abraham, DrPH, MPH, Erin Johnson Patton, MPH, Pamela Young, PhD, LCSW-C, Sarah Raihl, LCSW-C, Stephanie
Cockrell
Baltimore City Health Department, Maryland State Medical Society, Sinai Hospital of Baltimore
BACKGROUND: In 2010, women comprised 37.1% of HIV cases in Baltimore, 73.6% were 18 to 44 years. For 2001-2006,
17.5% of postpartum women participating in Maryland PRAMS reported that their health care provider had not talked with them
about HIV during pregnancy. The 2006-2010 perinatal HIV transmission rate was 2.5% for 850 births in Maryland; majority of
these births occurred in Baltimore City.
STUDY QUESTIONS: What are the characteristics and pregnancy planning status of births among HIV-positive women in
Baltimore?
METHODS: Baltimore FIMR-HIV compiled case histories from medical records, case management records, and maternal
interviews to conduct an in-depth multi-disciplinary committee review of nine births between 2008 and 2010 among HIV positive
women enrolled in case management at Sinai Hospital of Baltimore.
RESULTS: Maternal ages ranged from 17 to 37 years with the majority 25 years and older (66.7%), and pregnant previously
(77.8%). Pregnancy planning was unintended (55.6%), desired (22.2%), and unknown (22.2%). The majority (66.7%) of women
had been diagnosed with HIV between 3 and 16 years prior to the pregnancy under review, two (22.2%) during pregnancy, and
one (11.1%) at delivery. Prenatal care entry was <12 weeks (44.4%), 13-15 weeks (22.2%), and 20-21 weeks (22.2%). Maternal
risk factors included history of STD (11.1%), history of substance use (33.3%), and domestic violence (33.3%). All women
received HIV treatment prior to their pregnancy or following HIV diagnosis, and received case management services during
pregnancy. Infant outcomes were 77.8% full-term and 22.2% near-term gestation, 44.4% low birth weight, and none diagnosed
with HIV.
CONCLUSIONS: HIV positive women experience a number of risk factors and needs impacting retention in care and birth
outcomes. Women receiving intensive case management were successfully retained in care, which resulted in no perinatal HIV
transmissions among these births.
PUBLIC HEALTH IMPLICATIONS: Knowledge of HIV status and pregnancy planning influences infant health outcomes for
births occurring to HIV positive women. The most effective strategy for preventing mother-to-child HIV transmission is for women
to be routinely tested, diagnosed and enrolled in medical care, and to have reproductive counseling and pregnancy planning
provided as an integral component of HIV care.
1
IMPACT OF PATERNAL INVOLVEMENT ON BIRTH OUTCOMES AMONG
HIV+ MOTHERS
Amina Alio, PhD, Euna August, PhD, MPH, Cara de la Cruz, PhD, Alfred Mbah, PhD, Hamisu Salihu, MD, PhD, Phillip Marty,
PhD
University of Rochester, University of South Florida
BACKGROUND: Prior research indicates that infants with absent fathers are vulnerable to unfavorable fetal birth outcomes.
Furthermore, HIV-status of mothers has been found to increase the risk of adverse birth outcomes. However, previous studies
have not investigated the influence of paternal involvement on birth outcomes concurrently with maternal HIV-positivity.
STUDY QUESTIONS: This study sought to determine the impact of paternal involvement on birth outcomes among HIV-positive
mothers.
METHODS: Using linked hospital discharge data and vital statistics records for the state of Florida (1998-2007), we assessed
the association between paternal involvement and fetal growth outcomes (i.e., low birth weight [LBW], very low birth weight
[VLBW], preterm birth [PTB], very preterm birth [VPTB], and small for gestational age [SGA]) among HIV-positive mothers
(N=4,719). Propensity score matching was used to match cases (absent fathers) to controls (fathers involved). Conditional
logistic regression was employed to generate odds ratios (OR).
RESULTS: Mothers of infants with absent fathers were more likely to be black, younger (<35 years old), and unmarried with at
least a high school education (p<0.01). They were also more likely to have a history of drug (p<0.01) and alcohol (p=0.02) abuse.
However, these differences disappeared after propensity score matching. Infants of HIV-positive mothers with absent paternal
involvement during pregnancy had elevated risks for adverse fetal outcomes [LBW: OR=1.30, 95% CI=1.05-1.60; VLBW:
OR=1.72, 95% CI=1.05-2.82; PTB: OR=1.38, 95% CI=1.13-1.69; and VPTB: OR=1.81, 95% CI=1.13-2.90].
CONCLUSIONS: Absence of fathers increases the likelihood of adverse birth outcomes among a high-risk population of HIVpositive women. These findings underscore the importance of paternal involvement during pregnancy, especially in high-risk
women such as HIV-positive mothers.
PUBLIC HEALTH IMPLICATIONS: Intervention programs to improve perinatal paternal involvement may decrease the burden
of adverse birth outcomes among HIV-positive mothers.
2
INTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH SERVICES
FOR LOW-INCOME YOUTH
Noreen Almazora, MPH, CPH, Mark Olfson, MD, MPH, Jamie Moxham, MSPH, Greg Jensen, LCSW, ACSM, Emily
Schiefelbein, MPH
Lone Star Circle of Care, Columbia University
BACKGROUND: Most adolescents with mental disorders in the US receive no treatment for their symptoms. Widespread
delays in diagnosis and treatment impede recovery. Medicaid-insured and uninsured youth are at especially high risk of not
receiving timely care. Developing an effective model for delivering behavioral health (BH) services to these young people
represents a critical health care priority. Lone Star Circle of Care (LSCC), a federally qualified health center (FQHC), utilizes the
TeenScreen tool (which includes the Pediatric Symptom Checklist and questions on suicidal ideation and lifetime suicide
attempts) to identify cognitive, emotional, and behavioral problems in patients aged 11-17 years.
STUDY QUESTION(S): Does the use of a psychosocial screen in a behaviorally-enhanced patient-centered medical home
facilitate appropriate transitions of low-income pediatric patients to specialty BH care?
METHODS: Chart abstractions from LSCC were performed of 200 youth aged 11-17 years who screened positive on the
TeenScreen. The review focused on services delivered during the 90 days following the positive screen. To focus on new BH
care episodes, patients who had received specialized BH care during the 30-day period prior to screening were excluded.
RESULTS: Nearly 61% of screened positive patients were referred for internal BH services. Of referred patients, 62.8% had a
BH visit within 90 days of the positive screen. Moreover, 9.5% of the 200 patients received BH counseling in LSCC primary care
clinics. Over one-fifth (22.0%) of patients with BH visits were diagnosed with attention-deficit/hyperactivity disorder (ADHD),
18.3% with major depressive disorder, and 22.0% with other mood disorders (e.g. dysthymic disorder). Approximately 28% were
prescribed psychotropic medications, including antidepressants (14.7%), stimulants (11.0%), and antipsychotics (6.4%), as part
of their treatment plan during the follow-up.
CONCLUSIONS: Primary care providers are well positioned to follow-up on positive mental health screens with appropriate
referrals for BH care in an integrated BH model. Combining routine mental health screening with on-site BH professionals
facilitates fluid transitions into BH care.
PUBLIC HEALTH IMPLICATIONS: Mental health screening in primary care clinics identifies at-risk patients, but in order to
initiate timely and appropriate treatment, providers must have access to BH resources, such as those found within an integrated
BH care home.
3
MACROSOMIA IN THE MIDWIFERY POPULATION OF NORTHERN
AMERICA: AN EVALUATION OF PREVALENCE AND ADVERSE
OUTCOMES
Valerie Armendariz, MS
City of Philadelphia
BACKGROUND: While several studies have examined the adverse outcomes linked to fetal macrosomia, these investigations
have been limited to hospital delivery settings. To date, no research has focused on the prevalence and adverse outcomes
associated with macrosomic pregnancies using data that focuses on out-of-hospital midwifery care.
METHODS: We analyzed 10,011 midwifery reported pregnancy and birth records from the Midwives Alliance's Statistics Project
database from January 2007- December 2009. After excluding pregnant women with pre-existing high-risk conditions, we
examined the prevalence and adverse outcomes associated with categories of macrosomic infants (4000-4499 g, 4500-4999 g,
and >5000 g) compared to infants weighing between 3000-3999 g.
RESULTS: The prevalence of macrosomia was 18.7 for infants born 4000-4499 g, 4.7% for infants 4500-4999 g, and 0.6% for
infants >5000 g. Compared to those infants weighing 3000-3999 g, infants weighing 4000-4449 g had a fourfold higher risk of
shoulder dystocia (Odds Ratio [OR]: 4.1; 95% Confidence Interval [CI]: 3.3-5.1), with the risk even greater among those infants
weighing 4500-4999 g (OR:8.3; 95% CI: 6.2-11.1) and >5000 g (OR= 29.9; 95% CI, 17.4-51.4). Low five-minute Apgar scores
(<3) increased from threefold to tenfold across birth weight quartiles (OR:3.2; 95% CI: 1.2-8.5 for 4500-4999 g infants and
OR:10.2; 95% CI: 2.3-45.1 for >5000 g infants, both compared to infants weighing 3000-3999 g). The prevalence of cesarean
section among all birth weight groups was less than 9%.
CONCLUSIONS: Macrosomia was highly prevalent in the midwifery population and associated with an increased risk of
shoulder dystocia and low five-minute Apgar scores. However, rates of cesarean section were low and insignificant between
groups. Further research is needed to better elucidate the etiology of macrosomia in this population and to explore whether the
risks/benefits of vaginal births outweigh the risks/benefits of cesarean section for the heaviest infants.
PUBLIC HEALTH IMPLICATIONS: Until further research regarding the risks/benefits of macrosomic birth methods, we
recommend that strategies to prevent Grades II and III macrosomia need to be incorporated into the midwifery model of care.
4
EFFECTIVENESS OF A FEDERAL HEALTHY START PROGRAM ON
HIV/AIDS RISK REDUCTION AMONG WOMEN
Euna August, PhD, MPH, Mulubrhan Mogos, PhD, Abraham Salinas, MD, MPH, Alfred Mbah, PhD, Estrellita Berry, MA,
Hamisu Salihu, MD, PhD
University of South Florida, Dept. of Community & Family Health, REACHUP Inc.
BACKGROUND: The Central Hillsborough Healthy Start Project (CHHS) is a community-based program dedicated to improving
maternal and infant health outcomes in socio-economically challenged neighborhoods in Hillsborough County of Florida.
Previous research revealed CHHS is effective in reducing the preterm birth rate by 30% among service recipients. However,
minimal research has been conducted on the potential protective effect of Healthy Start services on related secondary health
outcomes, such as HIV/AIDS.
METHODS: Utilizing records from CHHS linked to hospital discharge data and vital statistics in Florida (1998-2007), this
ecological study compared trends in HIV/AIDS rates between the CHHS service area and the rest of Hillsborough County. The
study population consisted of women who had a singleton birth in Hillsborough County during the study period (N=129,979).
RESULTS: Women residing within the CHHS service area were more likely to be black, unmarried, and less educated with
inadequate prenatal care, and higher frequencies of pregnancy complications compared to the rest of the Hillsborough County
(p<0.0001). Over a ten-year period, HIV/AIDS rates among mothers in the CHHS service area declined by 50% (p for
trend=0.01), while the rates in the rest of Hillsborough County remained unchanged (p for trend=0.48).
CONCLUSIONS: Our study indicates that the CHHS Project contributed to the reduced prevalence of HIV/AIDS among
mothers. The Federal Healthy Start program is an effective comprehensive model for improving the reproductive health and
wellness of women within socio-economically challenged communities.
PUBLIC HEALTH IMPLICATIONS: Healthy Start services can improve maternal and child health by reducing the burden of
secondary health outcomes, such as HIV/AIDS.
5
A CASE-CONTROL STUDY OF THE ASSOCIATION OF PRE-PREGNANCY
BODY-SIZE DISSATISFACTION WITH EXCESSIVE GESTATIONAL WEIGHT
GAIN
Minoo Bagheri, MS, Ahmadreza Dorosty, PhD, Haleh Sadrzadeh-Yeganeh, PhD
Tehran University of Medical Sciences
BACKGROUND: Identifying the risk factors for excessive gestational weight gain (GWG) is of paramount importance to reduce
maternal and neonatal complications. Recent research has shown the association of body-size dissatisfaction with obesity, but
little is known about the influence of body-size dissatisfaction on excessive GWG and about the potential mechanisms mediating
the association.
STUDY QUESTION(S): Is pre-pregnancy body size-dissatisfaction associated with excessive GWG in Iranian pregnant women?
Is the association mediated by physical activity and energy intake (pregnancy-related behaviors)?
METHODS: The study was conducted in a sample of women who were 35-41 weeks gestational age and received prenatal care
in Shahid Akbarabadi Hospital. A total of 182 women with excessive GWG (case) were compared with 180 women with
adequate GWG (control). Body Image Assessment for Obesity (BIA-O) was used to help the participants in case and control
groups to recall their pre-gravid body size-satisfaction status. This tool was tested for validity and reliability among Iranian
pregnant women at the beginning of the study. Pregnancy-related behaviors in late pregnancy were also measured using valid
questionnaires. We performed bivariate and multivariable logistic regression to examine the association of pre-pregnancy body
size-dissatisfaction with excessive GWG.
RESULTS: The proportion of dissatisfied women with a thinner body-size preference was significantly higher in cases than in
controls (P < 0.0001). Compared with satisfied women, the odds of excessive GWG in dissatisfied women with a thinner bodysize preference were 1.63 (95% CI [Confidence Interval] 0.94-2.8) with adjustment for all potential confounders except energy
intake and 2.17 (95% CI: 1.17-4.02) with adjustment for all variables including energy intake (since physical activity did not differ
significantly between cases and controls, it was not included in multivariable analysis).
CONCLUSIONS: Our result showed that pre-pregnancy body-size dissatisfaction was associated with excessive GWG and
energy intake in late pregnancy supported the observed association. But further research is needed to examine whether
behavioral changes will influence this association and how correcting of pre-pregnancy body-size dissatisfaction will affect GWG.
PUBLIC HEALTH IMPLICATIONS: Plans to prevent excessive GWG among child-bearing aged women may make good
progress if they are accompanied by body dissatisfaction improvement programs.
6
CESAREAN DELIVERY AND RISK OF MATERNAL RE-HOSPITALIZATION:
ARE THERE DIFFERENTIAL EFFECTS BY AGE AND RACE/ETHNICITY?
Candace Belanoff, ScD, MPH, Eugene Declercq, PhD
Boston University
BACKGROUND: Previous studies have found an association between cesarean delivery and elevated risk of postpartum rehospitalization. This study examines how the association varies with maternal age and/or maternal race/ethnicity.
STUDY METHODS: Is the risk of maternal postpartum re-hospitalization associated with cesarean delivery modified by maternal
age or race/ethnicity?
METHODS: We used the longitudinal, population-based Massachusetts (MA) Pregnancy to Early Life Longitudinal Data System
(PELL) to examine risk of re-hospitalization among primiparous women delivering singleton infants in MA hospitals between
1998-2008 (n=372,499). Any maternal hospitalizations occurring up to one year postpartum were captured using longitudinally
linked hospital discharge records. Multivariable logistic models were used to adjust for maternal health risks, labor and delivery
complications and socioeconomic indicators, and to interact age and method of delivery. Stratified analyses examined the age
and MOD interactions separately by maternal race/ethnicity.
RESULTS: Overall, risk of re-hospitalization was higher among mothers who delivered by cesarean vs. vaginally (aOR 1.2, p <
.0001). Maternal age did not significantly modify this relationship (Type 3 analysis of effect, p = .16) however aORs by age group
were suggestive of a stronger relationship among younger compared to older women. Stratified by race/ethnicity, the strongest
pattern of risk modification by age was seen among Asian mothers, whose aORs associated with cesarean delivery ranged from
1.6 among women <20 to 0.9 among women 40 and over.
CONCLUSIONS: Cesarean delivery confers greater risk of postpartum re-hospitalization for primiparous women at every age,
however, maternal age does not appear to substantially modify this risk. Differences may vary by maternal race/ethnicity. Future
research should examine whether other maternal factors contribute to risk of re-hospitalization associated with cesarean
delivery.
PUBLIC HEALTH IMPLICATIONS: Because of the known elevated risk of re-hospitalization associated with cesarean delivery,
and a large increase in cesarean deliveries over the past fifteen years, it is important for both clinicians and MCH epidemiologists
to know whether and which maternal factors modify this risk.
7
GETTING THE PATIENT VOICE INTO THE ELECTRONIC MEDICAL
RECORD: USING PARENT-COMPLETED PRE-VISIT TOOLS TO
CUSTOMIZE AND IMPROVE WELL CHILD CARE
Christina Bethell, PhD, MBA, MPH, Kasey McCracken, MPH, Colleen Reuland, MS, Cambria Wilhelm, MPH, John Kilty,
PhD, MD
The Child & Adolescent Health Measurement Initiative, Oregon Pediatric Improvement Partnership, The Children’s Clinic
BACKGROUND: A pre-visit, online tool can educate parents prior to a visit, elicit priorities for care and enable linkage of parent
reported information in the EMR for use before a well child visit.
STUDY QUESTION(S): What is the acceptability and feasibility of an online, parent-completed tool, inserted into the EMR to
promote adherence to Bright Futures (BF) recommendations and customizes care to meet patient/family needs?
METHODS: A pre-visit tool (PlanYourChild'sWellVisit tool-PCW) was developed reflecting BF recommendations for well-child
care. The tool focuses on child/family health screening, identifying parent's anticipatory guidance priorities, parental education
and provision of a 'Visit Guide' for use during visits. Results are automatically inserted into the provider's EMR forms and used to
customize the visit. Results derive from a 12 pediatrician private practice and represent 2,076 PCW completions by parents.
Baseline and follow-up well child care quality, experience surveys and focus groups were conducted.
RESULTS: 43.2% of parents invited completed PCW. Median completion time was 9 minutes; 91.2% indicated comfort with
length. Results were reliably transferred into EMR. Nearly 90% of parents picked priority topics to discuss. 57.7% had concerns
about their child's development or behavior to discuss. Over 90% of parents reported they would recommend the PCW to other
parents. 85.2% reported PCW helped prioritize topics to discuss, especially regarding their child's development. Access to online
educational materials embedded in the tool was reported useful by 83.2% of parents. Each participating pediatrician reported an
intention to continue use of PCW and that it improved ability to provide recommended well-child care. Providers also noted
positive impact on quality of care for children whose parents did not complete the online, pre-visit tool due to the improvements
made in EMR forms.
CONCLUSIONS: Pre-visit patient engagement tools are feasible, effective in improving the experience of well child care visits.
PUBLIC HEALTH IMPLICATIONS: Widespread implementation of this tool has the potential to improve the quality of well-child
care, parent engagement in care, provider ability to assess family strengths and stressors. As such, it could help well-child care
better meet the needs of the child and their family and thus improve child health and wellbeing.
8
OPTIMIZING SYSTEMS OF CARE FOR CSHCN USING THE LIFE COURSE
PERSPECTIVE: NATIONAL DATA FINDINGS AND IMPLICATIONS FOR
RESEARCH AND SYSTEMS REFORMS
Christina Bethell, PhD, MBA, MPH, Paul Newscheck, DrPH, Cambria Wilhelm, MPH, Bonnie Strickland, PhD, Amy Fine, MPH,
Richard Antonelli, MD, Lynda Honberg, MHSA, Nora Wells, MSEd
The Child & Adolescent Health Measurement Initiative, University of California, San Francisco, Maternal & Child Health Bureau,
the Project on Pediatric Care Linkages for Developmental Services, Harvard Medical School, Maternal & Child Health Bureau,
Family Voices
BACKGROUND: To date, Life Course research has focused mainly on elucidating fetal and early life influences on adult health.
However, life course perspective also has special relevance for children with special health care needs (CSHCN), both in its
potential to reduce early risks that contribute to adult illness and to optimize early and lifelong well-being.
STUDY QUESTION(S): (1)What is the alignment between the life course perspective and the United States Maternal & Child
Health Bureau (MCHB) systems of care model for CSHCN? (2) What is the value and gaps in existing data for understanding the
health of CSHCN across developmental ages and in the context of current life course knowledge? and (3) How does this inform
research priorities and policy implications of integrating life course theory into our approach towards providing optimal health
systems for CSHCN?
METHODS: Data from the 2007 NSCH and 2009/10 NS-CSHCN were used to characterize a health need a system
performance profile for CSHCN at various aging according to the key life course conceptual domains: timeline, environment,
equity, timing.
RESULTS: The prevalence and needs of CSHCN increases with age and CSHCN have higher odds of factors known to impact
long-term well-being outcomes, such as grade repetition, than other children. However, receipt of high quality and coordinated
health care and positive environmental circumstances seems to attenuate the odds of negative outcomes such as lack of school
engagement and behavioral problems. CSHCN served by systems that do not meet the MCHB measures of system
performance are more likely to suffer greater impact on their daily activities than other CSHCN.
CONCLUSIONS: The MCHB systems of care model is well aligned with life course principles and values, but current
measurement not always reflect this. There is great value into incorporating life course knowledge and research into our
approach to researching and improving care systems for CSHCN; current research in this area is largely limited by lack of
longitudinal data sources.
PUBLIC HEALTH IMPLICATIONS: As we advance life course knowledge into practice, advance Title V programs and develop
accountable care organizations, placing a special focus on CSHCN may hold the greatest promise for achieving the triple aim.
9
PROBING THE PARADOX: EXAMINING THE ASSOCIATION BETWEEN
FOREIGN-BORN STATUS AND PRETERM BIRTH IN HISPANIC WOMEN OF
MEXICAN ORIGIN RESIDENT IN MCLENNAN
Sarah Blackwell, MPH
Wisconsin Division of Public Health
BACKGROUND: Hispanic populations in the United States, particularly those of Mexican origin, consistently have rates of low
birth weight and preterm birth comparable to or lower than the non-Hispanic white population despite higher prevalence of
socioeconomic risk factors. Additionally, among women of Hispanic-Mexican descent, birth in Mexico as opposed to the United
States has almost universally been found to be protective against poor birth outcomes.
STUDY QUESTIONS: Is there an association between foreign-born status and preterm birth (<37 weeks gestation) among
Hispanic women of Mexican descent in McLennan County, Texas?
METHODS: For this retrospective cohort study, we use the 2005-2008 live birth certificate record for mothers resident in
McLennan County at the time of birth. After exclusion for missing data, the study sample consists of 4,402 singleton live births to
Hispanic-Mexican women, of which 2,541 (57.7%) are to mothers born in the US and 1,861 (42.3%) are to mothers born in
Mexico. Data on duration of US residence are not available and cannot be used in analysis. Our analysis employs bivariate and
multivariate logistic regression to generate odds ratios and Breslow-Day tests to evaluate interaction.
RESULTS: The crude association between foreign-born status and preterm birth was non-significant with an OR of 0.85 (95%
CI: 0.69-1.05). We found a significant (p=0.008) interaction effect between foreign-born status and gestational hypertension.
After stratifying by gestational hypertension and adjusting for confounders, the effect of foreign birth on preterm outcome was
non-significant in women without gestational hypertension (aOR: 0.92, 95% CI: 0.70-1.20) but was a significant risk factor (aOR:
2.30, 95% CI: 1.14-4.65) in women with gestational hypertension.
CONCLUSIONS: Further study is needed before definitive conclusions can be made about the effect of foreign-born status on
preterm birth in McLennan County. However, being foreign-born is a significant risk factor for preterm birth among HispanicMexican women with gestational hypertension in this population.
PUBLIC HEALTH IMPLICATIONS: The interaction evident in this sample with regards to gestational hypertension should be
further explored in national samples. If the interaction exists, then it could have important implications for birth outcome
amelioration programs directed at the Hispanic-Mexican population.
10
PILOT STUDY OF WOMEN ATTENDING TITLE X CLINICS IN KENTUCKY:
PREGNANCY INTENTION MEASUREMENT AND CHARACTERISTICS OF
WOMEN AT HIGH-RISK OF UNPLANNED PREGNANCY
Jennifer Blasé, MPH, Sarojini Kanotra, PhD, MPH
Centers for Disease Control & Prevention, Kentucky Dept. of Public Health
BACKGROUND: Research shows that women with unplanned pregnancies suffer from increased adverse maternal and child
health outcomes and a higher abortion rate. But determinations of whether a pregnancy is planned or not varies widely by
question syntax and the type of pregnancy intention measure used. This analysis examines the prevalence of unintended
pregnancy using different intention measures and creates a profile of women at high-risk of unintended pregnancy.
STUDY QUESTIONS: How do different single-item pregnancy intention measures compare to the multi-item London Measure of
Unplanned Pregnancy (LMUP)? What are the characteristics among women who scored in the ambivalent and unplanned
ranges on the LMUP?
METHODS: This pilot study was conducted in three Title X family planning clinics in Lexington, Kentucky, over a one month
period. A cross-sectional, self-report, survey was administered to women who attended clinics for a pregnancy test or emergency
contraception. Bivariate analyses were conducted in SAS 9.3.
RESULTS: There were 96 survey respondents. According to the LMUP, a majority of women (57%) had ambivalent feelings
about pregnancy followed by women who planned theirs (23%) and women who were not intending a pregnancy (20%). Among
the two single-item measures, concordance between the LMUP and each measure was 45% and 52% respectively with the
largest discrepancy for both being in the ambivalent category. Results showed that women between the ages of 18-21, of
Hispanic ethnicity, with a high school education or lower and who are separated from their partners are more likely to be
ambivalent towards a pregnancy. Women who are 18-21, African-American, single, who have had at least some college or
completed college and have private health insurance are more likely to be classified as having an unwanted pregnancy.
CONCLUSIONS: Overall, single item pregnancy intention measures and the LMUP had poor concordance. By gaining an
understanding of women who are not planning a pregnancy, clinicians and public health professionals can tailor interventions
towards this group and reduce unintended pregnancy.
PUBLIC HEALTH IMPLICATIONS: Data will be used as a planning tool to improve counseling protocols in order to target highrisk populations and reduce unintended pregnancies in women attending Kentucky Title X family planning clinics.
11
PRODUCTION OF COUNTY LEVEL BIRTH DEFECT PROFILES –
TRANSLATING FLORIDA BIRTH DEFECT AND MATERNAL CHILD HEALTH
STATISTICS INTO USEABLE TOOLS
Suzanne Block, MPH, Jane Correia, Georgia Murphy, MFA, Sharon Watkins, PhD, Jean Paul Tanner, Jason L.Salemi,
MPH
Florida Dept. of Health, University of South Florida (BDSP)
PUBLIC HEALTH AREA:
FOCUS: Adverse perinatal outcomes, Preconception health
POPULATION: Infants, Children, Women
ISSUE: The Florida Birth Defects Registry (FBDR) received a request for a one-page document presenting information on the
FBDR, counts and prevalence rates of selected birth defects, associated risk factors, and the economic impact associated with
birth defects.
SETTING: Florida state, 10 counties.
PROJECT: A working group facilitated development of the profiles. The largest 10 counties (in number of live births) would each
get an individual profile; geographic areas that remained were grouped together, based upon previously established health
councils, to increase reporting power. Using the Florida Department of Health Community Health Assessment Resource Tool Set
(CHARTS), we assembled descriptive statistics for women of reproductive age and presented numbers and percentages of
births that occur annually to women with known risk factors for adverse pregnancy outcomes, for the area of interest. Partners
were queried about including additional information. A standardized format with graphics was developed for the profiles by a
graphic designer who was part of the work group.
RESULTS: County or regional level values for various risk factors were presented, including the proportion of births to women
covered by Medicaid, women categorized by BMI as overweight/obese, maternal smoking status, and diabetes diagnosis. Data
from the FBDR from 1998-2007 was used to estimate prevalence rates of birth defects for the county/region and was compared
to the state level rates. Economic cost was estimated from the average annual number of cases identified by the FBDR and
published cost estimates. Finally, a prevention message was developed.
BARRIERS: County and regional level stakeholders often request ‘local’ data in order to target prevention measures and
engage stakeholders. The FBDR developed county or regional one page profiles with standardized formatting and graphics that
supplied information on county/regional level risk factors, rates and costs in an eye-catching format.
LESSONS LEARNED: Turning data into meaningful informative documents for use at the “local” level is an essential component
of a public health agency. Feedback on birth defect profiles has been positive and partners have used the profiles during
meetings with providers, legislators and other stakeholders.
12
PROGRAM EFFECTIVENESS IN A SCHOOL BASED ORAL HEALTH
PROGRAM
Sandy Bodner, BA, MPH
Tacoma Pierce County Health Dept.
PUBLIC HEALTH AREA:
FOCUS: Chronic disease, Health equity
POPULATION: Children
ISSUE: A 2005 Smile Survey reported that children in Pierce County, WA had unmet dental needs.
SETTING: Children attending public elementary schools in 2 school districts not serviced by fluoridated water systems.
Evaluation looked at 2nd and 4th graders.
PROJECT: For 3 years, beginning with the 2006-07 school year, the local Health Department sent a dental team to visit schools
to provide oral health screenings and preventative services. School-based sealant delivery programs are recommended as an
effective public-health strategy for combating dental decay.
RESULTS: Among children receiving sealants, 3.2 % of first molars were decayed, missing or filled one year later compared to
6.7% among children who were eligible but did not receive sealants. There were no population-level improvements in any of the
measures examined in either second graders or fourth graders.
BARRIERS: Although many 2nd graders were eligible for sealants, only 17.8% of children eligible had sealants placed through
the program. Parental permission slips for services were often not returned.47.8% of sealed molars remained fully sealed a year
later. This suggests that either child-specific factors or improper application technique may have been responsible. Oral health is
closely linked to economic conditions, and the program was conducted during a period of economic downturn. Benefits of the
program may have been offset by economic factors in the community and that there may have been a decline in professional
dental care as a result.
LESSONS LEARNED: Sealant programs must be actively marketed to school administrators, teachers and families, particularly
those the program seeks to reach. Greater effort should be made to overcome barriers to participation among families. This
could include intensive case management among children at high risk of caries. Another approach is to offer participation
incentives to students who return their parental consent forms in order to increase the number of sealants placed on children.
Because complete sealant retention at 1 year was only 47.8% and penetration of sealant delivery among eligible 2nd graders
was relatively low, sealant services should be offered to children in grades other than 2nd. More children could be reached and
sealants that were not initially retained could be reapplied.
13
RACIAL AND ETHNIC HEALTH DISPARITIES OF SELF-REPORTED
POSTPARTUM DEPRESSION AMONG FOREIGN BORN WOMEN IN
OREGON
Ashley Borin, MPH, James Gaudino, MD, MS, MPH, FACPM
Multnomah County Health Dept.
BACKGROUND: Postpartum depression (PPD) may cause serious health consequences for both mother and child. Foreign
born women may experience stress due to feelings of isolation and adversity during acculturation. Stress has been linked to
PPD; however, due to the 'healthy immigrant effect', immigrant women may cope with stress differently.
STUDY QUESTIONS: The purpose of this study is to estimate the prevalence of postpartum depression among women in
Oregon, to examine maternal foreign born status as a risk factor for PPD and to determine whether the relationship between
foreign born status and nativity differs based on race/ethnicity.
METHODS: Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) respondents from 2005-2007 were asked about
PDS at 3 months postpartum, on average. We defined PDS when mothers reported that she always or often 1) felt down,
depressed or hopeless and/or 2) had little interest or pleasure in doing things. We estimated adjusted odd ratios (AOR) using
weighted multivariate logistic regression with SAS 9.2 survey procedures and tested for interaction by race/ethnicity. One
limitation of the PRAMS survey is that it is only available in Spanish and English making it difficult for immigrant women, and
possibly those less acculturated, to complete the survey.
RESULTS: The prevalence of PDS among foreign born women was 13.3% compared to 11.3% among US-born women and
11.8% overall. Foreign born women were not more likely to report PDS (OR=1.2, 95%CI: 1.0, 1.5). However, after controlling for
confounders, foreign born Asian women were 2.3 times more likely to report PDS (95%CI: 1.1, 5.0) than US-born NH-Whites and
1.9 (95%CI: 1.1, 3.3) times more likely than US-born Asians. This relationship was not found among other race/ethnicity groups.
Poverty (OR=1.5, 95%CI: 1.1, 2.2), partner-related (OR=2.4, 95%CI: 1.8, 3.2) and traumatic stress (OR=1.5, 95%CI: 1.1, 2.1)
were also associated with PDS.
CONCLUSIONS: Foreign born Asian women may be more likely to suffer from PPD when compared to US born Asian and NHWhites women. Other factors include partner-related and traumatic stress and poverty.
PUBLIC HEALTH IMPLICATIONS: Clinicians and public health professionals should provide culturally appropriate screening
and treatment for high risk populations.
14
CHLAMYDIA TRACHOMATIS: RETESTING AND REPEAT INFECTIONS,
INFERTILITY PREVENTION PROJECT — OREGON, JANUARY–JUNE 2010
Genevieve Buser, MD, MPH, Sean Schafer, MD, MPH, Katrina Hedberg, MD, MPH
Oregon Public Health Division
BACKGROUND: Approximately 1.2 million cases of Chlamydia trachomatis (CT) were reported in the United States during
2010, resulting in $701 million in direct medical costs. Because repeat infections can increase risk for sequelae, CDC
recommends concurrent patient and partner treatment, and retesting 3–6 months after initial infection. The Infertility Prevention
Project (IPP) collects detailed demographic and behavioral data on persons tested for CT, and reports one-third of total Oregon
CT cases.
METHODS: We analyzed 2010 Oregon IPP data. A CT infection was defined as a positive nucleic acid amplification assay for
an Oregon female aged =14 years during January–June 2010. We explored demographic and behavioral factors associated with
retesting and repeat infection 1–6 months after initial infection. We used log binomial regression to calculate adjusted prevalence
ratios (aPRs).
RESULTS: Of 19,443 females tested through IPP for CT, 1,229 (6%) had =1 positive result. Of these, 456 (37%) were retested
within 1–6 months; of those, 70 (15%) had a repeat infection. Females who were retested were more likely than those who were
not to be aged =24 years (aPR: 1.4; 95% confidence interval [CI]: 1.1–1.8), black (aPR: 1.3; 95% CI: 1.1–1.7), or Hispanic (aPR:
1.5; 95% CI: 1.2–1.8) and to visit a school, rather than a family planning, clinic (aPR: 1.9; 95% CI: 1.5–2.3). Females with repeat
infections were more likely than those without to report multiple partners during the previous 60 days (aPR: 1.6; 95% CI: 1.03–
2.6), after adjusting for age, race/ethnicity, and clinic site.
CONCLUSIONS: We conclude that (1) retesting after an initial CT infection is suboptimal and should be increased; (2) retesting
is a high-yield intervention with positivity rate 2.5 times that of initial testing; and (3) having multiple partners increased repeat
infection risk. Although not directly assessed, increasing retesting and improving expedited partner therapy (i.e., patients deliver
medication directly to their partners) might help reduce repeat infections.
PUBLIC HEALTH IMPLICATIONS: Supplemental data (e.g., IPP) provides practice, outcome, and risk factor data for
policymakers and practitioners.
15
THE ASSOCIATION BETWEEN MATERNAL EXPOSURE TO CHILD ABUSE
AND VERY PRETERM BIRTH AMONG NULLIPAROUS WOMEN
Alison Cammack, MPH, Carol Hogue, PhD, MPH
Emory University
BACKGROUND: Preterm birth, particularly very preterm birth (vPTB), is the leading cause of infant mortality in the United
States. It remains unexplained in most cases and is notoriously difficult to predict in nulliparous women. Stressors over the life
course, including exposure to child abuse, are proposed determinants of preterm birth; however, no population based studies
have examined this association, nor has vPTB or effects in nulliparous women been specifically addressed.
METHODS: Data come from the National Longitudinal Survey of Adolescent Health. Nationally representative participants
were initially recruited in grades 7-12 and have been followed through ages 24-32. Analytic methods include univariate and
multivariate logistic regression, accounting for complex survey design. Limitations include participant-reported birth outcomes,
the lack of older women, and bias due to study recruitment in a school setting. To address these limitations, we conducted
sensitivity analyses to address potential misclassification of vPTB and stratification by age.
RESULTS: There were 2208 singleton live births to nulliparous women age 19 older with complete information on abuse,
preterm birth, and potential confounders. Before age 18, 18.20%, 6.50%, and 51.60% experienced any physical, sexual, and
emotional abuse, respectively, by a parent or adult caregiver. Overall, 1.49% experienced vPTB, and physical, sexual, and
emotional abuse were not associated with vPTB. However, there was an increased risk of vPTB among 19-23 year old African
American women exposed to chronic (>= 3 times versus <3 times) sexual abuse (OR=7.36, 95% CI:1.03-52.62) and 19-23 year
old non-Hispanic white women exposed to chronic emotional abuse (OR=10.18, 95% CI:1.08-96.07); these point estimates were
not appreciably changed after adjustment for potential confounders.
CONCLUSIONS: The association between maternal exposure to child abuse and vPTB varies according to type and chronicity
of abuse, race, and maternal age.
PUBLIC HEALTH IMPLICATIONS: Assessment of preconception exposures, including potentially modifiable experiences such
as child abuse, may play a role in identifying women at risk of vPTB. Consideration of type and chronicity of abuse, maternal
age, and race are important in distinguishing exposed women who are most vulnerable.
16
ASSOCIATION OF MALTREATMENT WITH INFANT/CHILD (AGE <5)
DEATH: A PRELIMINARY ANALYSIS OF LINKED BIRTH/DEATH/CHILD
FATALITY REVIEW DATA
John Carter, PhD, MPH
Emory University Rollins School of Public Health
BACKGROUND: Infant and child maltreatment (abuse or neglect) is a persistent social and health issue. This abstract
addresses preliminary results from a Georgia effort to create and use a longitudinally linked child database to examine the risk
factors for child maltreatment.
STUDY QUESTION(S): How complete and representative are linked toddler (ages 1 through 4) death / birth records? Are
factors such as parity, sex, or birth weight associated with accidental or violent child deaths?
METHODS: The reported child deaths (ages 1 through 4) for the 1999 to 2003 birth cohorts (880) were linked back to the birth
records. 750 deaths (85%) were linked with a birth certificate. 391 of the 750 linked deaths were attributed to accidental, violent,
or unknown cause; and 350 of those 391 deaths were reviewed by a GA Child Fatality Review (CFR) team. The linked
CFR/death certificate/birth certificate data was used to describe the prevalence of maltreatment among deceased toddlers.
RESULTS: Since only 85% of the toddler deaths linked with a birth certificate, the crude rates underestimate the true rate. Low
birth weight (1500 to 2499 grams) is associated with increased risk (2.7 deaths per 1,000 singleton births surviving the first year
versus 1.0 for >2499) for death (all causes) as a toddler. First born infants have a lower risk; males and Medicaid-funded infants
are at a higher risk. The CFR team identified maltreatment (neglect or abuse, confirmed or suspected) for toddler deaths linked
with death and birth certificates varied by cause of death. Only 9% of medical deaths had identified maltreatment, compared to
40% for unintentional deaths and 85% for homicide deaths.
CONCLUSIONS: These preliminary findings identify risk factors for toddler deaths and the possible contribution of child
maltreatment. Additional record linking with child maltreatment, hospital discharge, and emergency room records offers
opportunities for expanded analysis.
PUBLIC HEALTH IMPLICATIONS: Improved data collection and data processing technology provide expanded opportunities
for analysis of complex social/health issues. Collaborative efforts among data owners and researchers are necessary to enable
progress.
17
INFANT MORTALITY: THE ROLE OF BREASTFEEDING & PUBLIC HEALTH
NURSING IN THE SPECIAL SUPPLEMENTAL NUTRITION PROGRAM FOR
WOMEN, INFANTS AND CHILDREN (WIC)
Nancy Castro, BS, Debra Mortwedt, BS
City of Milwaukee Health Dept.
PUBLIC HEALTH AREA:
FOCUS: Adverse perinatal outcomes, Racial & ethnic health disparities
POPULATION: Infants, Women, Families
ISSUE: The overall rate for infant mortality in Milwaukee in 2009 was 11.1 infant deaths per 1,000 births. For Milwaukee’s nonHispanic families, the White infant mortality rate was 5.9, and the Black rate was more than double this rate at 14.7. The
Hispanic rate was 8.8.
SETTING: City of Milwaukee Health Department (MHD) WIC clinics (3); audience: pregnant, postpartum, & breastfeeding
mothers
PROJECT: WIC is increasing its promotion & support for breastfeeding, which studies show reduces an infant’s risk of SIDS
and plays a vital role in improving the health of babies born prematurely. In 2008, MHD WIC received additional funding to
address infant mortality and hired a Public Health Nurse (PHN) to address this issue. She is responsible for assuring quality
breastfeeding promotion/support services and also provides education, screenings, support, and referrals to pregnant &
breastfeeding mothers with a primary focus on topics directly related to infant mortality.
RESULTS: Our main measurable results are seen in our breastfeeding rates. The current incidence of breastfeeding among
MHD WIC participants is 64.2%, which is an increase from previous years (2007: 49.4%, 2008: 58.5%, 2009: 60.5%, 2010:
58.9%, 2011: 63.4%). We also found that the percentage of preterm births among MHD WIC infants has decreased from 9.2% in
2009, 8.3% in 2010, and 8.1% in 2011 to 7.3% currently.
BARRIERS: Our main measurable results are seen in our breastfeeding rates. The current incidence of breastfeeding among
MHD WIC participants is 64.2%, which is an increase from previous years (2007: 49.4%, 2008: 58.5%, 2009: 60.5%, 2010:
58.9%, 2011: 63.4%). We also found that the percentage of preterm births among MHD WIC infants has decreased from 9.2% in
2009, 8.3% in 2010, and 8.1% in 2011 to 7.3% currently.
LESSONS LEARNED: While serving a diverse population, we have found that it is beneficial having a breastfeeding peer
counselor who has a similar cultural background as the participants served. It has been observed that our participants relate
differently (generally more positive) to a peer with the same cultural background. Because of the PHN's specialized nursing &
breastfeeding knowledge & experience related to infant mortality, she has been able to fill in the gaps in addressing these issues.
18
PRE-PREGNANCY OBESITY AND BREASTFEEDING PRACTICES:
DIFFERENCES BY RACE/ETHNICITY
Shin Chao, PhD, MPH, Chandra Higgins, MPH, Marian Eldahaby, BS
Los Angeles County Dept. of Public Health
BACKGROUND: Although there has been an increase in obesity among women of reproductive age, few studies have
investigated obesity and breastfeeding practices, especially among different race/ethnicity.
STUDY QUESTIONS: We examined the relationship between pre-pregnancy obesity and breastfeeding practices in a racially
diverse county, Los Angeles County.
METHODS: We analyzed data from the 2007 Los Angeles Mommy and Baby (LAMB) Survey, a mailed survey based on a
multistage clustered design with telephone follow-up for non-respondents. Women reported their height and weight before their
last pregnancy, and breastfeeding initiation and continuation at three and six months after delivery. BMI were calculated using
pre-pregnancy weight and height, and classified according to the Institute of Medicine categories for underweight, normal,
overweight, and obese. Multiple logistic regression models were used to assess the effect of pre-pregnancy obesity on initiation
and duration of BF after adjusting for potential risk factors and confounders. Sampling weights were used to adjust for design
and non-response effects.
RESULTS: Among 6,044 mothers who completed the survey, over 85% of respondents initiated breastfeeding, 54% continued
to breastfeed at three months and 45% continued at 6 months. Compared to normal weight women, obese women were least
likely to initiate breastfeeding and most likely to stop breastfeeding within the first 3 and 6 months (aOR=2.1,95% CI= 1.9-4;
aOR=2, 95%CI= 2-4). Race/ethnicity was not a predictor for breastfeeding initiation; however, compared to white women,
women of color had a higher risk of discontinuing breastfeeding at 3 months (aOR for African American, Hispanic, and
Asian/Pacific Islanders: 1.6, 1.3, 1.3) and 6 months (aOR=1.7,1.2,1.2).
CONCLUSIONS: Pre-pregnancy obesity and the initiation and duration of breastfeeding were inversely related. Compared to
white women, women of color were as likely to initiate breast feeding, but were less likely to continue breastfeeding.
PUBLIC HEALTH IMPLICATIONS: Health care professionals should consider obese women at risk for discontinuing
breastfeeding. These women need information on the importance of breastfeeding during pregnancy and the early postpartum
period to ensure initiation and continuation of breastfeeding. The findings also highlight the need to continue developing effective
and culturally appropriate strategies and policies to encourage continued breastfeeding among mothers of color.
19
THE ASSOCIATION BETWEEN PRE-PREGNANCY WEIGHT STATUS AND
PREGNANCY COMPLICATIONS AND BIRTH OUTCOMES
Shin Chao, PhD, Chandra Higgins, PhD
Los Angeles County Dept. of Public Health
BACKGROUND: Maternal overweight or obesity is associated with potential risks and complications for both the mother and
fetus. However, Los Angeles County (LAC) lacked local data to address this issue.
STUDY QUESTIONS: We examined the association between pre-pregnancy weight and pregnancy complications and birth
outcomes.
METHODS: We analyzed data from the 2007 Los Angeles Mommy and Baby Survey, a mailed survey based on a multistage
clustered design with telephone follow-up for non-respondents. The questionnaire asked women to report their height and weight
before current pregnancy and pregnancy complications (gestational diabetes mellitus, preeclampsia, cesarean delivery).
Information related to preterm birth (gestational age <37 weeks), macrocosmic neonate (> 4,000 g), stayed at NICU were
obtained from the vital record file. Women’s Body Mass Index (BMI) were calculated using pre-pregnancy weight and height, and
classified according to the Institute of Medicine categories for underweight, normal, overweight, and obese. Multiple logistic
regression models were used to assess the effect of pre-pregnancy weight on pregnancy complications/birth outcomes after
adjusting for potential confounders (age,race,family income,etc). Sampling weights were used to adjust for design and nonresponse bias.
RESULTS: Among 6,044 mothers who completed the survey, 20% were overweight, 7% were obese, and 7% were
underweight. Overweight, obese, and underweight women had more complications than normal weight women did. Adjusted
odd ratios (aOR) were significantly increased with increasing BMI category for gestational diabetes mellitus (aOR= 1.5,1.9,and
3.2), cesarean delivery (aOR=1.3,1.4, and 2), and giving birth to a macrocosmic baby(aOR=1.3,1,4,and 2). Prepregancy
overweight or obese were also associated with preeclampsia (aOR=1.8 and 2.8). The risk of a having a premature labor was
increased for mothers who were obese or underweight (1.3 and 1.4). No statistically significant associations were seen for NICU
stay or preterm birth. Asian/Pacific Islander is independently associated with gestational diabetes.
CONCLUSIONS: Not only pre-pregnancy obesity/overweight, but underweight increased the risk of pregnancy complications
and adverse pregnancy outcomes.
PUBLIC HEALTH IMPLICATIONS: To improve health of mothers and infant, local health departments and health providers
need to continue urging women of reproductive age to maintain normal body weight, including engagement in regular physical
activity and following a healthy eating plan.
20
FINDINGS FROM THE LOS ANGELES HEALTH OVERVIEW OF A
PREGNANCY EVENT (LAHOPE) PROJECT: AN EPIDEMIOLOGICAL
APPROACH TO ADDRESS FETAL AND INFANT DEATH
Shin Chao, PhD, Angel Hopson, MSN, MPH, RN, Diana Ramos, MD, MPH, Rozana Ceballos, BS
Los Angeles County Dept. of Public Health
BACKGROUND: Though overall fetal and infant mortality rates have been stable over the past few years, they continue to be a
health challenge in Los Angeles County(LAC). Between 2005 and 2010, LAC experienced over 1,400 fetal and infant deaths
annually. LAC needs detailed information on mothers who suffered a fetal/infant loss.
STUDY QUESTIONS: Identify issues experienced by women who suffered a fetal/infant loss.
METHODS: LACMCAH established the LAHOPE project in 2006. Sampled mothers received a mailed survey package including
a grief and bereavement booklet and a gift certificate. Telephone interviews were conducted with non-respondents. Due to the
diversity of the LAC population, the survey is translated into Spanish and can also be administered in over 88 languages through
a telephone translation service.
RESULTS: From 2007 to 2009, LAHOPE surveys were mailed to a random sample of over 2,400 mothers, seven to nine
months following a fetal/infant loss. Nine hundred thirty-eight eligible mothers completed the survey (adjusted response rate=
60%) representing 4,409 fetal and infant losses in LA County during 2007-2009. The data are weighted by the respondents’
selection probability. Mothers experiencing a fetal/infant loss were 61% Latinas,16% African Americans,15% Whites, and 7%
Asians; 66% had less than or equal to 12 years of education, and preconception health conditions/care were limited. About 60%
of mothers did not take multivitamins, 48% were overweight/obese pre-pregnancy, and 34% didn’t have any medical insurance
prior to pregnancy. During pregnancy, many women experienced cramps or back pain (47%), vaginal bleeding(32%), and severe
nausea, vomiting, or dehydration (26%). In terms of psychosocial conditions during pregnancy, 41% felt depressed and 21% felt
their neighborhood was not safe from crime. Since the loss of the baby, 77% of women were offered bereavement materials,
49% felt her religion provided the best bereavement support; and only 15% of women attended counselilng.
CONCLUSIONS: LAHOPE has changed the way MCAH Programs collect fetal infant mortality data and provides better
understanding of the target population.
PUBLIC HEALTH IMPLICATIONS: LACMCAH is collaborating with community stakeholders, including faith-based
organizations to promote preconception health, and discuss materneral depression. Furthermore,LACMCAH established a
support group to enhance support services.
21
THE EFFECT OF MATERNAL LOW BIRTHWEIGHT ON MEDICAL HISTORY
FACTORS AND LABOR/DELIVERY COMPLICATIONS AMONG BLACK AND
WHITE FIRST-BORN SINGLETONS IN VIRGINIA, 2005-2009
Derek Chapman, MS, PhD, Gandarvaka Gray, MPH
Virginia Commonwealth University, Virginia Health Dept., Chris Hill, MPH
BACKGROUND: Several studies have documented a positive correlation between mother and infant birthweight (Ounsted et
al., 1986). Mothers who were born low birthweight (LBW) had 1.4 to 2.0 times the odds of giving birth to a LBW infant (Coutinho
et al., 1997; Emanuel et al., 1993). Less is known about how specific medical history factors and labor/delivery complications
may contribute to this intergenerational effect on LBW.
STUDY QUESTIONS: Is maternal low birthweight associated with increased risk for medical history factors and labor/delivery
complications among black and white first-born singleton live births?
METHODS: A multi-generation dataset was created by linking 2005-2009 Virginia resident live birth data to 1960-1997 Virginia
resident live birth data. Maternal information from this recent birth cohort was matched to infant information in the historic birth
file using various combinations of mother’s birth date and first, middle, and maiden names. The initial linkage resulted in 173,821
matched records (87% of all eligible records). Because so few Hispanic infants had mothers who were born in Virginia, this
analysis was restricted to non-Hispanic white and black women. The final analysis dataset consisted of birth data for 72,945 firstborn, singleton infants matched to their mother’s own birth record. Maternal medical history factors and labor/delivery
complications were derived from 2005-2009 birth certificate data.
RESULTS: Compared to normal birthweight mothers, LBW mothers had an increased odds of diabetes (OR=1.20; 95% CI:
1.03, 1.39), hemoglobinopathy (OR=2.33; 1.10, 4.96), chronic hypertension (OR=1.36; 1.10, 1.71), and incompetent cervix (OR=
2.06;1.28, 3.30). Fetal distress (OR=1.19; 1.05, 1.33) and premature rupture of membranes (OR=1.32; 1.11, 1.57) were the only
two labor/delivery complications that were more likely among LBW mothers.
CONCLUSIONS: The present analysis provides evidence of an intergenerational effect of maternal LBW on selected medical
history factors and labor delivery complications.
PUBLIC HEALTH IMPLICATIONS: It is clear that public health programs and policymakers need to incorporate a life-course
perspective into their efforts in order to fully address the prevention of adverse birth outcomes.
22
FACTORS ASSOCIATED WITH ACUTE MALNUTRITION IN CHILDREN
UNDER FIVE YEARS IN HARARE CITY, ZIMBABWE 2011
Nozizwe Chigonga, MPH, BSc
University of Zimbabwe
BACKGROUND: Malnutrition is associated with 35% of the top five causes of childhood mortality in Zimbabwe. According to the
National Nutrition Survey of January 2010, the prevalence of acute malnutrition was at 2.1% in children under five with the rate
doubling among children between six and 18 months of age in Harare.
STUDY QUESTION(S): What are the factors associated with acute malnutrition in Harare?
METHODS: A 1:1 case-control study which was frequency matched for age (6 to 59 months) was conducted. A case was a child
with a Z score of less than 0.2 for (weight for height) or a mid-upper arm circumference <12,5cm.The mean Coping strategy
index (CSI) and house hold dietary diversity scores for cases and controls were calculated. Logistic regression on factors
associated with acute malnutrition using Epi Info 3.5.1 was done.
RESULTS: A total of 115 cases and 115 controls were enrolled. The median age was 18 months for cases (Q1=11, Q3=27) and
18 months for controls (Q1=10, Q3=29). Breastfeeding less than eight times the previous day [AOR=1.86 (1.03 - 3.38)] and
consumption of solid or semi-solid foods other than liquids less than 3 times per day [AOR=2.15 (1.20-3.85)] were independently
associated with acute malnutrition. Mean Dietary diversity score was 5 for cases (Q1=5, Q3=7) and 6 for controls(Q1=5, Q3=7),
p-value 0.05. Mean CSI for cases was higher 110 (Q1=92, Q3=122) as compared to controls 91 (Q1=78).
CONCLUSIONS: Infant care practices were significantly associated with acute malnutrition. Significantly lower dietary scores in
cases and the lower CSI score for controls as compared to cases suggest lack of food diversity for cases and the need to revert
to more coping strategies in order to find food for their families. We recommend that Community based nutrition programs should
also be implemented in urban areas.
PUBLIC HEALTH IMPLICATIONS: Health care workers need to emphasize to parents the importance of breastfeeding on
demand and frequency of nutritionally balanced meals in addition to liquids given to a child. Coverage of Community based
nutrition programs need to include urban settings.
23
BIRTH OUTCOMES FOR NATIVE HAWAIIAN AND OTHER PACIFIC
ISLANDER SUBGROUPS: HAWAII 2003-2005
Izumi Chihara, MD, MPH, Donald Hayes, MD, MPH, Linda Chock, RD, MPH
University of Illinois at Chicago School of Public Health, Hawaii Dept. of Health
BACKGROUND: Native Hawaiian and other Pacific Islander (NHOPI) population are extremely diverse, but few studies have
focused on perinatal outcomes of their subgroups.
STUDY QUESTIONS: How do birth outcomes differ between NHOPI subgroups among clients enrolled in Hawaii's Special
Supplemental Nutrition Program for Women, Infants, and Children (WIC)?
METHODS: Secondary data analysis was conducted using program and administrative data for WIC between 2003 and 2005.
Each client chose as many categories as needed from a list of race (e.g.,“Asian”, “Hawaiian or Pacific Islander (PI)”) and
ancestry (e.g., Tongans, Samoans). For this study, women who chose at least one NHOPI ancestry alone or in combination with
any other race/ancestry were included. Hawaiians or Part-Hawaiians who chose other race/ancestry category including PI
ancestry were categorized as part-Hawaiians. Women who chose any PI ancestry in combination with other race/ancestry
excluding Hawaiian/part-Hawaiian were categorized as mixed race PIs. Bivariate analyses examined the distribution of outcome
variables (low birthweight [LBW], high birthweight [HBW], small for gestational age[SGA], large for gestational age[LGA], and
preterm delivery). Logistic regression models examined the relationship between ethnic categories and outcome variables
adjusting for age, education, marital status, parity, smoking, prepregnancy BMI, and gestational weight gain.
RESULTS: A total of 6986 women were included for the analysis. Hawaiians (32.8%) and part-Hawaiians (24.9%) comprised
the majority of the sample. HBW and LGA were prevalent among Tongans and Samoans while LBW and SGA were prevalent
among Marshallese and Micronesians. After controlling for covariates, Tongans and Samoans showed increased odds of
delivering HBW and LGA infants compared to all others. Marshallese showed increased odds of delivering preterm compared to
all others (AOR 1.48, 95%CI 1.07-2.05). On the other hand, Micronesians showed increased odds of delivering a term LBW
infant (adjusted OR:1.92, 95%CI:1.24-2.98) and of delivering an SGA infant (AOR 1.79, 95%CI 1.42-2.25), indicating that they
may be growth restricted.
CONCLUSIONS: Significant differences on birth outcomes were shown among NHOPI subpopulations.
PUBLIC HEALTH IMPLICATIONS: Nutritional intervention to decrease intrauterine growth restriction may benefit Micronesians
while Marshallese may benefit from intervention strategies to prevent preterm delivery.
24
DETERMINANTS OF PREMATURE BIRTHS AT TWO CENTRAL HOSPITALS
IN HARARE ZIMBABWE, 2011
Gwendoline Chimhini, MBChB, M Med Paeds, MPH
University of Zimbabwe
BACKGROUND: Prematurity is a major determinant of neonatal morbidity and mortality in Zimbabwe. The survival of a
premature infant is a function of the level of maturity of the organs and the supportive environment available provided by the
health services. Although the prevalence rate of prematurity in the country is 8-10%, premature births contribute about 33% of
neonatal deaths. In Harare prematurity was responsible for 36-45% of neonatal deaths 2006-2010. Studying the risk factors for
prematurity could help come up with local intervention and prevention strategies.
STUDY QUESTIONS: What are the determinants of premature births in the central hospitals of Harare?
METHODS: A 1:1 unmatched case control study was conducted at two central hospitals in Harare. A case was a mother who
delivered a baby at less than 37 weeks gestation age and a control was a mother who delivered at or more than 37 completed
weeks of gestational age at the two Harare central hospitals. A questionnaire was administered to study participants to collect
data on determinants of prematurity.
RESULTS: A total of 188 cases and 188 controls were enrolled. History of premature delivery [AOR 3.15 (95% CI 1.17-8.49)]
and being admitted with a medical complication in pregnancy [AOR 2.15 (95% CI 1.18-3.92)] were independent risk factors for
premature delivery. Mothers who had a birth interval of more than 24 months [AOR 0.26 (95% CI 0.12- 0.59)] and were well
nourished (BMI =20kg/m2), [AOR 0.93 (95% CI 0.88- 0.97)] were less likely to have a premature delivery.
CONCLUSIONS: History of premature delivery, birth interval of less than 24 months and maternal under nutrition were
associated with premature delivery.
PUBLIC HEALTH IMPLICATIONS: Efforts are being made to identify the malnourished women during antenatal care and
health education given on dietary requirements and supplementary feeding to be instituted. There was no association of
premature delivery and HIV status. Plans are underway to give supplementary food packs to undernourished pregnant women.
25
INADEQUATE GESTATIONAL WEIGHT GAIN AND CAUSE-SPECIFIC
INFANT DEATH
Regina Davis, PhD, MPH, Sandra Hofferth, PhD, Edmond Shenassa, ScD
University of Maryland, College Park
BACKGROUND: More than 28,000 babies die before their first birthday in the United States each year. Programmatic and
Policy focus on prematurity and birth weight stem largely from their known relationship to infant mortality and morbidity. A large
body of literature exists linking low gestational weight gain to prematurity and low birth weight, but few studies have examined its
association with infant death as well as cause-specific mortality.
STUDY QUESTIONS: Are nutritionally-linked causes of death associated with infant mortality among women with inadequate
gestational weight gain?
METHODS: Using data from the Birth Cohort Linked Birth-Infant Death Data File, we investigated the association between the
2009 Institute of Medicine (IOM) weight gain guidelines and infant death among women who delivered a singleton infant during
2005 and analyzed the likelihood of death from nutritionally-linked causes of death. The International Classification of Diseases,
10th revision was used to group causes of infant deaths (based on the death certificate) into six, etiologically-related categories.
Descriptive and proportional hazards regression analyses were used to assess odds of infant death associated with nutritionrelated causes compared to infant death from rare or implausible causes. The main study limitation is that the cohort linked file
does not provide information about gestational weight gain relative to pre-pregnancy BMI. We reduce this loss in precision by
using the lower limit of the IOM weight gain range to define inadequate weight gain.
RESULTS: Among 9,268 deaths, infants of mothers of inadequate gestational weight gain had odds of infant death from
disorders related to length of gestation and fetal malnutrition that were 2.06 times the infant deaths from rare or implausible
causes (P<0.0001, 95% CI: 1.92, 2.12). Inadequate gestational weight gain was also associated with deaths from respiratory
conditions (OR = 1.42, P<0.0001, 95% CI: 1.30, 1.54) and birth defects (OR = 1.34, P<0.0001, 95% CI: 1.25, 1.44). Increased
odds remained after adjustment for medical, behavioral, and socioeconomic factors.
CONCLUSIONS: Nutrient deficiency is a biologically plausible mechanism through which inadequate gestational weight gain
may increase the risk of infant death.
PUBLIC HEALTH IMPLICATIONS: Improving the quality and quantity of the maternal diet may contribute to a reduction in
infant mortality.
26
HOSPITALIZATIONS AND ASSOCIATED CHARGES IN A POPULATIONBASED STUDY OF CHILDREN WITH DOWN SYNDROME
April Dawson, MPH, Cynthia Cassell, PhD, Jean Paul Tanner, MPH, Jane Correia, BS, Sharon Watkins, PhD, Russell
Kirby, PhD, MS, FACE, Scott Grosse, PhD
Centers for Disease Control & Prevention (NCBDDD), University of South Florida, Florida Department of Health
BACKGROUND: Healthcare use and costs for children with Down syndrome (DS) are significantly greater than those of
unaffected children. Information on hospitalizations and charges beyond the first few years of life and by the presence of critical
congenital heart defects (CCHDs) are lacking.
STUDY QUESTIONS: What are the differences in hospital use and associated charges for children with DS by the presence of
other anomalies?
METHODS: This was a retrospective, population-based, state-wide study of children with DS born 1998-2007, identified by the
Florida Birth Defects Registry and linked to hospital discharge records for 1-10 years after birth. Descriptive statistics on number
of hospitalizations, hospitalized days, and inpatient charges were calculated. Results were stratified by isolated DS (no other
major birth defect present); presence of congenital heart defects (CHDs); and presence of major non-cardiac birth defects.
Results for children with CHDs were stratified by presence or absence of 12 CCHD types.
RESULTS: 2,366 children with DS had 6,347 inpatient admissions of which 60% occurred during the first year of life. Of these
children, 24% (n=560) had isolated DS, 60% (n=1,414) had a CHD, and 17% (n=392) had non-cardiac birth defects. From
infancy through age two, children with CHDs had a greater number of hospitalizations, hospitalized days, and higher total
charges than children with isolated DS or with non-cardiac birth defects. These differences were not significant beyond age two.
Among children with CHDs, 14% (n=195) had a CCHD. Mean and median total charges were more than three times higher for
infants with CCHDs compared to infants with other CHDs. Infants with CCHDs also had significantly greater number of
hospitalizations and twice the number of hospitalized days compared to infants with other CHDs.
CONCLUSIONS: Results confirm that for children with DS the presence of other anomalies influences hospital use and
charges, and children with CCHDs have greater hospital resource utilization than children with other CHDs. Further examination
of demographic and clinical characteristics is warranted.
PUBLIC HEALTH IMPLICATIONS: Findings facilitate further assessments of CCHDs and DS on the health care system. Birth
defects registry and hospital discharge data provide useful tools for evaluating patterns of hospital use and associated charges
over time.
27
SUBSTANCE USE AND SEXUAL RISK BEHAVIORS AMONG AMERICAN
INDIAN AND ALASKA NATIVE HIGH SCHOOL STUDENTS
Lori de Ravello, MPH, Sherry Everett Jones, PhD, MPH, JD, Scott Tullock, BS, Melanie Taylor, MD, MPH, Sonal Doshi,
MS, MPH
Centers for Disease Control & Prevention (NCHHSTP, OSTLTS & DPHPI)
BACKGROUND: Compared to other U.S. adolescents, American Indian and Alaska Native (AI/AN) youth experience
disproportionately high rates of pregnancy, sexually transmitted infections (STIs), and substance abuse. However, there is a
dearth of nationally representative behavioral risk data for AI/AN high school students. A better understanding of AI/AN
adolescent risk behaviors may help improve future interventions to prevent teen pregnancy and STIs among AI/AN youth.
STUDY QUESTION(S): How do substance use and sexual risk behaviors among AI/AN high school students compare with
students of other races/ethnicities?
METHODS: We analyzed merged 2007 and 2009 data from the national Youth Risk Behavior Survey, a biennial, selfadministered, school-based survey of U.S. students in grades 9-12 (N=27,912). Logistic regression, controlling for sex and
grade, was used to examine associations among race/ethnicity, substance use, and sexual risk behaviors.
RESULTS: The adjusted odds of dating violence (AOR=1.9; 95% confidence interval [CI]: 1.5, 2.4) and ever using marijuana
(AOR=1.5; 95% CI: 1.2, 1.9) were higher among AI/AN than white students. The odds of ever having sexual
intercourse(AOR=1.5; 95% CI: 1.2, 1.8), having sex before age 13 years (AOR=2.1; 95% CI:1.5, 2.9), and having =4 lifetime
partners (AOR=1.8; 95% CI: 1.4, 2.3) were higher among AI/AN than white students, but lower among AI/AN than black students
(AOR=0.5; 95% CI: 0.4, 0.6; AOR=0.4; 95% CI: 0.3, 0.6; AOR=0.5; 95% CI: 0.4, 0.6, respectively).
CONCLUSIONS: AI/AN students had lower odds than black students but higher odds than white students of engaging in many
substance use and sexual risk behaviors that increased their risk for pregnancy and STIs.
PUBLIC HEALTH IMPLICATIONS: Our findings fill an important gap by providing nationally representative data for AI/AN high
school students for a variety of behaviors associated with sexual health and substance abuse. Many health risk behaviors
initiated during adolescence track into adulthood. Studies, including ours, have found that many of these behaviors occur
frequently among AI/AN youth. Hence, it is necessary to develop targeted, adolescent-specific interventions for reducing
behaviors that put AI/AN high school students at risk for teen pregnancy, STIs, HIV, and other detrimental health conditions.
28
USING GIS TO IDENTIFY GEOGRAPHICAL DISPARITIES IN ACCESS TO
DENTAL CARE PROVIDERS IN OHIO
Amber Detty
Background: Few studies have considered spatial relations when investigating access to dental care. Previous research has
found that disparities exist in the location of dentists and the populations they serve, but few recent studies have explored this
relationship simultaneously.
Study Questions: This study compares the geographical distributions of dentists and the population in Ohio to identify
geographic disparities in access to dental care.
Methods: Locations of dentists were obtained from the Ohio State Dental Board licensing data. Population data were obtained
from the 2010 U.S. Census. Medicaid data on dentists and enrollees were obtained from Medicaid claims data through the Ohio
Department of Job and Family Services. Using ArcGIS software, data from multiple sources were used to identify populations by
census tract which were a specified distance from a dentist.
Results: Over 103,000 Ohioans, including almost 28,000 children, are estimated to live more than 10 miles from a primary care
dentist. Thirteen census tracts in Ohio, twelve in Ohio’s Appalachian region, are estimated to have more than 2000 individuals
who live more than 10 miles away from a primary care dentist. Sixty-nine census tracts, forty-nine located in Ohio’s Appalachian
region, are estimated to have more than 1000 children who live more than 25 miles from the nearest pediatric dentist; this
represents nearly 207,000 children. Over 148,000 Medicaid enrollees (the majority of whom are children) are estimated to live
more than 10 miles away from a substantial Medicaid provider. Seventeen census tracts, twelve in Ohio’s Appalachian region,
are estimated to have more than 1000 Medicaid enrollees who live more than 10 miles away from a substantial Medicaid
provider.
Conclusions: Geographical disparities in the distribution of dentists still exist in Ohio. Populations without easy access to a
dentist are highly concentrated in Ohio’s Appalachian region. A limitation of this study includes whether licensing data accurately
reflect the location of practicing dentists in the community.
Public Health Implications: Identifying disparities in the geographic distribution of dentists in Ohio can assist dental public
health professionals to more effectively target resources and programs to improve access to dental care.
29
NEONATAL ABSTINENCE SYNDROME IN INDIANA, 2002–2010
Lisa Eastcott, MPH
Indiana State Dept. of Health
BACKGROUND: Neonatal Abstinence Syndrome (NAS) can occur when infants are exposed prenatally to illegal or prescription
drugs. During 2009-2010, 4.4% of U.S. pregnant women reported illicit drug use in the past month. It is likely this is
underreported and does not include prescription drug use. Nationally, during 2000-2009, the NAS rate increased from 1.2 to 3.4
per 1,000 hospital births.
STUDY QUESTIONS: Has the NAS rate changed in Indiana and how do infants with NAS compare to those without regarding
their initial hospital length of stay, cost, and co-morbidities?
METHODS: Cross-sectional data from the Indiana Hospital Discharge Database were used to examine the NAS rate (ICD 9-CM
779.5) in Indiana from 2002-2010. Differences in mean stay and mean cost for infants with NAS were compared to those without
using t-tests. Multivariate log binomial regression was used to estimate the adjusted prevalence ratios (aPR) and 95%
confidence intervals (CI) of co-morbidities, adjusting for sex, race, and payer.
RESULTS: During 2002-2010, 1,672 infants were discharged with NAS; 56.8% were male, 77.0% were white, and 65.2% were
Medicaid-insured. Indiana’s rate increased from 0.8 to 5.1 per 1,000 hospital births during this period. In 2010, the rate of NAS
among Medicaid-insured was 8.1 while the rate among privately insured was 2.4 per 1,000 hospital births; the mean stay was
five times longer and the mean cost was almost eight times greater among infants with NAS compared to those without
(P<.0001). Infants with NAS were more likely to have respiratory symptoms (aPR=4.1, 95% CI: 3.8-4.3), feeding problems
(aPR=7.3, 95% CI: 6.5-8.1), convulsions (aPR=14.0, 95% CI: 10.4-18.8), low birthweight (aPR=2.8, 95% CI: 2.5-3.1), and be
premature (aPR=2.7, 95% CI: 2.4-3.0).
CONCLUSIONS: The NAS rate in Indiana increased 6-fold during 2002-2010. Infants with NAS were more likely to be male,
white, receive Medicaid, have longer stays and higher costs, and were more likely to be affected by co-morbidities.
PUBLIC HEALTH IMPLICATIONS: This is the first study in Indiana looking at the implications of NAS; data should be used to
inform medical professionals about the importance of identifying women at risk for use/misuse of drugs and educating them
about risks to their fetus.
30
IDENTIFYING PREGNANCY RISK: USING ANALYTICS TO IMPROVE
MEDICAID BIRTH OUTCOMES
Laura Eiklenborg, MPH
Optum
BACKGROUND: Medicaid-enrolled women have more unintended pregnancies, deliver more low birth weight and premature
infants, experience more domestic violence, and have more mental health problems including anxiety and depression. Yet,
limited understanding of the relationships between maternal risk and birth outcomes, specifically psychosocial risks, hinders
improvements in maternal and infant health outcomes. Existing prenatal programs are likely to be less effective due to the lack
of empirically-based identification of maternal risks that lead to adverse birth outcomes in a Medicaid-enrolled population.
STUDY QUESTIONS: The objective of this study was twofold: to identify maternal psychosocial and clinical risk factors that were
predictive of adverse birth outcomes and to identify risk factors associated with increased medical expenditures among pregnant
women and their infants in Medicaid programs.
METHODS: In this study, we reviewed pregnancy assessment, pregnancy outcomes, and claims data for 1,903 Medicaidenrolled mothers who gave birth in six states and who were enrolled in a Medicaid managed care pregnancy management
program. Regression analysis was used to identify the correlation between predictor variables (i.e., maternal psychosocial and
clinical risks) and outcome variables (i.e., low birth weight, pre-term birth, NICU admission, infant mortality).
RESULTS: Our findings indicated a total of 22 percent (425) of women experienced an adverse birth outcome. Factors
associated with adverse birth outcomes included living in Tennessee; maternal substance use, including alcohol; less than a
12th grade education; and non-pregnancy related emergency department use. For the cost analysis portion of the study we
found NICU admission averaged $40,000 compared with $3,000 for an uncomplicated birth. Women with adverse birth
outcomes had 66% greater cost of care; women with diabetes had 31% higher costs; and women who used drugs or alcohol had
37% greater costs.
CONCLUSIONS: Maternal risk factors, both clinical and psychosocial, contribute to poor birth outcomes and increased medical
expense.
PUBLIC HEALTH IMPLICATIONS: This study supports the need for a validated and empirically-based pregnancy risk
assessment that captures the complex relationships between psychosocial and clinical risk factors and adverse birth outcomes
and increased medical expense.
31
ASSESSING NEIGHBORHOOD SOCIAL CONTEXT AND INDIVIDUAL
EXPOSURES TO PRENATAL POLYCYCLIC AROMATIC HYDROCARBONS
AS DETERMINANTS OF AGE 5 COGNITIVE TEST SCORES
Nicolia Eldred-Skemp, BA, Gina Lovasi, PhD, MPH, James Quinn, MA, Hsin-Wen Chang, MS, Virginia Rauh, ScD, MSW,
Andrew Rundle, DrPH, MPH, Manuela Orjuela, MD, ScM, Frederica Perera, DrPH, MPH
Columbia University Mailman School of Public Health, Columbia Institute for Social & Economic Research & Policy
BACKGROUND: Childhood cognitive and test-taking abilities have long-term implications for educational achievement and
health, and may be influenced by household environmental exposures and neighborhood contexts.
STUDY QUESTIONS: This study evaluates whether age 5 scores on the Wechsler Preschool and Primary Scale of IntelligenceRevised (WPPSI-R, administered in English), are associated with polycyclic aromatic hydrocarbon (PAH) exposure and
neighborhood context variables including poverty, low educational attainment, low English language proficiency, and inadequate
plumbing.
METHODS: The Columbia Center for Children’s Environmental Health enrolled 727 African-American and Dominican-American
New York City women during pregnancy, characterizing 1-km network buffers around prenatal addresses and collecting survey
data, home observations, and prenatal PAH exposure data from personal air monitors. Generalized linear models with clusterrobust standard errors included adjustment for sex, ethnicity, maternal education, maternal IQ, environmental tobacco smoke,
caretaking environment, and household language.
RESULTS: Among 277 participants with complete data, prenatal PAH exposure above the median predicted 3.5 point lower
total WPPSI-R scores (95% CI: -6.6 to -0.3) and 3.9 point lower verbal scores (95% CI: -7.0 to -0.8); the association was similar
in magnitude across models with adjustments for neighborhood characteristics. Neighborhood-level low English proficiency was
associated with 2.3 point lower mean total score (95% CI: -3.0 to -1.5), 1.2 point lower verbal score (95% CI: -2.4 to -0.1), and
2.7 point lower performance score (95% CI: -3.8 to -1.8) per standard deviation. Low neighborhood-level educational attainment
was also associated with 2.0 lower performance scores (95% CI: -3.5 to -0.5). In models examining effect modification,
neighborhood associations were similar or diminished among the high PAH exposure group, as compared with the low PAH
exposure group.
CONCLUSIONS: Early life exposure to personal PAH exposure or selected neighborhood-level social contexts predicted lower
cognitive test scores, which may affect access to educational opportunities and health outcomes later in life.
PUBLIC HEALTH IMPLICATIONS: These findings provide insight into the inter-relationship of multiple prenatal exposures on
children’s cognitive development, suggesting that both personal exposures and neighborhood contexts may be important targets
for promoting healthy neurodevelopment.
32
PUBLIC HEALTH AND PERINATAL NURSE MANAGEMENT
COLLABORATIVE TO ASSESS BABY FRIENDLY HOSPITAL INITIATIVE
(BFHI) 10 STEP READINESS STATUS, OHIO, 2011
Sylvia Ellison, MA, MPH
Wright State University
BACKGROUND: Lack of breastfeeding is an important factor in infant morbidity and mortality, and maternal health. Hospital
maternity care practices play a significant role in breastfeeding initiation. The WHO Baby Friendly Hospital Initiative (BFHI) is an
evidence based approach to improve maternity care practices. As more US hospitals investigate Baby Friendly, it is necessary
for them to know where they stand regarding BFHI requirements.
STUDY QUESTION(S): What is the readiness status of maternity care facilities with regard to the Baby Friendly Hospital
Initiative 10 Steps to Successful Breastfeeding?
METHODS: Ohio has six designated perinatal regions. Public Health faculty from Wright State University’s school of medicine
partnered with Perinatal Nurse Managers in Region II (Dayton) to assess the status of local maternity care facilities in
consideration of readiness for the Baby Friendly Hospital Initiative’s 10 Steps to Successful Breastfeeding. Each of the 10 steps,
along with accompanying sub-scale items, was self-assessed by all 16 maternity care facilities in the region. Using the standard
Baby Friendly self-assessment tool, ‘Yes’ / ‘No’ response items were reworded and responses plotted on a Likert scale. This
provides detailed indication for maternity care hospitals regarding how far they are from ‘Yes’ on items where their current
response is ‘No’.
RESULTS: Results demonstrate differences in readiness for some of the 10 Steps as compared to others. For Region II as a
whole, 3 of the 10 Steps to Successful Breastfeeding scored 5 or less (out of 10 possible). The remaining 7 steps scored above
6.
CONCLUSIONS: This study demonstrates the value in not only carefully assessing the 10 Steps to Successful Breastfeeding,
but also attending to status in the subscale items within each of the steps. In order to progress towards optimal maternity care
practice, clinical nurse managers and lactation consultants need fine-tuned information regarding where to best focus scarce
resources for positive change in perinatal care.
PUBLIC HEALTH IMPLICATIONS: If provided with detailed 10 Step readiness status, perinatal nurse managers can make
better decisions for optimal perinatal care. This in turn can improve breastfeeding initiation in hospitals, which will have positive
impact on maternal and child health.
33
INFLUENCE OF SOCIAL SUPPORT ON THE INITIATION AND SUCCESS OF
BREAST MILK EXPRESSION AMONG MOTHERS OF PREMATURE
INFANTS AT SOCIAL-ENVIRONMENTAL RISK
Camille Fabiyi, MPH, Kristin Rankin, PhD, Rosemary White-Traut, PhD, RN, Kathleen Norr, PhD
University of Illinois in Chicago College of Nursing, University of Illinois in Chicago School of Public Health
BACKGROUND: Premature infants often require gavage feeding initially but benefit from receiving expressed human breast
milk (BM) from their mothers during these feedings. Expressing BM is difficult for new mothers even when NICUs encourage BM
expression. Little is known about the association between social support and success in BM expression among mothers of
premature infants.
STUDY QUESTION(S): What is the effect of social support on the initiation and success of BM expression among socially
disadvantaged mothers of premature infants?
METHODS: Data were from a randomized trial testing a behavioral intervention at two urban hospitals for 181 mothers and
premature infants (29-34 weeks gestational age) with at least two of ten social-environmental risks (i.e., minority status, poverty).
We analyzed maternal intake interview data and daily infant data on proportion of nutrition from BM during the hospital stay.
Multivariable log-binomial regression examined the relationship between social support (PRQ-2000), initiation (Any BM
expressed vs. None), and success in BM expression (Mothers with babies consuming less than 30% BM during hospitalization
were categorized as Low). All models were adjusted for maternal race, language preference, age-appropriate education, hospital
site, infant morbidity at delivery, and gestational age. Social support was dichotomized (low=lowest quartile for social support).
RESULTS: In our sample, 70.3% of mothers initiated BM expression, and 32% of those mothers expressed low proportions of
BM. After adjustment in multivariable analyses, social support did not differ between mothers who initiated BM expression and
those who did not (p > 0.10). Low social support was significantly associated with low proportions of BM expressed for those
who initiated (adjusted Prevalence Ratio: 1.58, 95% CI = 1.00 – 2.50).
CONCLUSIONS: While social support was not associated with the initiation of BM expression among a sample of socially
disadvantaged mothers of premature infants, low social support was significantly associated with low proportions of BM
expressed during hospitalization.
PUBLIC HEALTH IMPLICATIONS: BM plays a critical role in reducing morbidity and mortality in premature infants. Mothers
who fail to initiate BM expression in hospital are unlikely to continue breastfeeding at home. Interventions designed to enhance
social support for new mothers of premature infants may increase long-term breastfeeding success.
34
ASSESSING INTERVENTIONS TO INCREASE MALE REPRODUCTIVE
HEALTH (RH) CLIENTS AND SEXUALLY TRANSMITTED INFECTION (STI)
SERVICES AT FAMILY PLANNING (FP) CLINICS
David Fine, PhD, Sarah Goldenkranz, MPH, David Johnson, MPH, Lee Warner, PhD
Cardea Services, Dept. of Health & Human Services (Office of Population Affairs), Centers for Disease Control & Prevention
(DRH)
BACKGROUND: While >95% of U.S. family planning (FP) clinic clients are women, men also benefit from reproductive health
(RH) services. The Male Reproductive Health Project, a 5-year DHHS/Office of Population Affairs initiative, is implementing
empirically-based interventions to increase the number of male RH clients and sexually transmitted infection (STI) service use by
males at FP clinics.
STUDY QUESTION(S): To assess impacts of clinic, staff, and community-level interventions on male RH client census, STI
services, and STI positivity.
METHODS: Project interventions (2010-11) were implemented at 2 Family Health Center (FHC) FP clinics (San Diego, CA) and
included: 1) outreach via female clinic clients, 2) clinic efficiency assessments, 3) staff training on male clinical services, and 4)
modifying clinic environments. We compared clinic service provision at FHC sites receiving interventions to 6 FHC clinics where
interventions were not introduced. Chlamydia and gonorrhea (CT/GC) testing and positivity were analyzed by male client
characteristics, timeframe (pre-intervention=2007-2008; post=2010-2011) and condition (experimental/comparison). Multivariable
models were developed.
RESULTS: Among 16,007 male RH visits (50%:50% E:C), most (69%) were Hispanic and aged <30 years (55%). Experimental
sites increased male visits 99% (pre-intervention: mean=671 visits/clinic/year; post-intervention: mean=1,336 visits/year/clinic);
comparison clinics increased male visits 4% (pre-intervention/post-intervention: mean=325/339 visits/year/clinic). The proportion
of male visits receiving CT/GC testing at experimental clinics increased 31% (pre-intervention=32%; post-intervention=42%,
p<0.01) while comparison sites’ CT/GC testing showed no change (pre/post=32%/33%). Controlling for demographics and visit
characteristics (insurance, new/continuing client), CT/GC testing was higher at experimental sites (AOR=1.23, 95%CI=1.12-1.34)
and overall during the post-intervention period (AOR=1.29, 95%CI=1.18-1.40). CT/GC positivity at experimental sites decreased
over time (CT+ pre/post=8.8%/5.4%; GC+ pre/post=8.4%/5.5%, p<0.01) and was stable at comparison clinics (CT+
pre/post=9.3%/10.1%; GC+ pre/post= 9.3%/10.2%, p=NS). Female FP visits fell over time but comparably by condition
(Comparison: pre/post=47,213/34,103, -28%; Experimental: pre/post=72,862/54,161, -26%).
CONCLUSIONS: Intervention clinics promoting male RH services showed significant increases in male client volume and
proportion tested for CT/GC versus clinics that did not change practices. Increasing male clinic services did not differentially
reduce female FP visits.
PUBLIC HEALTH IMPLICATIONS: Interventions promoting use of male RH services can be successfully implemented without
altering female client service access. Administrative databases can be useful for evaluating public health service delivery.
35
PREVENTING INTIMATE PARTNER VIOLENCE AMONG PREGNANT
ADOLESCENTS AND THEIR PARTNERS: RESEARCH FINDINGS AND
CLINICAL IMPLICATIONS
Paul Florsheim, PhD, Young Cho, PhD, Cristina Hudak, MA, Megan Howard, MA, Jason Burrow Sanchez, PhD
University of Wisconsin-Milwaukee – Zilber School of Public Health, University of Utah
BACKGROUND: Intimate Partner Violence (IPV) is a serious public health hazard affecting more that 25% of the US population
(Campbell et al., 2002). Pregnant adolescents and their partners are at particularly high risk for IPV because they have not
acquired the interpersonal skills to manage the stress of an unplanned pregnancy. IPV increases their risk for injury, depression,
birth complications and child abuse. This presentation will focus on the Young Parenthood Program (YPP), an innovative
program which provides co-parenting counseling designed to prevent IPV among high-risk young parents. The research findings
presented below are based on a randomized treatment-control study.
METHODS: 170 couples were randomized into three conditions: YPP, case management and TAU. Data collection occurred at
three time points: prior to childbirth, at 6 months, and 18 months post-birth. Relationship skills were assessed with the Capacity
for Interpersonal Bonding coding scheme (CIB) and IPV was assessed using combined reports provided by both partners.
Structural equation modeling (SEM) was used to test for treatment effects on change in CIB scores and IPV scores over time.
The study’s primary limitation was the lack of a multi-method approach to measuring relationship skills and IPV.
RESULTS: SEM results indicated that couples in the YPP condition were less likely to report increased IPV scores than couples
in the TAU condition. Although couples in YPP were also found to demonstrate significantly improved CIB scores, CIB scores did
not appear to mediate treatment effects on IPV.
CONCLUSIONS: Co-parenting counseling can help prevent IPV among pregnant adolescents and their partners. Future
research will focus on whether YPP lowers the risk for maternal depression, birth complications and child abuse.
PUBLIC HEALTH IMPLICATIONS: Most IPV prevention programs focus exclusively on women, missing the opportunity for
engaging young men in prevention efforts. Prenatal clinics provide a prime venue for delivering prevention programs for this high
risk population.
36
DO UNMET NEEDS DIFFER GEOGRAPHICALLY FOR CHILDREN WITH
SPECIAL HEALTH CARE NEEDS?
Kimberly Fulda, DrPH, Katandria Johnson, DrPH, MS, Kirstin Hahn, MPH, Kristine Lykens, PhD
University of North Texas Health Science Center
BACKGROUND: Children with special health care needs (CSHCN) are at risk for experiencing unmet needs for preventive,
specialty, and mental health care. States and regions vary with respect to the health and well-being of these special needs
children even after adjusting for state and child specific factors. While geographic disparities have been demonstrated for
accessing individual health services for CSHCN, regional disparities in overall unmet needs for CSHCN have not been
established.
STUDY QUESTIONS: The purpose of this study was to identify geographic differences in health indicators for CSHCN.
METHODS: Data were obtained from the National Survey of Children with Special Health Care Needs, 2005–2006. Nine
variables representing unmet needs were analyzed by geographic region. Logistic regression was utilized to determine
differences in unmet need by region after controlling for age, gender, ethnicity, race, federal poverty level, relationship of
responder to child, insurance status, severity of condition, and size of household.
RESULTS: A total of 40,723 CSHCN were represented. The greatest unmet need for routine preventive care, specialist care,
prescription medications, physical/occupational/speech therapy, mental health care, and genetic counseling occurred in the
West. The greatest unmet need for preventive dental care, respite care, and vision care occurred in the South. Significant
differences between regions remained for six of the nine services after controlling for potential confounders.
CONCLUSIONS: Geographic differences in unmet health care needs exist for CSHCN. For all nine services, the lowest unmet
needs were identified in the Midwest (lowest percent of unmet needs for six services) and Northeast (lowest percent of unmet
needs for three services). The highest percent of unmet needs were identified in the West (highest percent of unmet needs for
six services) and the South (highest percent of unmet needs for three services).
PUBLIC HEALTH IMPLICATIONS: Geographic differences in unmet needs may exist partly due to financial and other program
eligibility requirements for health care services. Regional differences may be due to state variations in eligibility for programs
such as Medicaid. State policy-makers in the southern and western regions should take into account the impact of
Medicaid/CHIP restrictive policies on CSHCN.
37
HOSPITAL INFLUENCES ON BREASTFEEDING PRACTICES IN TARRANT
COUNTY, 2008
Kimberly Fulda, DrPH, Anita Kurian, MBBS, DrPH, Micky Moerbe, MPH, Elizabeth Balyakina, MS, Ann Salyer-Caldwell,
MPH, RD/LD
University of North Texas Health Sciences Center, Tarrant County Public Health
BACKGROUND: The World Health Organization and American Academy of Pediatrics recommend exclusive breastfeeding to
age 6 months. Research indicates that breastfeeding helps to prevent conditions including, but not limited to, some infectious
diseases, allergies, otitis media, and childhood diabetes. It is important to understand factors that influence breastfeeding and
how to promote this behavior among women at high-risk for early breastfeeding cessation and low rates of initiation.
STUDY QUESTIONS: The purpose of this study was to identify barriers to breastfeeding among women receiving assistance
from Women, Infant, and Children (WIC) clinics in Tarrant County, TX and to identify variations in breastfeeding duration among
new mothers based on the quality of hospital breastfeeding practices experienced after giving birth.
METHODS: Cross-sectional data were collected using a 26 item survey instrument designed by Tarrant County Public Health in
Tarrant County, Texas. A purposive sample of 288 women with infants aged 6-12 months from four WIC clinics across Tarrant
County completed the survey. The outcome of interest was duration of breastfeeding. The main explanatory variable was
'breastfeeding practices' utilized by the hospital of birth. Logistic regression was performed.
RESULTS: More than one-quarter of mothers reported never breastfeeding their infant (26.7%), and slightly more than one-third
of respondents reported breastfeeding for six months or longer (34.1%). The most frequent reason given for never breastfeeding
was 'Baby did not want or could not breastfeed' (35.3%). Mothers who experienced positive hospital breastfeeding practices
were significantly more likely to breastfeed for six months or longer than mothers who did not experience positive hospital
breastfeeding practices (OR 2.7, 95% CI 1.2-6.2).
CONCLUSIONS: A low rate of continued breastfeeding for six months was observed among mothers attending WIC clinics, and
positive hospital breastfeeding practices were associated with continued breastfeeding.
PUBLIC HEALTH IMPLICATIONS: Efforts to increase breastfeeding duration among women enrolled in the WIC program
should encompass a range of strategies that include documented best-practices in the hospital setting. This is particularly the
case among women enrolled in WIC programs due to low rates of breastfeeding and the amenability of the WIC program to
tailored intervention of prenatal and postnatal services.
38
FERTILITY PREFERENCES, CONTRACEPTIVE USE AND KNOWLEDGE
AMONG MARRIED WOMEN OF REPRODUCTIVE AGE GROUP OF
BELHARA VDC
Anup Ghimire, MD, Rajan Bikram Rayamajhi, Surya Raj Niraula, PhD, Shyam Sunder Budhathoki, Resident, Paras
Kumar Pokharel, MD
B.P. Koirala Institute of Health Sciences
BACKGROUND: From the very beginning, Nepal has been a rigidly patriarchal society. In virtually every aspect of Nepalese
life, women are generally subordinate to men. So that men were always dominated over female. This is also seen in the case of
contraceptive use. Contraceptives are mostly used by females. The use of the contraceptives is also dependent on the socioeconomic status of the family and the education of the people.
STUDY QUESTIONS: Is sex preferences exits in the community? And what proportion of eligible couple using modern methods
of FP?
METHODS: The cross-sectional study was carried out among 291 married women of reproductive age group (15-49 years) in
Belhara VDC of Dhankutta District. Sample was drawn by systematic random sampling from a list provided by municipality. Face
to face interview with pretested semi-structured questionnaire was used as a tool for data collection. Data were entered in
Microsoft excel and analysis was carried out using the SPSS 17.0 version software.
RESULTS: ‘Male child Syndrome’ was found among 77% women. All most all of them seem to have knowledge about different
methods of modern contraceptives 91.7% even then only 60.14% are using Family Planning methods. Depo-Provera was found
to be the most widely used family planning method 51.50% with husband’s decision 34.60% regarding use of family planning
method being the main reason behind the practice, where 28% of respondent mentioned fair of the side effects as a reason for
not using Family Planning methods.
CONCLUSIONS: More than three fourth of the Nepalese eligible couple prefer to produce male child. Although more than 90%
couple knew at least one methods of modern FP, being a patriarchal society strong sex preference specially son preference is
exits. These situations directly indirectly affect the use of FP methods.
PUBLIC HEALTH IMPLICATIONS: Sex preference should be minimized by advocating the slogan “male child and female child
are equal”. Concerned author should focus to increase Women empowerment and female education. Use of family planning
methods among the eligible couples should be promoted extensively to reduce the family size and improve their quality of life.
39
ROLE OF MEN AND WOMEN FOR FAMILY PLANNING DECISION MAKING
IN HYDERABAD CITY, PAKISTAN
Rozeena Gillani, MBA, Sayeeda Amber Sayed, MBBS, MPH, MBA, Ayesha Aziz, MBBS
Aahung-NGO, The Aga Khan University,
BACKGROUND: Pakistan is the sixth most populous country in the world that recently surpassed 7 billion inhabitants, Pakistan
has South Asia’s highest fertility rate, at about four children per woman. Amid massive electricity shortfalls, failing schools, high
unemployment and rising Islamist militancy, the booming population is a ticking time bomb. Contraception is shunned under
traditional social mores. The bigger cultural hurdles are reported to be the inability of many women to make their own decisions.
STUDY QUESTIONS: What is the extent of involvement of husbands and wives in the decision making process of Family
Planning (FP)?
METHODS: We conducted a cross sectional survey with a total of 378 participants (who were ever married and aged 15-50
years) in Hyderabad city. Participants were recruited through multiple cluster stage sampling and interviewed through a
structured close ended questionnaire consisting of 22 items.
RESULTS: There is a huge gap between FP knowledge and practice. 70% participants knew about at least one method of FP
but only 30% participants have ever used contraceptives; among them only 18% chose contraceptive by themselves. Upon
asking the reasons of not using F.P methods, 37% participants reported the desire for male child, 35% had religious constraints
while 14% reported lack of cooperation from husbands. 56% females informed that their husbands never go with them to seek
family planning services. Moreover, 45% participants shared a misconception that usage of contraceptive pills and injection leads
to infertility.
CONCLUSIONS: Study results presents a complex picture, as the contraceptive prevalence rate has remained almost
unchanged over the last two decades. Undeniably, the knowledge regarding FP methods has increased but in the patriarchal
fabric of Pakistani society, Pakistani males need to be actively involved to ensure responsible parenthood.
PUBLIC HEALTH IMPLICATIONS: Structural changes are needed in the current national family planning programme, giving
more emphasis on broader participation of men in family planning. Men’s awareness should be raised through mass-media and
male focused Behaviour Change Communication activities need to be undertaken to motivate and inform men about the benefits
and choice of FP methods.
40
MEASURING RISK-APPROPRIATE FACILITY DELIVERIES IN A STATE
WHERE PERINATAL LEVELS OF CARE ARE SELF-DESIGNATED
Dave Goodman, MS, PhD, Arianne Weldon, Gordon Freymann, Brian Castrucci
Centers for Disease Control & Prevention (DRH), Georgia Dept. of Public Health, de Beaumont Foundation
BACKGROUND: The percentage of very low birthweight infants (<1,500g) delivered at facilities appropriate for high-risk
deliveries remains a Title V Block Grant national performance measure (NPM#17), but has been dropped by other national
efforts (Healthy People 2020 and The Joint Commission). State variation in the definitions and regulation of neonatal levels are
barriers to interpreting this measure. Needed is a measure of births occurring at risk-appropriate delivery sites that supports
comparisons within states over time and between states.
STUDY QUESTION(S): Based on neonatal mortality, can the volume of high-risk deliveries (<1,250g) in Georgia be used to
monitor the percentage of high-risk deliveries occuring at risk appropriate sites?
METHODS: The Georgia birth-infant death linked file was used to group birth facilities into deciles based on the number of
<1,250g births in 2006. Facilities were limited to those with at least six live births <1,250g. Excluded were deaths where a
congenital anomaly was the underlying cause of death. Decile-specific day 0, day 1-27, and day 0-27 mortality rates were
calculated. Natural break points in the mortality rates were identified. Using the 2002-2007 birth file, trends in the percentage of
<1,250g deliveries at low-, moderate-, and high-volume facilities were examined.
RESULTS: Among <1,250g births, two natural breaks were identified in the number of neonatal deaths, forming three
groupings: 6-14 deaths (low volume), 15-24 (moderate volume), and 25+ (high volume). The neonatal mortality rate per 100 live
births <1,250 grams was 43.9 for low-volume facilities, 29.4 for moderate-volume facilities, and 22.8 for high-volume facilities. All
self-designated level III facilities were classified as high volume, while self-designated level II facilities were distributed across
volumes. Time trends, based on the 3 volume categories, translated into different action than NPM#17 indicated.
CONCLUSIONS: High-risk delivery volume is inversely related to neonatal mortality among births <1,250g. This relationship can
be used to define facilities with low, moderate, and high volumes of high-risk neonatal deliveries.
PUBLIC HEALTH IMPLICATIONS: We present a measure for monitoring risk-appropriate delivery within a state with selfdesignated perinatal levels that may be useful for monitoring within states over time and for comparison between states.
41
AN EVALUATION OF THE EXPANDED PROGRAMME ON IMMUNISATION
IN UMGUZA DISTRICT, MATEBELELAND NORTH PROVINCE, ZIMBABWE,
2009-2011
Tafadzwa Goverwa, MBChB
University of Tanzania
BACKGROUND: Analysis of the Provincial Expanded Program on Immunisation (EPI) data showed that Umguza district has
been the worst performing in the province having not met the program targets from 2007 to 2010. The vaccine coverage for the
different vaccines have been below the global immunization target of at least 80% and the drop-out rates have been above the
recommended 10%.
STUDY QUESTION(S): What are the reasons for low vaccine coverage and high drop-out rates for the EPI program in Umguza
district?
METHODS: A Descriptive Cross-sectional study was conducted. The Logic Model Conceptual Framework was used to assess
the inputs, process, outputs and outcomes of programme. Data was collected from health workers, key informants and mothers
of children below five years using questionnaires. Focus group discussions (FGDs) were conducted with women in the
community. Checklist was used to assess EPI resource availability.
RESULTS: Twenty nine health workers and 55 mothers were interviewed and eight FGDs were conducted. Nine out of 29
health workers had been trained in EPI and less than half of them were competent in calculating the program indicators.
Outreach plans were to conduct an otreach every month but an average of four were conducted every year for the period under
review. This was due to unavailability of vehicles and fuel. Support and supervision of peripheral staff were noted to be erratic.
Twenty-three percent of the mothers indicated that their children’s vaccination status was not updated. The main barriers to
immunisation in the community reported from FGDs were religious objectors and too long distances to the health facilities.
CONCLUSIONS: Resources invested into the EPI program are inadequate. Health workers not trained in EPI coupled with
erratic support and supervision of the peripheral staff may have resulted in low proportion of health workers competent in the
program monitoring.
PUBLIC HEALTH IMPLICATIONS: The findings of this study shows that efforts to improve program performance should be
aimed at availing adequate EPI resources, training health workers, conducting regular outreaches and support and supervision
of peripheral staff.
42
OPTIMIZING HEALTH REFORM TO IMPROVE MATERNAL AND INFANT
HEALTH OUTCOMES
Piia Hanson, MSPH
Association of Maternal & Child Health Professionals
PUBLIC HEALTH AREA:
FOCUS: Preconception health
POPULATION: Women
ISSUE: While the United States has made some gains in improving infant mortality rates over the past several decades,
nationally these rates remain high and in some states, have even worsened. The Patient Protection and Affordable Care Act
(ACA) provides numerous opportunities to improve the health care delivery system and ultimately health outcomes for women,
infants and children. Research has shown that improving a woman’s health, including providing access to preconception care,
has the potential to improve reproductive health outcomes. To this end, many states are advancing initiatives to address
preconception health throughout the life course for women and girls to ultimately improve birth outcomes.
SETTING: State teams participated in various technical assistance activities to increase their capacity to develop and finance
preconception health promotion efforts and to integrate preconception health into the existing service delivery system.
PROJECT: With support from the W.K. Kellogg Foundation, the Association of Maternal & Child Health Programs (AMCHP) is
working with state maternal and child health (MCH) programs and their key partners (e.g., state Medicaid agencies, local health
department, community health centers) in selected states to increase their effectiveness and capacity to optimize implementation
of the ACA to address preconception health, adolescent health and reproductive health. These efforts include opportunities to
strengthen preconception care presented by changes to the health care service delivery system, home visitation programs, and
preventive services for women.
RESULTS: In advancing these initiatives, states are grappling with issues such as: How can quality of primary care and
postpartum visits for Medicaid-covered women be improved? How can use of evidence-based pre-and-interconception
screening assessments be encouraged in Medicaid? How are state Title V programs working with their Medicaid counterparts to
advance preconception care for women enrolled in Medicaid?
BARRIERS: While the state teams have made great gains in their efforts to optimize opportunities in the ACA to promote
preconception health, scheduling in-person meetings and state-to-state facilitated conference calls proved to be challenging as
team participants were often very busy.
LESSONS LEARNED: The Action Learning Collaborative is an effective way for state and local MCH professionals to share
lessons learned and collaborate of effective practices.
43
ASSESSMENT OF PRECONCEPTION HEALTH COUNSELING AMONG
WOMEN IN FLORIDA
Leticia Hernandez, PhD, MS, Ghasi Phillips, ScD, MS, William Sappenfield, MD, MPH, Cheryl Clark, DrPH, RHIA, Deborah
Burch, RN, MSN, CPCE
Florida Dept. of Health
BACKGROUND: Preconception health counseling (PHC) has been selected as a Florida MCH Block Grant Priority prevention
strategy and performance measure. To assess and monitor this issue, PHC was added as an optional question on the latest
PRAMS survey.
STUDY QUESTIONS: 1) Which women are receiving PHC? 2) What PHC topics are women receiving? 3) Are high risk women
more likely to receive PHC?
METHODS: Using the 2009 Florida PRAMS survey, we assessed health providers’ provision of 11 PHC topics prior to
pregnancy based on maternal recall. We also assessed maternal factors in relation to receiving any or five or more topics (5+).
Bivariate analyses were conducted to provide weighted prevalence estimates. Binomial regression was used to estimate
adjusted prevalence ratios (APR) and 95% confidence limits (CL). STATA (v.10.1) was used to account for the complex sampling
design. Only statistically significant findings are presented (P-value<0.05).
RESULTS: Thirty-one percent of 1,469 respondents received PHC. Of respondents, 6.1% received information on 5+PHC
topics. Intake of vitamins with folic acid (24.2%), alcohol consumption (21.6%), and smoking (21.1%) were the most covered
topics while the least common topics covered were getting vaccines updated (11.8%), controlling chronic medical conditions
(11.1%), and counseling or treatment for depression or anxiety (7.8%). Non-Hispanic Blacks (APR=1.5[95%CL:1.0-2.1]), women
with Medicaid (APR=1.9[95%CL:1.2-2.9]), women with previous chronic medical condition (APR=2.2[95%CL:1.6-2.9]), and
women in poverty (APR=1.6[95%CL:1.0-2.5]) were more likely to receive 5+PHC topics than non-Hispanic Whites, women with
private insurance, who had not previous chronic medical condition, or who were not in poverty, respectively. Women with
previous adverse birth outcomes were not more likely to receive PHC than women without previous adverse birth outcomes
(APR=1.2[95%CL:0.8-1.8]).
CONCLUSIONS: In 2009, less than 1 in 3 women in Florida received PHC. The frequency of topics varied from 7.8% to 24.2%
and the likelihood of receipt differed for some demographic groups. Women who had a previous adverse birth outcome were not
more likely to receive PHC than women who were not in this high risk group.
PUBLIC HEALTH IMPLICATIONS: PHC appears to be an underutilized strategy in Florida. Efforts are needed to promote its
use among providers for all women on multiple important topics.
44
THE RELATION OF AGE AND NEIGHBORHOOD INCOME TO PRETERM
BIRTH AMONG URBAN WHITE AND AFRICAN-AMERICAN WOMEN: THE
WEATHERING EFFECT OF CIGARETTE SMOKING
Shayna Hibbs, MD, Kristin M. Rankin, PhD, Richard J. David, MD, James W. Collins, Jr., MD, MPH
Lurie Children’s Hospital of Chicago, University of Illinois at Chicago
BACKGROUND: Preterm birth (< 37 weeks, PTB) rates decline with increasing age among < 36 yo White but not AfricanAmerican mothers. A weathering pattern of rising PTB rates with advancing age is absent among women with a lifelong
residence in low-income neighborhoods.
STUDY QUESTION(S): To what extent does cigarette smoking modify the relationship between age, neighborhood income, and
PTB rates among urban non-Latino White and African-American mothers?
METHODS: Stratified and multivariate regression analyses were performed on an Illinois transgenerational dataset of White
(N=31,620) and African-American (N=38,995) infants (1989-1991) and their mothers (1956-1976) with appended U.S. census
income information.
RESULTS: White mothers did not exhibit a weathering pattern of rising PTB rates regardless of smoking status and
neighborhood income. For example, teen smokers with a lifelong residence in low-income neighborhoods had a PTB rate of
18.4% compared to 8.4% for their counterparts aged 30-35 years. Interestingly, among African-American mothers with a lifetime
residence in low-income neighborhoods only non-smokers (N=20,107) exhibited an age-PTB relationship similar to Whites: PTB
rates decreased from 18.5% among teens to 15.0% for those aged 30-35 years, p <0.0001. In contrast, African-American
smokers (N=5,936) with a lifelong residence in low-income neighborhoods demonstrated a weathering phenomenon: PTB rates
increased from 17.5% for teens to 22.9% for those aged 30-35 years, p < 0.008. A weathering pattern occurred among AfricanAmerican smokers (N=756) with early-life residence in low-income areas and adulthood residence in high-income areas: PTB
rates increased from 11.1% among teens to 24.9% for those aged 30-35 years, p=0.04. A weathering pattern did not occur
among non-smokers who experienced upper economic mobility or had a lifelong residence in high-income neighborhoods.
CONCLUSIONS: Similar to the pattern observed in the majority population, PTB rates actually decline with increasing age
among African-American non-smokers with a lifelong residence in low-income neighborhoods. Most striking, PTB rates rise with
advancing age only among African-American women smokers with an early-life residence or lifelong residence in low-income
neighborhoods.
PUBLIC HEALTH IMPLICATIONS: African-American mothers’ weathering pattern of rising PTB rates with advancing age is
amenable to smoking cessation interventions particularly among impoverished teens.
45
IDENTIFYING THE MOST EFFECTIVE MESSAGING STRATEGIES FOR
AFRICAN AMERICANS TO REDUCE INFANT DEATHS RELATED TO SIDS
AND UNSAFE SLEEP PRACTICES
Angel Hopson, MSN, MPH, RN, Cinthiya Ather, Diana Liu, MPH, Diana Ramos, MD, MPH, Cynthia Harding, MPH
Los Angeles County Dept. of Public Health
BACKGROUND: Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant less than one year of age remaining
unexplained after post-mortem investigation including an autopsy, examination of the death scene and review of medical history.
Though SIDS exists in all levels of socioeconomic status, educational background and racial groups, disparities remain evident
among the African American (AA) population. AA infants in California continue to be twice as likely to die from SIDS as
White/non-Hispanic and Hispanic infants. According to the California Department of Public Health (CDPH), the three year SIDS
rate for 2005-2007 and 2006-2008 increased 104% in Los Angeles County. During this same period, the AA SIDS rates
increased from two times to almost four times the rate of White/non-Hispanic and Hispanic infants. Research shows this
persistent disparity is attributed to parental decisions to engage in unsafe infant sleep practices.
STUDY QUESTION(S): Can we identify the best messaging strategies for African American Communities to reduce Infant
Deaths related to SIDS and Unsafe Infant Sleep Practices?
METHODS: A 22 question, self-administered questionnaire, completed either online (survey monkey) or in person assessed the
preferred style, delivery mode and messenger for information and education on SIDS risk reduction and safe infant sleep.
RESULTS: 112 Los Angeles County African American men and women completed the survey., 90.2% were female; doctors,
nurses and their mothers were the most trusted source of health information; 71% would prefer culture specific messaging, via
flyers/brochures, magazines, newspaper, radio and television; 65% stated messaging by celebrities would not influence their
health behaviors. Real life stories resonate the best for them.
CONCLUSIONS: Results suggest SIDS risk reduction and safe sleep messages that are culture specific with real life SIDS and
unsafe sleep stories via flyers/brochures, magazines, newspaper, radio and television; delivered by a doctor, nurse or mother
would be the most effective among the AA community.
PUBLIC HEALTH IMPLICATIONS: Using Culture specific real life stories are the most effective means of delivering public
health messaging to the African American Community. The messaging should be delivered by a doctor, nurse or mother via
culture specific flyers/brochures, magazines, newspaper, radio and television.
46
FACILITATING DATA-DRIVEN STRATEGIC PLANNING WITH AN EARLY
LEARNING-FOCUSED COMMUNITY AGENCY
Shannon Hoskins, MPH
Clark County Public Health
BACKGROUND: Support for Early Learning and Families (SELF) is a nonprofit organization in Clark County, WA. The agency
aims to prepare young children and their parents for success in school by creating environments and systems that ensure
children enter kindergarten ready to learn. In 2011, the Board of Directors determined that they needed data to inform their
strategic planning efforts.
STUDY QUESTION(S): What are the most pressing concerns and greatest assets related to kindergarten readiness in Clark
County that can be identified by reviewing a broad set of early-learning related indicators?
METHODS: Four frameworks were used to select indicators – the Determinants of Health, the Socio-ecological Model, Life
Course Development, and a School Readiness framework. Over 80 indicators were chosen from a multitude of data sources,
including the Census, birth certificates, and early childhood programs, among others. Indicators were analyzed for trends over
time and disparities, and compared to Washington State. Many indicators had not been looked at previously in Clark County,
and this was the first time that school district boundaries were used to identify geographic disparities. Chi-square and JoinPoint
regression were used to determine statistical significance. Incomplete data availability limited statistical testing as well as
disparity and trend analysis.
RESULTS: Wages for childcare employees were low and most bachelor-degree-level early childhood education students did not
intend to enter the childcare field. Demand for low-income preschool programs far outweighed supply. A new school readiness
assessment was being piloted for Washington State kindergarteners.
CONCLUSIONS: Low child care wages compromise the field’s ability to attract and retain talent needed to provide high-quality
child care, and limited low-income preschool availability compromises already-challenged children. Finally, standardized
assessment of kindergarten readiness will provide data needed to evaluate and tailor early learning in our county.
PUBLIC HEALTH IMPLICATIONS: SELF has formed a Data Subgroup to identify indicators and stories to include in an
indicator report. In addition, these data are informing a media campaign intended to raise awareness of early learning and
support pubic policy issues such as universal preschool and increased wages for child care providers. Finally, data at the school
district level will help bridge SELF’s work with the K-12 educational system.
47
THE IMPACT OF FLUORIDE EXPOSURE ON DENTAL CARIES AMONG
SCHOOL AGE CHILDREN
Shaheen Hossain, PhD, Robert Satterfield, MS, Celsa Bowman, MS, Nan Streeter, MS, RN, Steven Steed, DDS, Michelle
Martin, RDH, MPH
Utah Dept. of Health
BACKGROUND: Several Utah communities have natural or adjusted water supplies with optimal levels of fluoride. However,
many counties still do not supply fluoridated water to its residents.
STUDY QUESTIONS: What is the association and impact of optimal fluoridation level on the mean decayed, missing or filled
tooth surfaces (dmfs/DMFS)?
METHODS: The authors used the data from Utah 2010 Oral Health Survey. The survey consisted of two separate data
collection methods: a parent questionnaire and a dental screening. Based on the data from parents, the level of fluoride
exposure was calculated using the child’s county of residence, residential history, fluoride supplementation history, age of child
when supplements were taken, primary source of drinking water, and level of fluoride concentration in city/community water
supplies. The fluoride exposure was then categorized into 4 groups: long-term exposure, some/mixed exposure, no exposure,
and unknown.
RESULTS: Twenty five randomly selected elementary schools across the state participated in the survey. A total of 3,573 parent
questionnaires were returned, for a 63% response rate. More than three thousand children received a dental screening. Close to
one-third (29.7, 95% CI 27.7% -31.7%) of children had met the criteria of long-term systemic fluoride exposure. However, 16% of
children were not exposed to optimal fluoridations. Children who were exposed to long-term fluoride, either from fluoridated water
or supplements, have an average of three fewer tooth surfaces affected by caries compared to children with no fluoride exposure
[4.5 (SE 0.3) vs. 7.8 (SE 0.6)]. Overall, majority of parents (69.7%) identified tap water as the main source of drinking water for
their child. However, the use of bottled water was significantly higher among Hispanics compared to non-Hispanics (51.0% vs.
14.6%). Usage of fluoride supplements was also significantly lower among minority children.
CONCLUSIONS: Comparison of average number of tooth surfaces with a history of decay among children with long-term
fluoride and children with no fluoride shows a significant reduction in dmfs/DMFS (42%).
PUBLIC HEALTH IMPLICATIONS: The results highlight the benefit of fluoridation in reducing caries experience. We need to
dispel the myths among certain population groups regarding the usage of tap water.
48
PLUS-SIZED WOMEN WITH PLUS-SIZED ADVERSE BIRTH OUTCOMES
Shaheen Hossain, PhD, Brenda Ralls, PhD, Robert Satterfield, MS, Laurie Baksh, MPH
Utah Dept. of Health
BACKGROUND: Public health interventions tend to focus on obesity but few interventions are directed at reducing obesity
during pregnancy. In Utah, the percentage of births among women who are obese prior to pregnancy has risen dramatically, with
the greatest increase observed for women with Class III obesity (body mass index =40). Since 2000, the percentage of pregnant
women in this class increased 75%, from 1.6% to 2.8%. Maternal obesity is not only linked to poor obstetric outcomes but to a
greater obesity risk for offspring as well. Too little is known about the characteristics of women who meet Class III criteria prior to
pregnancy and their birth outcomes.
STUDY QUESTIONS: What are the characteristics and birth outcomes of women who meet Class III obesity criteria during
pregnancy?
METHODS: Our study included 2010 Utah resident births (n=52,164). Selected maternal characteristics, including Medicaid
coverage, were examined by pre-pregnancy obesity. In order to identify mothers covered by Medicaid, Utah 2010 birth certificate
data were linked to 2010 Medicaid Eligibility data and matched on selected demographic characteristics: name, residence, date
of birth, and social security number, using deterministic probabilistic hybrid matching. Descriptive and regression analyses were
performed.
RESULTS: A significantly increased risk of adverse outcomes was observed for Medicaid mothers. Medicaid mothers had
significantly higher rates of preterm birth than their non-Medicaid counterparts (11.5% vs. 9.0%; p<.01) and low birth weight
(8.6% vs. 6.3%; p< .01). Much of this increased risk might be explained by their higher rates of Class III obesity. Medicaid
mothers had one and one-half times the prevalence of Class III obesity than their non-Medicaid counterparts (3.6% vs. 2.1%).
CONCLUSIONS: Medicaid mothers have higher rates of obesity and higher rates of poor birth outcomes.
PUBLIC HEALTH IMPLICATIONS: Approximately one-third of all Utah births are covered by Medicaid. As Medicaid mothers
have an increased risk for obesity during pregnancy, prenatal interventions that limit weight gain during pregnancy may reduce
the risk of adverse birth outcomes births and reduce costs to Medicaid.
49
MEASURING THE SUCCESS OF PRENATAL CARE SMOKING CESSATION
PRACTICES IN WEST VIRGINIA USING 2010 PRAMS DATA
Traci Hudson, MS, Author
West Virginia Dept. of Health & Human Resources (OMCFH)
BACKGROUND: According to Vital Statistic and PRAMS data, the smoking rate of pregnant West Virginia women is
approximately 30% -- nearly triple the national average. Several approaches are used for smoking cessation. However, no one
method will work for all women. Prenatal care providers are ideal routes to aggressively target pregnant women who smoke and
provide individually-tailored smoking cessation plans.
STUDY QUESTIONS: Among West Virginia women who smoke during pregnancy, what were the outcomes of the top providerrecommended smoking cessation methods? Did women stop smoking, reduce the number of cigarettes smoked or make no
changes in smoking habit?
METHODS: West Virginia PRAMS 2010 data were used. Variables include smoking habit change from before pregnancy to
pregnancy and prenatal care provider smoking cessation intervention type. SAS and SUDAAN programs were used for the
analysis.
RESULTS: Of women who smoked during pregnancy, 67.0% responded they were advised to stop smoking by their prenatal
care provider. The top smoking cessation methods were: time spent discussing how to quit (47.6%), provided books, video or
other materials (48.3%), and suggested setting a specific date to quit (29.3%). Women who indicated their provider suggested at
least one of these methods had the following smoking habit changes from 3 months before pregnancy to last 3 months of
pregnancy: 19.4% stopped smoking, 51.8% reduced smoking, and 28.6% smoked the same or more.
CONCLUSIONS: This study suggests the top smoking cessation practices used by prenatal care providers in West Virginia
were effective at encouraging women to reduce smoking during pregnancy but not to stop smoking. However, nearly a third of
pregnant women who smoked during pregnancy reported their prenatal care provider did not advise them to quit.
PUBLIC HEALTH IMPLICATIONS: In West Virginia, many efforts have been implemented to reduce smoking during
pregnancy, but little has been done to determine what efforts have had the most success. Greater effort needs to be taken to
educate prenatal care providers on the most successful tobacco cessation practices and the importance of confirming every
pregnant woman who smokes understands she must quit.
50
STRENGTHENING MCH SURVEILLANCE AMONG AMERICAN INDIAN AND
ALASKA NATIVE WOMEN IN WASHINGTON STATE
Katherine Hutchinson, PhD, MSPH, Marsha Crane, RN
Washington State Dept. of Health, American Indian Health Commission for Washington State
PUBLIC HEALTH AREA:
FOCUS: Immunization, Racial & ethnic health disparities
POPULATION: Infants, Women
ISSUE: American Indian/Alaska Native (AI/AN) women and infants experience significant disparities in maternal and child health
(MCH) outcomes. In 2010, the American Indian Health Commission for Washington State (AIHC) completed a Tribal Maternal
and Infant Health Strategic Plan to address key MCH priorities, including infant mortality and immunization access. The
Washington Pregnancy Risk Assessment Monitoring System (WA-PRAMS) has the unique ability to provide AI/AN specific data
on MCH behaviors and outcomes, including influenza vaccination coverage, which can support the Strategic Plan. However, low
response rates have limited the use of WA-PRAMS data. Strengthening Tribal partnerships with the WA-PRAMS program will
help increase access to and reliability of Washington AI/AN MCH data.
SETTING: The AIHC represents the 29 federally recognized Tribes and 2 Urban Indian Health Organizations in Washington.
These were the target populations of this project.
PROJECT: This project had three aims: 1) develop a partnership between the WA-PRAMS program and the AIHC, 2) through
the dissemination of WA-PRAMS influenza data, work to increase influenza immunizations access for AI/AN pregnant women,
and 3) increase awareness of and access to WA-PRAMS data for WA Tribes and health organizations to support program
planning for tribal MCH priorities.
RESULTS: The WA-PRAMS program successfully partnered with the AIHC and increased Tribal engagement in WA-PRAMS.
The development of the PRAMS Tribal Steering Committee brought together tribal health leaders and representatives from the
Urban Indian Health Institute, the Northwest Portland Area Indian Health Board, and DOH programs, including WA-PRAMS,
WIC, and Immunizations. With input and guidance from the Committee, we identified strategies for dissemination of data to
Tribes and other partners, and developed a joint letter of support to help increase response rates to the PRAMS survey. The
letter is included in PRAMS survey mailings to AI/AN women.
BARRIERS: Funding limited the scope of the project. Additional funding will be necessary to continue the partnerships
developed.
LESSONS LEARNED: The AIHC is a unique and valuable organization for working with WA Tribes and health organizations.
Continued partnerships with the AIHC are necessary to support access to quality data and the development of tribally-driven
programs to address AI/AN MCH priorities.
51
CHALLENGES IN CONGENITAL SYPHILIS SURVEILLANCE: HOW IS A
SURVEILLANCE CASE DEFINED?
Camille Introcaso, MD, Heather Bradley, PhD, DeAnn Gruber, MD, Hillard Weinstock, MD, Lauri Markowitz
Centers for Disease Control & prevention (Division of STD Prevention), Louisiana Office of Public Health
BACKGROUND: Congenital syphilis is a devastating consequence of sexually transmitted disease; however, it is preventable
when women are screened and appropriately managed during prenatal care. Despite the existence of a surveillance case
definition, congenital syphilis investigations are sometimes classified using an algorithm on the CDC case reporting form. This
algorithm is intended to aid in application of the case definition. However, in some cases investigations may be classified
differently by the algorithm and the case definition. This inconsistency makes interpreting surveillance data challenging.
STUDY QUESTIONS: How is congenital syphilis case status assigned using the case definition compared to the algorithm
classification system?
METHODS: We reviewed the electronic reporting system for all congenital syphilis investigations performed in State X from
January 1, 2010–October 6, 2011. We abstracted data required to classify the investigations according to the case definition and
the algorithm. We classified investigations according to both systems and noted the primary reason for classification for each
investigation.
RESULTS: There were 349 congenital syphilis investigations reviewed. Using the algorithm, 160 investigations were classified
as cases. Using the case definition, 60 investigations were classified as cases. Fifty-five investigations were classified as cases
by both systems. The most common reason an investigation was classified as a case using the algorithm was documented
inadequate maternal serologic response to treatment (49% of 160 cases). Serologic response is not a criterion for case
classification in the case definition. In 52% of 160 cases classified by the case definition and 19% of 60 cases classified by the
algorithm, no maternal treatment for syphilis was documented. In 22% of 160 cases classified by the case definition and 8% of
60 cases classified by the algorithm, maternal treatment occurred less than 30 days prior to delivery.
CONCLUSIONS: Challenges in the prevention of congenital syphilis occur in the United States. However, many more
investigations are classified as cases when the algorithm classification system is used instead of the case definition.
PUBLIC HEALTH IMPLICATIONS: Accurate and consistent case classification can improve the quality of surveillance data and
better inform congenital syphilis prevention programs. Outreach is needed to assist states with consistent application of the case
definition.
52
LOCAL MCAH SERVICE/PROGRAM DELIVERY IN TOUGH ECONOMIC
TIMES
L. Michele Issel, PhD, RN, Hale Thompson, Jessica Carda-Auten, MPH, Laura Snebold, MPH, Carolyn J. Leep, MS, MPH,
Christine Brickman Bhutta, PhD, Nathalie Robin, MPH, Arden Handler, DrPH
University of Illinois at Chicago School of Public Health, National Association of County & City Health Officials
BACKGROUND: Since the start of the recession, many local health departments (LHDs) have faced budget cuts and reduced
revenues. The financial crisis at the local level is affecting maternal, child, and adolescent health (MCAH) community-based
services, which have historically constituted a large portion of LHD programs and services. Yet, we know little of how LHDs have
restructured MCAH services and programs and what services are currently provided at the local level.
STUDY QUESTION(S): Does the availability of MCAH services/programs vary by size of jurisdiction served?
METHODS: An online survey was conducted in April-May 2012, using a sample of National Association of County and City
Health Officials (NACCHO) members stratified by size of LHD and randomly selected within strata. Of the 546 invited to
participate, 269 returned usable surveys (49%). Respondents were mostly from LHDs serving populations of fewer than 50,000
(n=137, 51%). All data were collected via a secure link to an online questionnaire designed in Qualtrics. NACCHO’s members
pilot tested the survey and defined a list of 35 MCAH services/programs. Respondents indicated whether the service/program
was provided/contracted out, provided by another agency, or not available in the community/jurisdiction. All analyses are
performed in STATA.
RESULTS: Of the 35 possible services/programs, LHDs provided zero to 34 services (mean=16.64, sd=7.44). Large LHDs
provided more services/programs (mean=19.30, sd=6.34, n=27) than medium LHDs (mean=17.42, sd=6.65, n=105) or small
LHDs (mean=15.52, sd=8.02; n=137). Ten to fifteen percent of respondents reported key services such as prenatal home visits,
prenatal care, pediatric dental care, and school-based healthcare as not available at all. Future analyses will be stratified by
governance structure and the service portfolio will be correlated with MCAH Essential Service performance.
CONCLUSIONS: This is the first comprehensive, national profile of local-level MCAH services/programs. Preliminary findings
suggest that the portfolio of MCAH services/programs varies by LHD size, with childhood immunizations, STI/HIV testing, and
lead poisoning provided regardless of size and other key programs not provided at all.
PUBLIC HEALTH IMPLICATIONS: In these stressful economic times, local MCAH programs are responding in a variety of
ways. Further research is needed to understand whether this response negatively impacts the health of women, children,
adolescents and families.
53
PRECONCEPTION DIETING AND MULTIVITAMIN USE: RESULTS FROM
MICHIGAN PRAMS, 2009
Hannah Jary, BA, Cristin Larder, MS, Sarah Lyon-Callo, MS
Michigan Dept. of Community Health
BACKGROUND: Recent research has found that maternal preconception dieting may be a risk factor for neural tube defects.
The Multivitamin Research Council has concluded that folic acid supplementation beginning before pregnancy is the most
effective method in preventing neural tube defects in children. However, little is known about the association between prepregnancy dieting and multivitamin use among women delivering a live birth.
STUDY QUESTIONS: Is preconception dieting associated with preconception multivitamin use in the Michigan PRAMS
population?
METHODS: We used 2009 PRAMS data to measure exposure (dieting to lose weight at any time during the 12 months before
pregnancy) and outcome (use of a multivitamin during the month before pregnancy). Logistic regression was used to estimate
prevalence ratios for multivitamin use among women who were dieting before pregnancy compared to those who were not
dieting. Potential confounders considered were maternal age, race, education, insurance status, marital status, parity,
pregnancy intention, BMI, number of stressors, and anemia. However, none of these had more than a 10% effect, so they were
not included in the final model.
RESULTS: About 43% of Michigan mothers delivering in 2009 used multivitamins within the month before pregnancy began.
Women who were on a diet in the year before pregnancy were 1.18 times more likely to use a multivitamin in the month before
pregnancy than those who were not on a diet [95% CI: (1.03, 1.36)]. Multinomial analysis indicated that the association was only
present at the lowest frequency of vitamin use: dieters were 65% more likely (95% CI: [1.12, 2.37]) to take multivitamins 1-3
times per week than non-dieters. Dieters were not more likely to take vitamins 4-6 times per week (PR: 0.86; 95% CI: [0.51,
1.45]) or every day (PR: 1.12; 95% CI: [0.91, 1.38]) than those not dieting before pregnancy.
CONCLUSIONS: Dieting before pregnancy was associated with increased preconception multivitamin use, but not at the
recommended daily frequency.
PUBLIC HEALTH IMPLICATIONS: These findings suggest that women of reproductive age, particularly those dieting prior to
pregnancy, may benefit from public health interventions designed to increase daily multivitamin use, in order to help prevent
neural tube defects.
54
COUNTING MATERNAL DEATHS AND UTILIZING DATA FOR ACTION:
NATIONAL MATERNAL MORTALITY SURVEILLANCE SYSTEM IN SRI
LANKA
Imbulana L.K. Jayaratne, MBBS, DCH, MD
Family Health Bureau Sri Lanka
PUBLIC HEALTH AREA:
FOCUS: Adverse perinatal outcomes, Community collaboration
POPULATION: Women
ISSUE: Counting maternal deaths (MD) in resource-poor setting is challenging when there are no quality sources of data
especially robust vital registration systems. More problematic is the utilizing information for corrective action at different levels.
These aspects are worst in South-East Asian Region from where majority of the MDs are reported.
SETTING: Sri Lanka is an industrially developing country in Indian sub-continent. In comparison with countries with similar
economic background, it has achieved relatively high levels of health and social indicators despite a Gross Domestic Product per
capita of 2399 USD and nearly 9% of population living below the standard poverty line. With a life expectancy of females 77.9
years, country is well-placed in Global Gender Gap Index rankings. Every year nearly 400000 live births, 99% in institutions, are
reported in the country. Over 5500 Public Health Midwives (PHM), 600 community medical officers, 250 health administrators,
220 Obstetricians and other curative health staff provide maternal care services. Each household in the country is designated to
a PHM.
PROJECT: Sri Lanka has a single maternal mortality surveillance system covering the entire country. It adopts a mixture of
community level investigation, facility-based review and modified clinical audit methodology based on 'no-fault finding' and
modified 3-delay concept in reviewing MDs. An effective notification system is in operation from both field and hospital to capture
all MDs. Conducting Postmortem is mandatory. Different review levels and action points are in-built in the system at field,
hospital, district and national levels with the participation of service providers and reviewing experts. Several mechanisms are
underway to translate lessons learnt at these reviews into policies and to formulate preventive strategies.
RESULTS: Sri Lanka boasts of reduction of maternal mortality ratio (31 per 100000 live births)in 2010, in par with industriallydeveloped countries, with a history of an estimated MMR 2495 in 1915, largely contributed by maternal mortality review process.
Country has already achieved millennium developmental goals.
BARRIERS: Lack of legal immunity; Negative platform; Professional issues; Data gaps; Issues with data linkage; and Interdistrict disparity.
LESSONS LEARNED: If commitment of all stakeholders are there, counting MDs and utilizing data for improving maternal care
service delivery is not a challenge.
55
DELIVERIES WITH COMPLICATIONS AND MATERNAL RISK FACTORS IN
NEW YORK STATE
Marilyn Kacica, MD, MPH, Richard Schaeffer, MS, Trang Nguyen, MD, DrPH, MPH
New York State Dept. of Health
BACKGROUND: Birth is the leading cause of hospitalization for women of childbearing age. In New York State (NYS), there
are approximately 250,000 births per year. Of these, three quarters result in normal deliveries without complications while the
rest suffer a complication. It is important to characterize what these complications are and identify women with higher risk of
these complications as we develop prevention initiatives to improve perinatal outcomes.
STUDY QUESTIONS: What are maternal risk factors and complications associated with deliveries in NYS?
METHODS: Hospital discharge and birth data between 2006 and 2009 were merged and analyzed to characterize complicating
conditions (CC) associated with deliveries. Deliveries with CCs were identified using diagnosis related group (DRG)
classification. Distribution for specific CCs was examined separately for vaginal and Cesarean deliveries based on primary and
secondary diagnoses. Length of stay (LOS) and associated conditions were calculated for deliveries with and without CC.
Mothers' risk factors were analyzed to identify association with deliveries with CCs. Analysis was conducted using SAS v9.2.
RESULTS: Analysis included 949,260 deliveries from 2006-2009. Deliveries included: vaginal 66% and Cesarean 44%. Of the
total, 26% had CCs (vaginal 17.5% and Cesarean 8.3%). Among vaginal deliveries, 26% had CCs compared to 23% of
Cesareans and 37% of high risk (HR) Cesarean deliveries. Median LOS for Cesareans and HR Cesareans with CC was 2 and
2.5 times that of vaginal deliveries. Infection related diagnoses were an important facet of CCs and LOS. Significant risk factors
for deliveries with CCs included mothers who were black compared to white mothers (RR=1.34), alcohol use (RR=1.2), tobacco
(RR=1.1), diabetes (RR=7.2), gestational diabetes (RR=3.4), hypertension (RR=3.8), and previous preterm infant (RR=1.3).
CONCLUSIONS: Deliveries with CCs are a major health concern representing one quarter of all deliveries. These CCs resulted
in longer hospital LOS. Indentified maternal risk factors include alcohol and tobacco use, hypertension, diabetes, previous
preterm infant, and pregnancy associated infections. Black mothers are also at higher risk for these CCs.
PUBLIC HEALTH IMPLICATIONS: More detailed information about risk factors for deliveries with CCs will guide prevention
strategies, reduce health care costs and improve mother, infant and family quality of life.
56
A TALE OF TWO MCH SURVEILLANCE SYSTEMS: IOWA PRENATAL
CARE SURVEY AND THE PREGNANCY RISK ASSESSMENT MONITORING
SYSTEM (PRAMS)
Debra J. Kane, PhD, Sarah Mauch, MPH, Stephanie Trusty, BSN
Iowa Dept. of Public Health
PUBLIC HEALTH AREA:
FOCUS: Pregancy Risk
POPULATION: Women
ISSUE: The Iowa Department of Public Health (IDPH) has two surveillance systems to monitor maternal health outcomes. The
Iowa Prenatal Care Survey, known as the Barriers project, has been used to collect data since 1991. Iowa will begin PRAMS
data collection in September 2012. In today’s environment of shrinking resources, what is the value to the IDPH in retaining both
surveillance systems?
SETTING: The Barriers questionnaire is distributed to women at all Iowa birthing hospitals (n=78) after the birth of their infant.
Women complete the questionnaire in the hospital and return it to maternity staff before discharge. The PRAMS questionnaire is
mailed to a sample of women between two and six months after their baby’s birth, with telephone follow-up to encourage
completion of the questionnaire. Both questionnaires can be linked to the birth certificate and each other.
PROJECT: IDPH staff conducted a content analysis of the Barriers and PRAMS surveys to assess the questionnaires’
uniqueness and overlap, and the ability to use resulting data to compare maternal intention with postpartum behaviors if both
questionnaires were implemented. Using the PRAMS sampling protocol, the IDPH drew a mock PRAMS sample from 2011 birth
certificates to assess the proportion of women who would be likely to complete both questionnaires.
RESULTS: IDPH staff conducted a content analysis of the Barriers and PRAMS surveys to assess the questionnaires’
uniqueness and overlap, and the ability to use resulting data to compare maternal intention with postpartum behaviors if both
questionnaires were implemented. Using the PRAMS sampling protocol, the IDPH drew a mock PRAMS sample from 2011 birth
certificates to assess the proportion of women who would be likely to complete both questionnaires.
BARRIERS: After completing a Barriers questionnaire, women invited to complete a PRAMS questionnaire may experience
survey fatigue, leading to a lower PRAMS response rate among these women. We will examine response rates among women
selected to participate in PRAMS who have previously completed a Barriers survey.
LESSONS LEARNED: Through an examination of each dataset, we avoided “either/or” thinking, recognized Barriers and
PRAMS to be complementary data sources, and in a climate of shrinking resources, have built a strong case to retain both
surveillance systems.
57
POTENTIAL NUTRITIONAL RISK FACTORS FOR DEVELOPING
GESTATIONAL HYPERTENSION AMONG IRANIAN WOMEN
Elham Kazemian, MS, Ahmadreza Dorosti, Gity Sotoudeh,
Tehran University of Medical Sciences
BACKGROUND: Pregnancy induced hypertension is one of the most dangerous disorders, which affects child’s and mother’s
morbidity and mortality .It has been proposed that nutrition may be involved in etiology of pregnancy induced hypertension.
Altogether, a few studies provide a clear view about the effect of nutrient determinants on hypertensive disorders of pregnancy
STUDY QUESTIONS: The aim of our observational study was to compare intakes of energy, macro and micro nutrients of
women who developed gestational hypertension with healthy pregnant women.
METHODS: Current research was a case-control study accomplished on 113 women with gestational hypertension and 150
healthy pregnant women referring to Shahid Akbarabadi Hospital of obstetrics and gynecology located in south of Tehran. All
subjects were interviewed for demographic information and dietary intakes of participants were assessed by Validated Semiquantitative food frequency. Residual model was used to adjust nutrients for energy intake and Logistic regression was utilized to
find the association of energy and nutrients intakes with gestational hypertension. One limitation should be mentioned is a casecontrol design of this study which cause and effect relationship is not clear.
RESULTS: We did not find any significant association between Protein, carbohydrate, total fat, saturated fatty acids, Vitamin A,
Vitamin D, vitamin E, Vitamin K, calcium, iron, zinc, copper, selenium and manganese intake and risk of gestational
hypertension. Intakes of Energy (OR, 1.38; 95% CI: 1.19-1.59), Mono unsaturated fatty acids (OR, 1.35; 95% CI: 1.06-1.71) and
Poly unsaturated fatty acids (OR, 1.28; 95% CI: 1.00-1.64) showed a significant positive association with developing gestational
hypertension. In addition, results of present investigation revealed a somewhat lower risk of gestational hypertension with higher
intakes of vitamin C (OR, 0.88; 95% CI: 0.82-0.94), potassium (OR, 0.45; 95% CI: 0.29-0.71) and magnesium (OR, 0.64; 95%
CI: 0.49-0.84).
CONCLUSIONS: Present study demonstrates higher intakes of energy, mono unsaturated fatty acids and poly unsaturated fatty
acids and lower intakes of vitamin C, potassium and magnesium as possible risk factors for developing gestational hypertension.
PUBLIC HEALTH IMPLICATIONS: We believe that our findings could be of interest to public health science since there are a
few modifiable risk factors for hypertensive
58
MATERNAL PERICONCEPTIONAL OCCUPATIONAL EXPOSURE TO
PESTICIDES AND SELECTED MUSCULOSKELETAL BIRTH DEFECTS
Christine Kielb, MS, Shao Lin, PhD, Michele Herdt-Losavio, PhD, Erin Bell, PhD, Bonnie Chapman, MPH, Carissa
Rocheleau, PhD, Christine Lawson, PhD, Martha Waters, PhD, Patricia Stewart, PhD, Richard Olney, MD, MPH, Paul
Romitti, PhD, Yanyan Cao, PhD, Charlotte Druschel, MD, MPH
New York State Dept. of Health, University at Albany School of Public Health, Upstate Medical University, Centers for Disease
Control & Prevention (NIOSH & NCBDDD), University of Iowa
BACKGROUND: Pesticides are commonly encountered compounds containing chemicals with the potential to impact fetal
development. This population-based study investigated the association between selected major musculoskeletal malformations
and periconceptional maternal work in jobs with potential pesticide exposure.
STUDY QUESTIONS: Are infants of mothers occupationally exposed to pesticides during the periconceptional period more likely
to be born with craniosynostosis, gastroschisis, diaphragmatic hernia, or transverse limb deficiencies than infants of mothers not
occupationally exposed?
METHODS: We conducted a multi-site case-control study using data from the National Birth Defects Prevention Study among
women with due dates or infant birth dates from October 1997 through December 2002. Cases included 871 live-born, stillborn,
or electively terminated fetuses with isolated craniosynostosis, gastroschisis, diaphragmatic hernia, or transverse limb
deficiencies. Controls included 2,857 live-born infants without major malformations. Using self-reported maternal occupational
information, an industrial hygienist used a job-exposure matrix and expert opinion to evaluate each job held between one month
pre-conception and three months post-conception for exposure potential to insecticides, herbicides and fungicides. Exposure
groupings analyzed included ever worked in job with potential exposure to any pesticide, to insecticides only, to both insecticides
and herbicides (I+H), and combined exposure to insecticides, herbicides and fungicides (I+H+F). We used logistic regression to
evaluate the association between exposures and defects, controlling for infant and maternal risk factors.
RESULTS: Occupations most frequently evaluated as involving exposure to pesticides included those in education/training, food
preparation and service, and sales. Occupational exposure to I+H+F was associated with gastroschisis among infants of women
aged 20 years or older (adjusted odds ratio [aOR] = 1.88; 95% confidence interval [CI]: 1.16-3.05), but not for women under age
20 (aOR=0.48; 95% CI: 0.20-1.16). We found no significant associations for the other defects.
CONCLUSIONS: Joint exposure to I+H+F was associated with gastroschisis in infants of mothers age 20 and older, but not in
those under age 20. Future research will evaluate more detailed exposure metrics, including cumulative exposure, exposure
frequency, and exposure intensity.
PUBLIC HEALTH IMPLICATIONS: Maternal occupational pesticide exposure may be a potential contributor to gastroschisis, a
serious birth defect that is increasing in prevalence.
59
THE BURDEN OF CHRONIC CONDITIONS DURING PREGNANCY AMONG
LOUISIANA MEDICAID-ENROLLED WOMEN
Lyn Kieltyka, MPH, PhD
Centers for Disease Control & Prevention
BACKGROUND: Despite 85% of Louisiana Medicaid-enrolled women receiving adequate prenatal care, the 2009 Louisiana
infant mortality rate was 10.1 per 1,000 births.
STUDY QUESTIONS: What is the prevalence of hypertension and diabetes during pregnancy among Louisiana Medicaidenrolled women based on birth certificate, Pregnancy Risk Assessment Monitoring System (PRAMS), and combined sources
(CS)?
METHODS: Louisiana linked 2009 PRAMS-birth certificate data, including a Medicaid-paid delivery flag from the Medicaid
claims data, were analyzed. The prevalence of chronic and pregnancy-associated hypertension and diabetes among Medicaidenrolled women experiencing a live birth were calculated using CS. Capture-recapture methods were used to estimate the CS
prevalence and 95% confidence intervals (95% CI). The 2009 PRAMS response rate was 53%, but sensitivity analysis suggests
any non-responder bias was insufficient to alter conclusions. The primary limitations are differences in question wording and
reporting sources between birth certificate and PRAMS data.
RESULTS: Forty-nine percent of the study sample were black and 45% were white; 72% were high school graduates; 61% were
20-29 years old; and 72% were unmarried. Birth certificate prevalence was 5.2% for hypertension and 2.0% for diabetes.
PRAMS prevalence estimates were 17.2% for hypertension and 12.2% for diabetes. Results of capture-recapture methods
indicated the CS prevalence of hypertension was 23.6% (95% CI: 23.0, 24.1); diabetes CS prevalence was 13.9% (95% CI: 13.6,
14.2). Completeness of birth certificate reporting was 22.0% (95% CI: 21.5, 22.5) for hypertension and 14.7% (95% CI: 14.3,
15.0) for diabetes. Completeness of PRAMS reporting was 72.8% (95% CI: 71.2, 74.5) for hypertension and 87.7% (95% CI:
85.8, 89.7) for diabetes.
CONCLUSIONS: Both birth certificate and PRAMS data may have underestimated the burden of chronic disease among
Medicaid-enrolled women in Louisiana. The birth certificate data severely underestimated both conditions in comparison to
PRAMS.
PUBLIC HEALTH IMPLICATIONS: Life course methods recognize the need to shift from prenatal care to life-long preventive
care for promoting optimal birth outcomes. As this paradigm shift occurs, it is increasingly important to accurately capture chronic
conditions to effectively guide interventions and allocate resources. Improvement of existing data and novel data sources, such
as electronic health records, can help monitor chronic health conditions.
60
DOES ALCOHOL CONSUMPTION INTERACT WITH DEPRESSION IN THE
RESOLUTION OF INTIMATE PARTNER VIOLENCE DURING PREGNANCY?
Michele Kiely, DrPH, Ayman El-Mohandes, MBBCh, MD, MPH, Harlan Sayles, MS, Jane Meza, PhD, Marie Gantz, PhD
National Institutes of Health (NICHD), University of Nebraska Medical Center College of Public Health, RTI International
BACKGROUND: Exposure to intimate partner violence (IPV) is associated with a range of negative psycho-behavioral risks and
increased risk of poor physical health, physical disability, psychological distress, mental illness, heightened substance use
including alcohol and illicit drugs, and with depression.
STUDY QUESTIONS: Does alcohol consumption interact with depression in the resolution of intimate partner violence during
pregnancy?
METHODS: We conducted a randomized controlled trial in which 1,044 African-American women were recruited at six prenatal
care sites in Washington, DC and followed through pregnancy. Women were randomized to individually-tailored counseling
sessions to address IPV and other risks or to usual care. Women were interviewed at baseline, in the second and third trimester
and in the postpartum period. Logistic regression was used to model IPV victimization recurrence.The study was powered for
risk resolution rather than the efficacy of the intervention with respect to adverse pregnancy outcomes. Women in the study
were only modestly invested in participating in the intervention. The mothers in this study had many behavioral challenges, such
as alcohol and drug use that were not addressed by the intervention.
RESULTS: Women reporting continued IPV during pregnancy or postpartum (n=94) were significantly different from those who
reported no further episodes of IPV (n=212) beyond baseline with respect to care group (p=0.006), gestational age at baseline
(p=0.035), alcohol use during pregnancy (p=0.014) and depression at baseline (p=0.009).Controlling for these four variables in
the logistic regression, only care group, alcohol use and depression were significant in the reduced model. Logistic regression
results for continued IPV at all interviews during pregnancy and postpartum (n=94) showed that women in the intervention were
less likely to have recurrent episodes of IPV (AOR=0.48, 95% CI=0.29-0.80). No interaction was found between alcohol use
during pregnancy measured at baseline and depression in resolution of IPV.
CONCLUSIONS: This study evaluated efficacy of a psycho-behavioral intervention during prenatal and postpartum care on the
reduction of IPV recurrence in African-American mothers reporting IPV.
PUBLIC HEALTH IMPLICATIONS: The findings of this analysis confirm the importance of emphasizing a more global approach
towards risk assessment and service provision to high risk African-American mothers.
61
LIFE SKILLS FOR WOMEN: SAVING FOR THE FUTURE AND BEYOND
Andrea L. Kimple, BS, Thelma Jackson, MS
Healthy Start Inc.
PUBLIC HEALTH AREA:
FOCUS: Life course perspective, Obesity
POPULATION: Women, Families
ISSUE: Life skills are often taught by observation and are learned as children. However, when traditional family structure and
healthy relationships have broken down, the most basic life skills are often lost. In 2010 the Healthy Start Multi-Disciplinary
Team, recognized the need to enhance services to Participants and introduced a series of Life Skills Focus Groups. The goal
became to empower Participants with the knowledge and skills in everyday life.
SETTING: The Life Skills Focus Groups were divided in to two 6-week tracks, presented at the Healthy Start office. The
intended audience were program Participants identified by the Healthy Start Multi-Disciplinary Team.
PROJECT: The first track focused on home maintenance and economic stability. Classes such as housekeeping and
organization; laundry tips and tricks; budgeting; professional resume writing and dress for success were the focus. The second
track focused primarily on nutrition. Classes such as meal planning; food safety and eating smart on the run were the focus.
RESULTS: Participants were armed with the tools to enrich their lives and the lives of their children. This program will be
incorporated into the Healthy Start model for all Participants of Healthy Start to receive.
BARRIERS: Specific barriers were childcare costs; budgeting; identifying a want versus a need; living within their means; and
eating healthy on a budget. Participants overcame these barriers through the tools and lessons learned through each focus
group.
LESSONS LEARNED: Participants discovered areas where improvement was needed; goals were established; and information
amongst each other was shared.
62
HEALTH INDICATORS AMONG WOMEN BEFORE PREGNANCY—TEXAS,
2002–2010
Rochelle Kingsley, MPH, Noha Farag, MD, PhD, Mark Canfield, PhD, Rebecca Martin, PhD, Diana Bensyl, PhD, Amy Case,
MAHS
Texas Dept. of State Health Services, Centers for Disease Control & Prevention
BACKGROUND: Despite substantial improvements in women’s health care during pregnancy, the incidence of adverse
pregnancy outcomes is higher in the U.S. compared with most developed countries. The first few weeks after conception are the
most critical for fetal development, but most women are not aware they are pregnant until after this period. Therefore, the CDC
and others have called for addressing preconception health, and beginning interventions before conception.
STUDY QUESTIONS: What is the preconception health status of women in Texas?
METHODS: Data for 15,386 mothers from the Texas Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed
for 2002–2010. Preconception health indicators included physical inactivity, weight status, diabetes, hypertension, anemia, and
multivitamin, alcohol, and tobacco use. Differences in preconception health indicators by demographic variables (race, age, and
education), pre-pregnancy insurance status, Medicaid payment for delivery, and pregnancy intention were evaluated using
weighted prevalence estimates and crude prevalence ratios and multivariate logistic regression models were used to adjust for
these variables.
RESULTS: Overall, 48% of women were uninsured before pregnancy, and 46% reported an unintended pregnancy. Compared
with white women, black and Hispanic women had 50% and 30% higher prevalence, respectively, of obesity, and 20% higher
prevalence of being overweight and not consuming a daily multivitamin. Compared with white women, black women had three
times the prevalence of hypertension and anemia, and twice the prevalence of diabetes. These differences remained significant
in adjusted models. The prevalence of several unfavorable indicators was high even among insured women with an intended
pregnancy (smoking=13%, binge drinking=18%, and obesity=20%).
CONCLUSIONS: Women in Texas reported unfavorable levels of preconception health indicators that are traditionally
associated with adverse birth outcomes.
PUBLIC HEALTH IMPLICATIONS: Despite the presence of recommendations and practice guidelines for preconception care,
the preconception health status of women in Texas is suboptimal with several documented disparities. Targeted interventions
addressing the observed disparities in preconception health and health care of women in Texas are needed. The prevalence of
unfavorable indicators among insured women with an intended pregnancy suggests that education messages targeting both the
health care providers and women in their reproductive years are needed.
63
USING THE THREE DELAYS MODEL TO UNDERSTAND MATERNAL
MORTALITY IN TANZANIA: AN ANALYSIS OF MATERNAL DEATH
NOTIFICATION AND CASE REVIEW SURVEILLANCE DATA 2010
Rogath Kishimba, MSc, MD, Janneth Mghamba, Rose Mpembeni, Mohamed Mohamed, Azma Simba, Zubeda Ngware,
Senga Sembuche, Peter Mmbugi
Tanzania Field Epidemiology & Laboratory Training Program, Muhimbili University of Health & Allied Sciences
BACKGROUND: Globally, maternal mortality has persisted as a major public health problem. In Tanzania, the maternal
mortality ratio is estimated at 474 per100, 000 live births, which is far from the fifth Millennium Development Goal. Maternal
mortality can be reduced by addressing the three delays model. This study examined how the three delays model addresses
maternal mortality Tanzania.
STUDY QUESTIONS: How do factors contributing to maternal mortality in Tanzania distribute among the three delay types?
METHODS: We reviewed all maternal deaths notification forms received for the year 2010. We examined factors associated
with maternal deaths, including maternal socio-demographic factors and medical history. The first delay type was defined as a
failure of the deceased to recognize pregnancy complications by herself or by family members or community; including sociocultural barriers for seeking health care. The second delay type was defined as a physical inaccessibility to health care. The third
delay type was defined as inadequate emergency maternal care.
RESULTS: In 2010, 215 maternal deaths were reported. Delay as a whole was associated with 177 (82.3%) of all maternal
deaths. Delay in receiving care at health facilities had the highest proportion 82(46.3%, N=177), followed by delay in seeking
care 75(42.4%) and delay due to physical inaccessibility 20(11.3%). Majority 172(80%) of health workers who attended the
deceased reported these deaths could be avoided.
CONCLUSIONS: The majority of maternal deaths were attributed to delays and were preventable.
PUBLIC HEALTH IMPLICATIONS: Our analysis suggests that by improving the quality of emergency obstetric care and access
to skilled personnel and materials maternal deaths could be prevented. Introducing maternity waiting homes for pregnant women
may help reduce maternal mortality in Tanzania.
64
ALCOHOL USE DURING PREGNANCY: EXAMINATION OF RISK FROM A
LIFE COURSE PERSPECTIVE
Panagiota Kitsantas, PhD, Kathleen Gaffney, PhD
George Mason University, George Mason School of Nursing
BACKGROUND: A Healthy People 2020 objective is to decrease the number of US babies born with fetal alcohol spectrum
disorders (FASD) by increasing alcohol abstinence during pregnancy to 98.3%. Despite public health initiatives targeting the
harmful effects of alcohol exposure on fetal growth, 12% of pregnant women report current alcohol use.
STUDY QUESTIONS: What life course factors predict risk for alcohol use during pregnancy?
METHODS: We used 2000-2008 PRAMS data (362,752 records of women residing in 37 US states) to examine life course
factors that may predict the risk of prenatal alcohol use. Based on the Life Course Health Development Model, we selected
demographic characteristics, health status, health behaviors, and psychosocial factors as potential risk factors. Logistic
regression models were built by weighing the data to account for the complex PRAMS design. A limitation of this approach is that
PRAMS data are self-reported and thereby subject to a potential social desirability response bias. Further, findings can be
generalized only to women who delivered a live-born infant as the PRAMS data does not include women who experienced a
stillbirth.
RESULTS: We found that 49.4% of the women drank alcohol during the 3 months prior to pregnancy. Of those who drank
before pregnancy, 87% quit drinking during pregnancy and 13% reduced/drank the same or more/or resumed drinking during the
last 3 months of pregnancy. Black and Hispanic mothers were more likely to consume alcohol during pregnancy than white
mothers. An increased risk of drinking alcohol during the last 3 months of pregnancy was associated with the following life course
factors: higher education, greater parity, experiencing health problems during pregnancy, smoking, experiencing abuse during
pregnancy, being homeless, and having relatives who used illegal drugs.
CONCLUSIONS: Cumulative life course factors, including stressful events occurring during the sensitive prenatal period,
predicted alcohol use during late pregnancy.
PUBLIC HEALTH IMPLICATIONS: The Life Course Health Development Model provides a useful framework for identifying the
constellation of risk factors that contribute to prenatal alcohol use and for designing targeted interventions to reduce the
incidence of FASD and meet the Healthy People 2020 objective for alcohol abstinence during pregnancy.
65
POSTPARTUM CHECK-UPS: INCREASING THE RATE
Marlene Kolosky, BS, Joanne White, MSW, Barbara Duda, MS, LaShawn Tipton, BA,
Healthy Start, Inc.
PUBLIC HEALTH AREA:
FOCUS: Reproductive health, Family planning
POPULATION: Women
ISSUE: The low number of mothers returning to their doctors for a postpartum check-up. The baseline numbers showed that
only 20 out of 56, or 36%, of our participants returned for their postpartum check-up. The initiative was to explore the participants'
reasons for not attending the six-wk. postpartum check-up and try to change the behavior.
SETTING: The initiative took place at a Healthy Start project based in Fayette County, SW Pennsylvania. The target population
included pregnant and postpartum women with average age of 18-26 years, low socioeconomic status, low health literacy, and
limited social support.
PROJECT: Held staff meeting to discern participants' reasoning for not attending postpartum appointments, and ask staff what
they thought might help the participants see the value in attending their check-ups. Interviewed local OB/GYN’s to learn patient
education they provide during OB visits, and follow up after delivery. Developed decision-making tool, the 6-week Check-up
Survey, and taught staff how to use the survey. Compared baseline data to data received after implementation of intervention.
RESULTS: Data showed postpartum check-ups increased from 36% to 70%. Relationships with local Ob/Gyn's was enhanced.
Staff was trained in use of new tool to improve interconceptional care.
BARRIERS: Overcame the health literacy barrier by explaining that the postpartum check-up and 6 week check-up are one in
the same. Increased participant awareness of the importance of postpartum care. Implemented reminder cards and phone calls
to assist new moms with scheduling and attending the visit.
LESSONS LEARNED: In order to have participants understand that an issue is important our interventions must demonstrate
that. Focusing time and activities on understanding the reasoning behind and barriers to obtaining a postpartum check-up results
in better interconceptional health.
66
FOLLOW-UP STUDY FOR CHILDREN WHO PARTICIPATED IN THE INFANT
FEEDING PRACTICES STUDY II
Ruowei Li, MD, PhD, Sara Fein, Laurence Grummer-Strawn
Centers for Disease Control & Prevention (DNPAO), U.S. Food & Drug Administration
BACKGROUND: The Infant Feeding Practices Study II (IFPS II), a national study by FDA and CDC from 2005-2007, collected
data on ~3000 mother-infant pairs by almost monthly mail questionnaires from late pregnancy until 12 months postpartum. The
purpose of the IFPS II follow-up study is to determine the association of infant feeding practices of these infants with health
outcomes at age six.
STUDY QUESTION(S): To describe the development of the IFPS II follow-up study.
METHODS: Mothers enrolled in the IFPS II are now being re-contacted by mail since March 2012 to collect in-depth information
on diet and behavioral, developmental, and health outcomes. Information collected for children included anthropometry, dietary
practices, child behavior, psychosocial and physical development, acute and chronic health outcomes, such as asthma, food
allergy, oral health, and potential confounders: demographics, mothers’ feeding styles, food environment, physical activity,
screen time, and sleep patterns. Information about mothers included physical activity, anthropometry, depression, pregnancy and
family history, employment, and health insurance. Pilot surveys were administered to mothers of six-year-olds to test feasibility of
survey administration and instrument (n=133).
RESULTS: Of 2,958 mothers eligible for re-contact for the follow-up study, current addresses were found so far for 2,747 (93%).
Responses from 133 mothers in pilot surveys indicated the instrument easy to complete and high prevalence of various illness in
previous year (colds/upper respiratory 54%, ear infections 21%, strep throat 19%). Prevalence of physician diagnosed
respiratory allergies was 23%, skin allergies 17%, and drug allergies 3%. Mothers expressed attitudes toward child feeding
indicative of controlling behaviors, e.g. “I make sure that my child does not eat too many sweets or junk foods” (50%), and “I am
especially careful to make sure my child eats enough” (38%).
CONCLUSIONS: We demonstrated that re-contacting mothers who were interviewed 6 years earlier is feasible and questions
developed for follow-up study were well accepted and easily completed. The data will be completed and released to the public in
late 2013.
PUBLIC HEALTH IMPLICATIONS: IFPS II follow-up study is the largest longitudinal study in the US to examine long-term
consequences of infant feeding and identify modifiable risk factors for unhealthy behaviors and their impact.
67
GESTATIONAL DIABETES: CONTINUITY OF CARE FROM PREGNANCY TO
POSTPARTUM – AN EXPLORATORY QUALITATIVE STUDY
Emily Lu, MPH, Hafsatou Diop, MD, MPH, Patricia Daly, MS, RN, Hannah Oakley, MPH
Massachusetts Dept. of Public Health
BACKGROUND: Women with gestational diabetes mellitus (GDM) are at greater risks for pregnancy complications. While GDM
may resolve after birth, it is associated with an increased risk for future type 2 diabetes. Generally, women with GDM are closely
monitored and managed by their providers during pregnancy; however, less is known regarding their care after pregnancy.
STUDY QUESTIONS: Among women with GDM, what were the concerns and barriers to care related to GDM during pregnancy
and the postpartum period?
METHODS: We analyzed combined data from the Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS)
and a retrospective one-year follow-up study for women with GDM who had delivered a live birth between August 2008 and
December 2010 (n = 50; response rate, 24%). The follow-up survey was conducted by telephone only, which could potentially
explain the low response rate. We examined the survey results by frequency and major themes.
RESULTS: Respondents are more likely to be college-educated, less likely to receive Medicaid, and less likely to be Black nonHispanic than non-respondents. Over 96% of women with GDM saw a nutritionist, dietitian, or diabetes educator. Women
reported needing more information on ways to tailor nutritional and dietary advice to their cultural and racial background and
wanting to know more about the causes and future risks of GDM. Approximately 40% of women were told about risks of GDM in
future pregnancies. Although 92% reported having a postpartum check-up, only 56% reported that they were screened for
diabetes postpartum. About 4% of those were diagnosed with chronic diabetes. Barriers to postpartum diabetes testing included
lack of time, having other competing priorities, provider or insurance issues, and lack of awareness about the importance of
screening and long-term risks of developing type 2 diabetes.
CONCLUSIONS: Women with GDM identified areas for improvement including ways to tailor advice received, knowledge of
future risks, and barriers to follow-up care after delivery.
PUBLIC HEALTH IMPLICATIONS: Patient education is important to supporting lifestyle changes, which are key to delaying or
preventing future GDM and type 2 diabetes. Women should be monitored after pregnancy through regular screenings. PRAMS
states might consider adding a postpartum diabetes-screening question.
68
COMMUNITY-LEVEL BI-NATIONAL PLANNING TO ADDRESS HIGH TEEN
BIRTH RATES
Adriana C. Luevanos, MBA, Katharine Perez-Lockett, MPH, Michelle Fournier, MPH, Janet Flores, DrPH, MPH, Alejandro
Alvarado Robles, MD, Federico Alberto Castro Lopez, MD, Elisa Aguilar, MD
Texas Dept. of State Health Services, New Mexico Dept. of Health, City of El Paso Dept. of Public Health, Servicios de Salud de
Chihuahua, U.S.-Mexico Border Health Commission
PUBLIC HEALTH AREA:
FOCUS: Reproductive health, Family planning
POPULATION: Adolescents, Women
ISSUE: Teen birth rates are high in contiguous Paso del Norte (PDN) communities along the US-Mexico border, ranging from
38% to 88% over respective national rates. Reducing teen births is a goal in these communities, yet progress is slow and
collaborative approaches to the problem have not been explored.
SETTING: The PDN corridor includes Doña Ana County, NM; El Paso County, TX; and Ciudad Juarez in Chihuahua, Mexico.
The population is 2.5 million, largely Hispanic and lacking maternal and child health (MCH) resources. In 2009, MCH was not
represented among the committees on the PDN Binational Health Council (BHC).
PROJECT: In 2009, program leads from local and state health agencies in each community took advantage of an opportunity to
build binational MCH capacity and teamed up to address the problem of teen birth in PDN communities. Team objectives were to
highlight the problem, establish baseline profiles for adolescent sexual risk behaviors, and use the information to leverage
resources and inform PDN and community-based intervention efforts.
RESULTS: The team has met regularly since 2009. In 2010 it successfully lobbied to add the sexual risk behavior measures
used in school-based surveys in TX (YRBS) and NM (YRSS) to a similar survey in Ciudad Juarez. In 2011, the team became an
official MCH committee on the PDN BHC. It now uses committee funding to support local university assistance for data analysis
and is developing risk behavior profiles from the combined Mexican survey, YRBS and YRSS data.
BARRIERS: Different survey methods and public health policies in the three communities limit the comparability and
representativeness of survey data. Health department budget cuts and competing priorities make it difficult for team members to
clear time for collaborative activities and continuing violence in Mexico restricts ease of travel.
LESSONS LEARNED: Motivated by similar MCH goals, it is possible for local public health agencies to work across state and
international boundaries. Results of such collaboration provide inspiration for future binational teen pregnancy prevention efforts
through strengthening relationships among binational public health professionals, demonstrating the usefulness of local data,
and maximizing the limited resources available for binational research.
69
FACTORS AFFECTING UPTAKE OF MEASLES VACCINATION SERVICES
IN TEMEKE DISTRICT, DAR ES SALAAM, 2012
Joyce Lyimo, MSc, DDS, Janneth Mghamba, Innocent Semali
Tanzania Field Epidemiology & Laboratory Training Program, Muhimbili University of Health & Allied Sciences
BACKGROUND: Measles outbreaks have been recurring in Tanzania despite ongoing efforts. In May 2011, an outbreak of
Measles occurred in Temeke district, Dar es Salaam affecting 588 people. In this outbreak a large proportion of under five cases
who had measles had not received neither routine nor supplementary measles vaccination despite existence of a supplementary
immunization campaign which was done in 2010 targeting children below five years. Tanzania is in the measles elimination
phase and understanding community determinants of measles vaccination uptake is important to improve service delivery.
STUDY QUESTION(S): What factors are associated with uptake of both routine and supplementary measles vaccination
services among children aged 12-23 months in this district?
METHODS: A cross-sectional survey was conducted to assess uptake of routine and supplementary measles vaccination
services and their determinants among children aged 12-23 months. Bivariate and multivariate analysis was performed using
EpiInfo.
RESULTS: A total of 295 children (mean age 17 months) and their caretakers were studied. A total of 272 (92.2%) children had
received routine measles vaccination while 228 (77.3%) children had received supplementary measles vaccination. Uptake of
both routine and supplementary measles vaccine was 72.2% (213 out 295). The significant factors associated with uptake of
both routine and supplementary vaccinations were age of 12-13 months (AOR 2.11 CI 1.10-4.38), low education level of the
caretaker (AOR 3.36 CI 1.17-9.62), caretaker’s lack of knowledge on the purpose of supplementary measles vaccine (AOR 2.04
CI 1.06-3.93), caretaker’s lack of knowledge of the month for routine measles vaccination (AOR 4.71 CI 2.47-8.99), residing in a
ward where there are high measles cases (AOR 2.29 CI 1.23- 4.27) and residing in a ward for less than 2 years (AOR 2.24 CI
1.12-4.48).
CONCLUSIONS: The uptake of both routine and supplementary measles vaccine in Temeke District is below the national
estimated coverage. Household and childhood factors played a role in determining the uptake of measles vaccination services in
Temeke.
PUBLIC HEALTH IMPLICATIONS: To improve the uptake of vaccination services community awareness on vaccination and
vaccination services should be increased. There is need to repackage the health.
70
EXPLAINING RACE AND ETHNIC DISPARITIES IN US INFANT MORTALITY
RATES
Marian MacDorman, PhD, T.J. Mathews, MS
Centers for Disease Control & Prevention, National Center for Health Statistics
BACKGROUND: The reasons for the large and persistent racial and ethnic disparities in US infant mortality are poorly
understood.
STUDY QUESTION(S): What factors explain race/ethnic differences in US infant mortality rates?
METHODS: We used the 2008 linked birth/infant death data set to examine disparities in US infant mortality rates with a
particular focus on explaining the high infant mortality rates for non-Hispanic black, American Indian, and Puerto Rican women.
We assessed the percent contribution of the distribution of births by gestational age and gestational age-specific infant mortality
rates to race/ethnic differences. We also calculated the percent contribution of leading causes of death to the higher infant
mortality rates for non-Hispanic black, American Indian, and Puerto Rican women.
RESULTS: For non-Hispanic black women, 78% of their elevated infant mortality rate when compared to non-Hispanic white
women was due to their higher percentage of preterm births, while 22% was due to higher gestational age-specific infant
mortality rates. For Puerto Rican women, all of their elevated infant mortality rate when compared to non-Hispanic white women
was due to their higher percentage of preterm births. However, American Indian women had a very different pattern in which
63% of their higher infant mortality rate was due to their higher gestational age-specific infant mortality rates (primarily at 34+
weeks), and 37% was due to their higher percentage of preterm births. These findings were consistent with the cause-of-death
analysis. When compared to non-Hispanic white women, 54% of the higher infant mortality rate for non-Hispanic black women,
and 86% for Puerto Rican women was accounted for by preterm-related causes. In contrast, for American Indian women,
higher infant mortality rates from SIDS and unintentional injuries contributed the most to the American Indian - non-Hispanic
white infant mortality gap.
CONCLUSIONS: Prematurity was the major factor contributing to high infant mortality rates for Non-Hispanic black and Puerto
Rican women, while for American Indian women, higher infant mortality rates for term and near-term infants from SIDS and
injuries were major contributors.
PUBLIC HEALTH IMPLICATIONS: These dissimilar patterns suggest different prevention strategies.
71
BODY MASS INDEX (BMI) AND BIRTH DEFECTS — TEXAS, 2005–2008
Lisa Marengo, MS
Texas Dept. of State Health Services, Birth Defects Epidemiology & Surveillance
BACKGROUND: Texas ranks 12th nationally in the proportion of obese adult residents. Obesity is associated with adverse
pregnancy outcomes. Studies to date have shown that obesity is associated with some birth defects, but small numbers have
prevented an in depth exploration of this association
STUDY QUESTIONS: What is the association between maternal body mass index (BMI) and birth defects in a population based
Registry based on approximately 1.6 million births?
METHODS: Texas Birth Defects Registry reports were linked to 2005–2008 vital records. Maternal BMI was calculated using
prepregnancy weight and height measurements and categorized as follows: underweight (BMI <18.5), normal weight (BMI 18.5–
24.9), overweight (BMI 25–29.9), and Class I–III obesity (BMI 30+). Prevalence ratios (PRs) for specific birth defects among BMI
categories and the presence of maternal diabetes were calculated by using normal weight as the referent and adjusted by
maternal age and race/ethnicity. PRs were considered statistically significant when their 95% confidence intervals did not include
1.0.
RESULTS: PRs for heart defects increased with increasing BMI category. Conversely, babies born to mothers with higher BMI
were at reduced risk for gastroschisis.Among nondiabetic mothers, both underweight and obese women had an increased risk of
delivering a baby with any birth defect. Obese mothers were significantly more likely to deliver a baby with a birth defect than a
normal weight mother (Class II obesity by 11% and Class III by 22%).Mothers with diabetes and with Class I obesity were 15%
more likely, Class II were 17% more likely, and Class III were 38% more likely to deliver a baby with a birth defect than normal
weight mothers with diabetes.
CONCLUSIONS: Maternal obesity is associated with birth defects.
PUBLIC HEALTH IMPLICATIONS: The obesity epidemic has implications for current and subsequent generations.
72
DELAYED INITIATION AND COMPLETION OF HPV VACCINATION AMONG
COMMERCIALLY INSURED MICHIGAN RESIDENTS
Amanda Markovitz, MPH, Michael Paustian, PhD, Ji Young Song, PhD, Darline El Reda, DrPH
Blue Cross Blue Shield of Michigan
BACKGROUND: The human papillomavirus (HPV) vaccine series, licensed in June 2006, is considered effective against
viruses responsible for cervical cancer. However, less than half of females aged 13-17 years in 2010 had initiated HPV
vaccination, and only 70% of initiators had completed the series - far short of national goals. Longitudinal assessment of factors
contributing to delayed HPV vaccine series initiation and completion may inform interventions aimed at adherence to
recommended vaccine guidelines.
STUDY QUESTION(S): What population characteristics are associated with delayed HPV vaccine series initiation and
completion?
METHODS: This retrospective cohort study followed commercially-insured Michigan females aged 8-12 years at baseline for
five years, from June 2006 through May 2011 using combined immunization data from administrative claims and the statewide
immunization registry. We examined vaccination rates at two time points during follow-up, age 13 years and the end of the five
year follow-up, with censoring for gaps in coverage = 45 days. We applied Kaplan-Meier curves and proportional hazards
models to observe and test associations between population characteristics and both delayed vaccine series initiation and
completion.
RESULTS: Among 92,789 females (314,525 person-years), the HPV vaccine series initiation rate and completion rate were
35% and 82% respectively after the five year follow-up. Delayed initiation by age 13 years was greatest among females aged 1112 but similar among females aged 8-10. Factors associated with delayed vaccine initiation included African American race, rural
or highly urban residence and less household education. Factors associated with delayed vaccine series completion included
older age at initiation, African American race, Hispanic ethnicity, residence in highly urban settings, less educated households
and lower income households.
CONCLUSIONS: Despite longer vaccine access, younger females were only slightly more likely to have initiated the HPV
vaccine series by age 13, but significantly more likely to have completed the vaccine series. Traditionally disadvantaged
populations were more likely to have delayed initiation and completion of the vaccine series.
PUBLIC HEALTH IMPLICATIONS: Interventions to promote vaccination and reminders to complete the HPV vaccine series
should target traditionally disadvantaged communities. Efforts to increase HPV vaccination rates may have greater effectiveness
when targeting younger populations due to greater likelihood to complete vaccination.
73
EXPOSURE TO ENVIRONMENTAL TOBACCO SMOKE AND RISK OF
ANTENATAL DEPRESSION: APPLICATION OF LATENT VARIABLE
MODELING
Alfred Mbah, PhD, Hamisu Salihu, MD, PhD, Getachew Dagne, PhD, Ronee Wilson, MPH, Karen Bruder, MD
University of South Florida
BACKGROUND: Despite the known adverse effects of active maternal tobacco use, there is limited information in published
reports regarding the influence of passive smoking on maternal health during the perinatal period.
STUDY QUESTIONS: This study sought to determine the impact of passive smoking on the risk for depression during
pregnancy.
METHODS: In this prospective study, 236 pregnant women were recruited at less than 20 weeks’ gestation from a university
affiliated obstetric clinic from November 2009 to July 2011. Tobacco use/exposure was measured by questionnaire and
confirmed by salivary cotinine analysis. The Edinburgh Perinatal Depression Scale (EPDS) was employed to measure perinatal
depressive symptomatology. Traditionally, a cutoff of 13 is utilized to indicate depression in the perinatal population. However,
this approach is vulnerable to measurement errors that are inherent in assessing depression using cutoff points. Therefore, in
this analysis we apply a flexible approach (latent variable modeling) that can account for measurement errors thereby reducing
bias in the estimates.
RESULTS: Significant differences were observed in the mean EPDS scores among non-smokers (mean ± SD = 4.8 ± 4.8),
passive smokers (5.3 ± 5.5) and active smokers (7.4 ± 6.1) [p-value=0.02]. For each itemized response of the EPDS, passive
smokers demonstrated an increased risk for depression with the greatest risk exhibited by item 8 and item 9 of the questionnaire
(feeling sad or miserable and feeling unhappy [and] crying, respectively). In addition, for each item of the EPDS a dose
response pattern was revealed with non-smokers having the least risk of depression during pregnancy and active smokers
having the greatest risk.
CONCLUSIONS: Women who are exposed to secondhand smoke are at elevated risk for depression during pregnancy. A
dose-response relationship exists with non-smokers having the least risk and those who smoke actively during pregnancy
exhibiting the greatest risk.
PUBLIC HEALTH IMPLICATIONS: An estimated one-third to one-half of non-smoking pregnant women are involuntarily
exposed to ETS. Elucidating the impact of passive smoking on maternal health will provide an avenue for reducing the burden of
maternal depression during pregnancy, as ETS exposure at home is preventable.
74
THE BORDERMACH INITIATIVE: BUILDING BINATIONAL MCH CAPACITY
Jill A. McDonald, MS, PhD,
Centers for Disease Control & Prevention (NCCDPH)
PUBLIC HEALTH AREA:
FOCUS: Reproductive health, Family planning
POPULATION: Intergenerational
ISSUE: The US and Mexico formed a binational commission to improve health and well-being in the border region in 2000.
Disparities in maternal and child health (MCH) have since received more attention, but the region lacks resources, including
epidemiologic data and staff, to address them.
SETTING: The region extends 2,000 miles and comprises 44 US counties and 80 Mexican municipios. Most of the 15 million
residents reside in pairs of interdependent county/municipios (sister cities) that straddle the border and record 300,000
births/year.
PROJECT: CDC’s MCH Epidemiology Program launched the BorderMACH Initiative with stakeholder agencies in 2007 to build
MCH infrastructure, binational collaboration, and data competency in the region. Sister city teams of program directors, data
managers, and decision-makers have been established and encouraged to use data to effect change. Teams are supported
through training and technical assistance as they develop projects targeting shared MCH priorities. Effectiveness is evaluated
through training assessments and team accomplishments. Minimal CDC funding and widespread in-kind support sustains the
Initiative.
RESULTS: Four BorderMACH teams now have 1-3 years of collaborative experience each. Faculty were identified from US
and Mexican government and academic institutions. They created 6 days of bilingual workshop curricula for teams covering
leadership, communications, data access and use, and project planning and evaluation. Systematically collected feedback
indicates workshop content is highly useful. Teams have expanded, been incorporated into the Binational Health Councils (BHC)
in two sister cities, developed surveys to increase influenza vaccine coverage among pregnant women and assess adolescent
risk behavior, and developed proposals for reducing teen pregnancy in their communities.
BARRIERS: Multiple federal and state health agencies in both countries have jurisdiction in the region and have little experience
collaborating with one another. US and Mexican agencies operate within different health systems and in two different languages.
Funding is limited, and staff turnover is frequent.
LESSONS LEARNED: Coalitions can be assembled from different stakeholder groups based on local priorities. Training content
and activities need to be adapted to local skills and interests. Measurable progress can be made poco a poco (little by little) on a
shoestring budget.
75
EMERGENCY MEDICAL TRANSPORTS AMONG REPRODUCTIVE AGE
WOMEN IN A BINATIONAL SETTING
Jill McDonald, MS, PhD, Karen Rishel, MD, MPH, Danielle Arellano, MPH, Timothy Cunningham, ScD
Centers for Disease Control & Prevention (DRH & MCCDPHP), New Mexico State University, Oak Ridge Institute for Science &
Education
BACKGROUND: Emergency medical services (EMS) data from El Paso, Texas, indicate obstetrical reasons account for 4.7%
of EMS transports for women of reproductive age (WRA; 12-49 years). In contrast, anecdotal information about EMS calls from
ports of entry (POE) along the US-Mexico border suggests obstetrical reasons are the majority of such transports.
STUDY QUESTIONS: What proportion of POE EMS transports in El Paso,Texas comprise obstetrical-related conditions?
Where do pregnant women using EMS transport at the border reside?
METHODS: Using “First Watch” (an electronic web-based system used by El Paso Quarantine Station to monitor EMS
transports), we identified all obstetric-related calls to POE addresses for WRA from 12/01/2008-12/31/2009 (period 1) and
1/1/2010-7/31/2011 (period 2). We abstracted call and demographic information from EMS and emergency department records.
For women admitted to labor and delivery (L&D), we collected country of residence from the hospital record. We compared the
proportion of obstetric-related transports in the city of El Paso in 2009 to the proportion originating from El Paso POE during
period 1 using chi-square tests.
RESULTS: In period 1, 47. 6% (68/143) of EMS calls to POE for WRA were for an obstetrical condition, higher than the 4.7%
(371/7867) of calls to the city of El Paso EMS (P<0.0001). During periods 1 and 2, 154 obstetrical POE EMS transports occurred;
62 were admitted to L&D, hospital records were missing for 45, and most of the remainder were sent home. Among the 62
admitted to L&D, 45 (73%) reported US residence and 17 (27%) reported Mexican residence.
CONCLUSIONS: Compared with women in the city of El Paso, a higher proportion of women entering the US from Mexico
through POE use an ambulance for an obstetrical-related call. Our data suggest a large percentage of those using EMS
transport at POE have residence in the US.
PUBLIC HEALTH IMPLICATIONS: Special consideration may be needed for “transnational” women, i.e., those who spend time
residing on both sides of the border, in planning for border EMS/obstetrical services. Such women, who may seek prenatal care
on one side of the border and delivery services on the other could experience disrupted continuity of care.
76
USE OF EXCESS RISK ANALYSIS BASED ON COUNTY-LEVEL RACIAL
AND ETHNIC DEMOGRAPHICS AND DISPARITIES IN INFANT MORTALITY
TO DETERMINE HOME VISITING PROGRAM CASELOAD
Patricia McKane, DVM, MPH, Sarah Lyon-Callo, MS, PhD candidate, Nancy Peeler, Ed.M., Paulette Dobynes Dunbar,
MPH, Brenda Fink, MSW, ACSW
Michigan Dept. of Community Health
BACKGROUND: The Michigan infant mortality rate (IMR) (7.5/1,000 live births in 2009) remains higher than the national rate
(6.3/1,000 provisional 2009 data) with persistent racial disparities (B:W rate ratio = 3). A home visiting program serving lowincome, first time mothers in Michigan’s highest risk counties and cities is one strategy to reduce infant mortality in high risk
populations. Within some counties, the program’s caseload demographics did not reflect the at-risk community or racial
disparities. To maximize efficiency of limited resources, a method was needed to identify high risk populations and to create a
recommended caseload for each county.
STUDY QUESTION(S): Can caseload targets based on IMR stratified by race/ethnicity be developed using statistical methods?
METHODS: The Kitagawa formula was used to calculate the excess risk percent of IMR by race/ethnicity for each of the high
risk counties. Decomposition addresses the additive contributions of the effects of the differences in rates and distribution by
strata in two populations to the differences in their overall rates. Data from the 2007 to 2009 Michigan Resident Live Birth/Infant
death linked file were used. Infants born to Michigan women > 20 years old and > 13 years of education in 2007-2009 were the
reference population. Targets for each county were calculated by adjusting the excess mortality rate for each race/ethnicity to
eliminate negative risk, then calculating the percent of the total risk for each racial/ethnic group.
RESULTS: Compared to state race/ethnicity specific rates, excess mortality was highest for Black infants (56.5% to 132.8%) in
7 counties, for Hispanic infants (86.6%) and White infants (48.2%) in one county each. The largest racial disparity in excess
mortality within one county was -84.4% in White and 123.1% in Black infants. The analysis identified high risk populations within
each county and caseload targets were determined by the differences in the race/ethnicity distribution and IMR between the
county and the reference population.
CONCLUSIONS: Targets based on this analysis were included in contracts between MDCH and Local Health Departments,
thus encouraging outreach into underserved communities.
PUBLIC HEALTH IMPLICATIONS: Excess risk analysis can be used for small areas, allowing limited resources to be focused
on areas of most need.
77
THE TENTH STEP: INTEGRATING HOSPITAL AND COMMUNITY SUPPORT
FOR BREASTFEEDING IN ILLINOIS
Jeretha McKinley, BA, CLC, Brenda Reyes, AD, CLC
HealthConnect One
PUBLIC HEALTH AREA:
FOCUS: Adverse perinatal outcomes, Community collaboration
POPULATION: Infants, Women, Families
ISSUE: Breastfeeding is a critical strategy for lifelong health promotion and disease prevention. Recently, significant national,
state and local initiatives have emerged to support increased breastfeeding rates. The bulk of recently funded projects have
focused on improving hospital breastfeeding practices. Yet it is clear that primary health care and public health must be
integrated to achieve strong breastfeeding outcomes. Implementing the tenth step of the Ten Steps to Baby-Friendly Hospitals,
i.e. hospital referral of mothers to community breastfeeding support, is a necessary step in the achievement of optimal
breastfeeding rates.
SETTING: This presentation will describe Illinois’ experience with linking hospital and community breastfeeding initiatives.
There is a connection between low breastfeeding duration and exclusivity rates in Illinois and the fragmentation of services
delivered by hospital and community programs.
PROJECT: The Illinois Blueprint for Breastfeeding (2011) documented the state’s breastfeeding status, including significant
socioeconomic disparities, and developed strategic recommendations for improvement. The Blueprint has become part of the
infrastructure for implementing and evaluating policy, practice and systems changes. There has been significant progress in new
programs that support integration of care.
RESULTS: In Cook County, 15 of 36 (42%) of maternity hospitals have committed to pursuing Baby Friendly designation. 9/36
(25%) of hospitals utilize breastfeeding peer counselors. Hospital breastfeeding initiation rates are now made public through the
IL Hospital Report Card. In 2013, maternity hospitals in IL will be required to implement an evidence-based infant feeding policy
and a quality improvement initiative.
BARRIERS: The lack of collaboration between hospitals and community-based primary care settings prohibits continuity of care
for breastfeeding support and in some cases, underutilization of available services. Forming multidisciplinary committees
provides an opportunity for involving all relevant stakeholders, addressing gaps in services and establishing strategies for
efficiency in care provision.
LESSONS LEARNED: To fully support optimum breastfeeding, community-based organizations and hospitals must collaborate
in providing continuity of care. Culturally appropriate services, such as peer counselor programs, are particularly important for
mothers at high risk of not breastfeeding; they link mothers to available services from preconception to early parenting. This
coordinated breastfeeding support gives mothers the best chance for breastfeeding success.
78
ANALYSIS OF THE BURDEN OF HOSPITALIZATIONS ASSOCIATED WITH
CONGENITAL ANOMALIES
Karen Moffitt, MPH, Noha Farag, MD, PhD, Mark Canfield, PhD
Texas Dept. of State Health Services, Centers for Disease Control & Prevention
BACKGROUND: Congenital anomalies affect 3-4% of babies born in the United States. Public-Use Hospital Inpatient discharge
data in Texas offers important data regarding the impact of hospitalizations due to congenital anomalies.
STUDY QUESTIONS: What are the hospitalization charges and days in the hospital associated with congenital anomalies?
METHODS: Public-Use Texas Hospital Inpatient Data Files for 2001–2010 were analyzed. Most hospitals are required to submit
discharge data, but there are limitations to the data, for example, rural and smaller hospitals are not required to submit
information. Hospitalizations for congenital anomalies (ICD 740–759), not associated with prematurity, were analyzed as the
primary diagnosis, and separately if a congenital anomaly was listed under any of the other diagnosis codes. Hospitalizations
associated with congenital anomalies for children aged 0–17 years were compared with total hospitalizations for children aged
0–17 years. Average, median and total hospital charges, and average and median number of days in the hospital were analyzed
to determine the most costly congenital anomalies and those associated with the greatest number of hospitalization days.
RESULTS: Average hospital charge for congenital anomalies, not associated with prematurity, was approximately triple the
average hospital charges overall for ages 0–17 (in 2010, the average hospital charge for congenital anomalies was
approximately $53,000 per stay, compared with approximately $19,000 per stay overall) . Over the 10-year span of this study,
the increase in charges for all infants and children ages 0–17 years with congenital anomalies has outpaced the overall increase,
with congenital anomalies increasing 152% during the time span, compared with 127% increase overall. The average hospital
stay is approximately 2 days longer for congenital anomalies (for 2010, 6.2 days were spent in the hospital for congenital
anomalies, compared with 4.1 days overall). Despite the fact that congenital anomalies as a primary diagnosis contribute 1.3% of
all hospital discharges, charges associated with them constitute over 7% of all hospital charges.
CONCLUSIONS: Despite limitations of hospital discharge data, they provide invaluable information about the burden of
congenital anomalies on the health care system.
PUBLIC HEALTH IMPLICATIONS: Congenital anomalies contribute significantly to health care costs, both for time in the
hospital and associated hospital charges.
79
SISTER'S TOGETHER EMPOWERING PEER
Lisa Morris, MA, Ramona Benson, BA
Sisters Together Empowering Peers, Organization
PUBLIC HEALTH AREA:
FOCUS: Community collaboration, Environment
POPULATION: Children, Women, Families
ISSUE: Sisters Together Empowering Peers (S.T.E.P.) is a peer-led support and empowerment group that was developed to
address health inequities between African-American and all other families in our community.
SETTING: S.T.E.P. serves African-American parenting women who live in Berkeley and the surrounding metropolis, specifically
targeting “graduates” from the California State funded Black Infant Health (BIH) Program.
PROJECT: In response to national data showing that Berkeley’s Low Birth Weight rate among African Americans was nearly
four times that of whites (twice the national rate), BIH was established in Berkeley in 2001. State program funds are limited to the
prenatal period; however, socioeconomic conditions and issues that face a new or repeat mother and her family continue to
exist. S.T.E.P. was established in 2003 by BIH staff and participants to provide continuing social support and education to
empower women to become strong advocates for their families and community regarding health issues. S.T.E.P.S. curriculum is
based on the stated needs of the group and is delivered by a leadership team consisting of S.T.E.P. peers. With a philosophy
based on the social determinants of health, education is provided regarding issues such as access to essential goods and
services, housing, education, job training, health information and other opportunities by providing a forum to share information
and experiences.
RESULTS: To date, five participants have assumed leadership of the group and carry out all functions of organizational
development, including grant writing, contract negotiation, and community collaboration building. We also recently joined with a
mental health agency to provide a clinician for support during group meetings.
BARRIERS: Because it is a volunteer effort with operational costs supported by small grants and donations, S.T.E.P.’s scope of
work is limited by the availability of funds. We recently received two years funding from the City of Berkeley to expand our
activities, increase numbers served, and conduct leadership development training.
LESSONS LEARNED: The peer-led support group model encourages positive, open interactions in which the experiential
knowledge of the collective contributes to improving the quality of life for all participants. Peer support leaders are viewed as
credible role models who inspire the group to strive for more.
80
HEALTHY NEIGHBORHOOD PARTNERSHIPS – LESSONS FROM THE
STREET
Tricia Mortell, RD, MPH
Clark County Public Health
PUBLIC HEALTH AREA:
FOCUS: Community collaboration, Faith-based initiatives
POPULATION: Women, Families, Intergenerational
ISSUE: MCH efforts have often focused on programs directed at individual behavior change but as public health funding
continues to shrink and research shows efforts targeted at upstream approaches are most needed, Clark County PH is working
to focus MCH resources on “place” based approaches. This effort aligns with the Life Course Model which supports moving from
individual interventions to those targeting social, economic and environmental factors which are the underlying causes of
persistent inequalities in health and disease.
SETTING: The Partnerships for Healthy Neighborhoods area encompasses 5 elementary school areas, 10 neighborhoods and
approximately 52,000 residents. This area in Central Vancouver was selected through an assessment process which identified
high need coupled with community assets and readiness to partner.
PROJECT: Partnerships for Healthy Neighborhoods launched as a non-prescriptive approach to support and promote
neighborhood level health. 3 goals led the initial community discussions; babies born healthy, babies and children safe from
abuse and neglect and children ready to learn which ultimately impact chronic disease. In this presentation we will share lessons
learned with others working to reduce risks and increase protective factors through place based work.
RESULTS: Accomplishments to date include strengthening of coalitions and partnerships already in existence in the target area.
From there work has begun to direct coalition efforts towards common goals and objectives; improving access to healthy food
and creating stronger school-community-family networks. Partnerships staff have been very successful at developing community
connections and is working towards building a neighborhood level connector model that can sustain the work over time.
BARRIERS: Political and systems barriers are commonly encountered in neighborhood based efforts. Even though a thorough
assessment process was used and multiple stakeholders engaged, community engagement efforts always uncover differing
realities. Economic issues are also barriers, particularly as shrinking government budgets impact vulnerable communities. We
will discuss strategies Partnerships has used to move this body of work forward.
LESSONS LEARNED: In this session we will share lessons learned in; workforce development and support, evaluation system
development and community relationships and neighborhood level politics.
81
FOOD INSECURITY AND EATING HABITS OF CHILDREN WITH SPECIAL
HEALTH CARE NEEDS IN OREGON
Laurel Murphy, BA, Elizabeth Adams, PhD, RD, Ken Rosenberg, MD, MPH
Oregon Health & Science University
BACKGROUND: Food insecurity occurs when families lack reliable access to nutritious food due to financial hardship. Over
14% of U.S. households reported food insecurity in 2010. Families that include children with special health care needs (CSHCN)
may be at increased risk for food insecurity. This risk may arise from the financial burdens associated with special health care
needs and care provider employment limitations, but this association has not been established in current literature.
STUDY QUESTIONS: How do the food security statuses and dietary patterns differ between households with children who do
and do not have special health care needs?
METHODS: This study uses data from the 2004-05 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS
collects state-specific, population-based data on maternal attitudes and experiences before, during, and after pregnancy.
PRAMS-2 reinterviews PRAMS respondents shortly after the child turns 2 years old. Chi-square tests were applied to quantify
relationship of CSHCN status to food security and consumption of milk and sweets. Stata 11.1 was used for analysis.
RESULTS: 1846 women completed PRAMS-2 survey and are included in this analysis. 12.1% of households with two-year-old
children reported food insecurity. Compared to women whose 2-year-old did not have special health care needs (10.9%), women
were more likely to report food insecurity if their 2-year-old child had special health care needs 21.1% (p<.05). CSHCN
consumed sweets and milk less frequently than others (p<.05). A greater proportion of CSHCN parents reported that their “child
doesn't eat enough” (16.8% vs. 10.8%, p < 0.0024).
CONCLUSIONS: CSHCN are at risk for food insecurity, because financial struggles associated with having CSHCN may
increase the risk for food insecurity. They are also more likely to be connected to a medical home, offering opportunity for
screening and intervention against food insecurity and other dietary risks.
PUBLIC HEALTH IMPLICATIONS: This investigation supports more widespread screening for food insecurity among providers
of health care to all children and especially those with special health care needs.
82
PREDICTORS OF BREASTFEEDING INITIATION IN PHILADELPHIA, 20082009
Maria Ness, MPH, Niti Mehta, MPH
Philadelphia Dept. of Public Health
BACKGROUND: Despite well documented health benefits for both mother and infant, rates of breastfeeding initiation in
Philadelphia have consistently remained below national levels. Baby-friendly hospital policies and practices are crucial to support
the initiation of breastfeeding immediately following birth. When resources are limited, as in Philadelphia, hospitals should focus
their efforts on the women who are least likely to initiate breastfeeding, in order to maximize the impact of these activities.
STUDY QUESTION(S): What are risk factors associated with the initiation of breastfeeding in Philadelphia that delivery hospitals
can use to identify women that may benefit most from breastfeeding promotion practices?
METHODS: Data for this analysis was from 2008–2009 birth certificate records, and was limited to singleton live births of =37
weeks gestational age. We used Chi-squared statistics to examine the distribution of each risk factor, and bivariate and
multivariable logistic regression to examine the association of risk factors with breastfeeding. Interaction of select risk factors was
assessed. Limitations of birth certificate data include minimal information regarding behavioral risk factors and no measure of
breastfeeding duration or exclusivity.
RESULTS: Of the 43,822 women in this sample, 60% reported initiating breastfeeding on the infant’s birth certificate. After
adjusting for demographics and covariates, the risk factors that were significantly associated with a decreased odds of
breastfeeding initiation were the use of Medicaid as a payment method for the birth (AOR=0.75, 95%CI=0.70-0.80), the presence
of maternal diabetes or hypertension (AOR=0.83, 95%CI=0.76-0.90), mothers with at least one previous live birth (AOR=0.60,
95%CI=0.57-0.64), and Cesarean delivery (AOR=0.89, 95%CI=0.84-0.94).
CONCLUSIONS: We found multiple risk factors which delivery hospitals in Philadelphia can use to target their breastfeeding
promotion activities. These risk factors were the use of Medicaid, the presence of maternal chronic health conditions, mothers
with prior live births, and Cesarean deliveries.
PUBLIC HEALTH IMPLICATIONS: Delivery hospitals in Philadelphia should target breastfeeding promotion activities towards
women who use Medicaid to pay for the delivery of their infant, those who have a chronic health condition such as diabetes or
hypertension, those who have had at least one previous live birth, and those who delivered via Cesarean section.
83
PERCEPTIONS OF AFRICAN-AMERICAN PROFESSIONALS AND
COMMUNITY MEMBERS’ ON GENETIC RESEARCH INVOLVING CHILDREN
AND PREGNANT WOMEN
Emmanuel Ngui DrPH, MSc,, Teddy D. Warner, PhD, Laura W. Roberts, MD, MA
University of Wisconsin – Milwaukee Zilber School of Public Health, University of New Mexico, Stanford University School of
Medicine
BACKGROUND: Genetic research interest is growing but perspectives of minorities are not clearly understood.
STUDY QUESTION(S): To examine perspectives of African-American health professional and community members on genetic
research (GR) involving children and pregnant women.
METHODS: We used a mixed methods approach comprising of a brief survey, structured interviews with health care
professionals (N=20) and three focus groups of community member living with and without mental illness (n=26) in Milwaukee,
Wisconsin.
RESULTS: Participants had a mean age of 44 (range 21-68) years. Compared to healthcare professionals, community
members had significantly more favorable attitude towards participation of children (mean 2.7 vs 3.3, p<0.05) and pregnant
women (mean 2.7 vs 3.8, p<0.05) in GR and were about twice more willing to allow their children to participate in GR studies
(84% vs. 47%). Emergent themes included: limited understanding and distinction of GR, biomedical and clinical care; ethical
concerns about confidentiality, risks and benefits, the need to protect children and pregnant women from harm; and the
importance of sharing study findings with participating communities. Parental duty to protect children from harm was a recurring
theme. Although participants felt that pregnant women can make their own decisions, their concerns focused more on the
protecting the fetus than maternal health. We found limited understanding of GR even among professionals who had taken
genetic courses. Participants expressed interest in GR and also ethical and confidentiality concerns based on historical conduct
of biomedical and GR. Some felt GR findings could help dispel stigma.
CONCLUSIONS: African-American professionals and community members have a strong interest but limited knowledge of GR
and ethical concerns of the potential harm of GR to children and pregnant women. They valued sharing GR findings with
communities to building trust.
PUBLIC HEALTH IMPLICATIONS: Findings suggest the need for better genetics education for African-American professional
and community member including directly addressing the risks and benefits, privacy and ethical concerns related to participation
of children and pregnant women. Further, there is critical need to engage and collaborate with racial/ethnic communities early
with genetic and biomedical education, address concerns, and translate and share findings with their respective communities.
84
THE CHOKING GAME: PREVALENCE AND INCREASED RISK FOR
SERIOUS INJURY OR DEATH AMONG OREGON 8TH & 11TH GRADE
PARTICIPANTS
Robert Nystrom, MA, Liz Thorne, MPH
Oregon Public Health Division
BACKGROUND: The 'choking game'(CG)is an activity in which persons strangulate themselves to achieve euphoria through
brief hypoxia. Research on the choking game has been sparse. In 2008, CDC reported 82 deaths attributed to the choking game
during the period 1995-2007. Oregon established the first statewide scientific study that determined prevelance of the choking
game using 2008 Oregon Health Teen (OHT) Survey data (MMWR, 2010). Previous published studies were based on small or
non-random samples. Subsequently, Oregon examined additional statewide data, including frequency of participation, from the
2009 OHT survey. That study reported on risk profiles, identified possible disparities and made screening suggestions for
Pediatricians (Pediatrics, 2012) at the well-child and adolescent visit within the health risk assessment.
STUDY QUESTIONS: 1 How often and under what conditions (NEW) do youth participate in the choking game?2. Is there a risk
profile associated with choking game participation among adolescents and does it vary by demographics?3. (NEW) Which
adolescents are at most serious risk for injury or death.
METHODS: The study design is modeled after previous studies on the Choking Game among Oregon 8th grade youth. The
study uses Oregon Healthy Teen (OHT) survey data (see above) A single awareness/participation question was asked in 2008 of
8th grade students only; a second question (frequency) was added in 2009 and asked of both 8th and 11th; a third question was
added in 2011 which identified setting (group or alone) which is the focus of the current analysis.
RESULTS: Key findings in the first two analysis determined youth awareness (~30%) of the choking game (CG) and
participation (6%); no significant differences between male/female overall participation were found. Strongest predictors for CG in
both males/females were sexual activity and substance use, followed by poor nutrition (F) and exposure to violence (M). The
current study suggests a significant number of youth participate frequently (>5) and alone (~25%)[new question].
CONCLUSIONS: Final analysis is not complete due to a final 2011 OHT data set delay. Preliminary results;1.There is subset of
youth at high risk for injury/death who practice both frequently and alone (pop estimates will be generated)
PUBLIC HEALTH IMPLICATIONS: Risk profile/predictors will be refined for this group to potentially improve identification by
clinicians.
85
UTILIZING CLIENT RECORDS FOR A COLLABORATIVE SURVEY
PROJECT: A PROCESS FOR CONTACTING FAMILIES WHILE
MAINTAINING CONFIDENTIALITY
Elizabeth Oftedahl, MPH, Lori Anderson, PhD, RN, CPNP, Ann McCall, MSW
Wisconsin Dept. of Health Services, University of Wisconsin-Madison
PUBLIC HEALTH AREA:
FOCUS: Children and youth with special health care needs, Community collaboration
POPULATION: Children, Adolescents, Families
ISSUE: As a state agency we're allowed to collect, for public health purposes, individually identifiable information on families,
children and service provision. We're usually unable to participate in any collaborative projects because we cannot provide
confidential information to researchers.
SETTING: Collaboration between the University of Wisconsin School of Nursing and the Wisconsin Maternal and Child Health
program.
PROJECT: Dr. Lori Anderson - UW School of Nursing - proposed to survey families with CYSHCN to collect information on
school nursing services and whether families were satisfied with the services they received. MCH Program staff developed a
process to allow collaboration on the project within the limitations of our legal obligation to protect the confidentiality of our clients
and their families.
RESULTS: Preliminary analysis showed we had close to 800 families that met the criteria for the study and that we could readily
develop a mailing list in random order with contact information for the families. The process: (1) analyst compiles list of names
and addresses from our MCH reporting system (2) CYSHCN epidemiologist creates a spreadsheet and assigns a tracking
number to each record (3) all mailings are sent from the state mailroom (4) responses are anonymous (5) completed surveys are
sent to UW (6) undeliverable mail is returned to the CYSHCN epidemiologist (7) a spreadsheet with tracking numbers only is
used by UW project staff (8) CYSHCN epidemiologist and UW staff finalize counts
BARRIERS: Assuring confidentiality - the analyst who derived the data did not keep a copy of the records; only the CYSHCN
epidemiologist had access to the final list; UW staff only had a checklist of tracking numbers. Tracking - Returns came to the
CYSHCN epidemiologist; completed surveys went to UW - ongoing consultation assured a complete tally. Assuring IRB
requirements - both partners received organizational IRB approval.
LESSONS LEARNED: In 2011-2012, Wisconsin MCH worked out a process for allowing a partner agency to survey families
without ever knowing their names or addresses. This process successfully demonstrated that confidentiality can be maintained at
the same time that valuable information on the needs of families with special needs children can be collected.
86
PATERNAL INFLUENCES ON MATERNAL RISK TAKING BEHAVIOR AND
NEONATAL OUTCOMES AMONG PREGNANT HISPANICS
Esohe Ohuoba, MD, MPH, Susan Raines, JD, MD, LLM, Halen Sangi-Haghpeykar, PhD
Baylor College of Medicine,
BACKGROUND: Consequences of unintended births are well established. Currently, most available literature concerning
pregnancy related behavior /outcome has centered on mother’s intention status. However, research has shown that some
pregnancies that are unwanted by the mother are in fact wanted by the father.
STUDY QUESTIONS: Does father’s feelings towards a pregnancy provides a risk or protection for mother’s risk taking behavior
and neonatal outcomes independent of mother’s feelings towards the index pregnancy?
METHODS: A total of 613 Hispanic women were surveyed immediately post-partum about their and their partner’s level of
happiness about the index pregnancy at the time they heard about the pregnancy. We recruited women in this study from clinics
providing services to low income and medically indigent women. Analyses consist of Chi square, t-tests and logistic regression.
Limitations include self-reporting and generalizability.
RESULTS: Mean age and education was 28 and 9 years. About 42% were married and 82% were non-US born. Overall, in 83%
(N=508) of pregnancies, both the mother and father were happy about the pregnancy, 8% both were unhappy, 4% only the
mother was unhappy, and 5% only the father was unhappy. Paternal feeling toward the pregnancy was unrelated to mother’s
smoking, drinking or exercise during pregnancy, amount of weight gain by her, infant’s low birth weight (<2500 grams) or preterm
birth (<37 weeks). However, father’s unhappiness with the pregnancy pose a risk to timely prenatal care (onset <12 weeks) or
plans for breastfeeding at least 6 months. When the father was unhappy about the pregnancy but the mother was happy, odds
for delayed care was 1.6 times higher (95% confidence interval [CI]=1.18-2.04) and odds for inadequate breastfeeding (none to
less than 6 months) was 3 times higher (CI=1.42-7.31) than when both parents were happy about the pregnancy. This trend was
stronger among married than unmarried couples. All associations were independent of potential confounders including education
and level of acculturation.
CONCLUSIONS: Screening for father’s attitude and happiness about the pregnancy may help improve prenatal services and
breastfeeding practices among Hispanics.
PUBLIC HEALTH IMPLICATIONS: Comprehensive efforts are needed to involve male partners in programs aimed at
expanding adequate prenatal and postnatal behaviors among Hispanics.
87
DEVELOPMENT AND IMPLEMENTATION OF CLIENT PROFILE FORMS
FOR WEST VIRGINIA HOME VISITATION PROGRAM
Kathryn Oscanyan, MPH
West Virginia Dept. of Health & Human Resources
PUBLIC HEALTH AREA:
FOCUS: Other
POPULATION: Infants, Women, Families
ISSUE: The Maternal Infant Early Childhood Home Visiting Program identified 6 benchmark areas ranging from Prenatal Care to
Community Collaboration to be explored as part of data collection efforts for MIECHV funded programs. Of the 35 constructs
embedded in 6 benchmark areas, 19 constructs required additional measurement tools that were not covered elsewhere with
standardized assessment tools such as the Ages and Stages assessment.
SETTING: The Client Profile forms are used in Home Visiting Agencies throughout West Virginia. The collection of information
will benefit WV parents, children, stakeholders, home visitors and communities.
PROJECT: Standardized interview forms were developed by the Epidemiologist using language from home visiting model intake
forms. Remaining constructs were addressed by developing questions that were reviewed for validity by Home Visiting Program
Director and 2 additional Epidemiologists. Form structure and format was developed with input from 3 different home visiting
model supervisors; Parents as Teachers, Maternal Infant Health Outreach Worker and Healthy Families America. All home
visitors in the state were trained to use the forms during agency site visits by the same trainer to avoid discrepancies. The
Epidemiologist reviews all forms for correctness and completeness. The forms were implemented for use on a pilot basis in 5
MIECHV funded agencies beginning April 1, 2012. By July 1, 2012, all WV home visiting agencies will be using the forms.
RESULTS: The pilot period was successful with home visitors actively engaging in data collection. The forms are being used as
a springboard for additional discussion and counseling for families.
BARRIERS: Several barriers were identified with development and implementation of the forms, including the use of 3 different
home visiting models in the state and home visitor perception of additional data collection. After thorough discussion with home
visitors to explain the reasons for additional forms, many of the barriers were eliminated.
LESSONS LEARNED: Trainings were effective for gaining program acceptance of added data requirements. Asking
representatives of each model for input proved to be beneficial in creating a positive attitude regarding the forms. Although
trainings were well-received, it may have been more effective to have all agencies conduct a pilot period before implementation
was required.
88
IMPROVING CARE FOR WOMEN WITH A HISTORY OF GESTATIONAL
DIABETES — A PROVIDER PERSPECTIVE
Reena Oza-Frank, PhD, RD, Jean Y. Ko, PhD, Andrew Wapner, DO, Jo M. Bouchard, MPH, Elizabeth J. Conrey, PhD, RN
Research Institute at Nationwide Children’s Hospital, Centers for Disease Control & Prevention, Ohio Dept. of Health
BACKGROUND: Prior gestational diabetes mellitus (GDM) increases future risk of developing type 2 diabetes. Appropriate
postpartum care for women with GDM includes providing counseling on lifestyle changes, including diet and exercise, to reduce
future risk of type 2 diabetes. However, many women transition between provider types during the postpartum period, which can
negatively impact delivery of GDM-related postpartum care.
STUDY QUESTION(S): How do postpartum care providers perceive their role in type 2 diabetes risk reduction for women with
prior GDM and what resources are needed to improve provision of care?
METHODS: From a state licensure database, a random sample of licensed obstetricians and gynecologists (OB/GYN), certified
nurse midwives (CNM), family practitioners, and internists practicing in Ohio were selected and mailed and emailed a survey
from October-December 2010 (N = 2,035). Chi-squares were used to assess differences across provider types. Because the
survey included providers in Ohio, results may not be generalizable to other states.
RESULTS: The overall survey response rate was 46%. Over 70% of CNMs strongly agreed that it is part of their job to help
women with prior GDM to improve diet and increase exercise, compared with 60% of family practitioners and internists, and 55%
of OB/GYNs (P < 0.001). Approximately half of OB/GYNs and CNMs identified a need for additional local nutrition specialists,
compared with 40% of family practitioners or internists (P < 0.05). Between 60–70% of OB/GYNs and CNMs reported affordable,
community-based lifestyle modification programs and improving provider reimbursement for counseling patients on nutrition and
exercise would better support them to reduce or prevent future risk of type 2 diabetes in women with prior GDM.
CONCLUSIONS: Postpartum care providers have varying perceptions of their roles in type 2 diabetes prevention among
women with prior GDM. The majority of respondents reported that both availability of and reimbursement for lifestyle programs
are needed to improve care.
PUBLIC HEALTH IMPLICATIONS: Postpartum continuity of care is critical for improving the health of reproductive-aged
women. By making nutrition and physical activity counseling the standard of care for women with prior GDM and including
reimbursement by health insurance plans, missed opportunities for preventing type 2 diabetes may be reduced.
89
SEROPREVALENCE OF HEPATITIS B AMONG PREGNANT WOMEN AND
ASSOCIATED RISK FACTORS, MOSHI MUNICIPALITY, TANZANIA, 2012
Boniface Panga, MSc, Mecky Matee, Janneth Mghamba, Mohamed Mohamed
Tanzania Field Epidemiology & Laboratory Training Program, Muhimbili University of Health & Allied Sciences
BACKGROUND: Mother-to-child transmission of hepatitis B virus (HBV) is a major concern because of the associated longterm morbidity and mortality. The presence of hepatitis B e antigen (HBeAg) in a positive HBV pregnant woman is a marker for
high viral load and has shown to be associated with a 70-90% risk for perinatal transmission. This study investigated
seroprevalance of Hepatitis B surface antigen (HBsAg) among pregnant women and of HBeAg among positive HBsAg pregnant
women to provide opportunities for prevention and control.
STUDY QUESTION(S): What is the seroprevalance of Hepatitis B and HBeAg and associated factors among pregnant women in
Moshi municipality?
METHODS: A cross-sectional study was conducted among pregnant women attending antenatal clinics at Moshi Municipality,
January-March 2012. Blood collected from consenting pregnant women was screened for HBsAg by rapid test strip. Positive
samples were subjected to Enzyme linked Fluorescent Assay (BIOMUREX-SA) for HBeAg detection. A questionnaire containing
socio-demographic and behavioral risk factors was administered. Data was analyzed using EpiInfo.
RESULTS: A total of 346 pregnant women were recruited. Their mean age was 24.7 (SD 5.4) years. Out of 346 pregnant
women 10 (2.9%) had serological evidence of infection with at least one pathogen and 3 (0.8%) had multiple infections. Seven of
the 346 pregnant women were positive for HBsAg giving a sero-prevalence of 2.0%. One (14%) of the seven positive HBsAg
pregnant women had co-infection with Syphilis. Among the seven HBsAg seropositive women, one (14.3%) was positive for
HBeAg. Risk factors for HBsAg were age 30-34 yrs (OR 4.9, 95%CI 1.01-24.13), history of mutiple sexual partners in the past
year (OR 3.09, 95%CI 1.01-9.42) and ritual scarification (OR 10.1, 95%CI 1.89-54.20 ).
CONCLUSIONS: The seroprevalence of HBsAg among this population of pregnant women lies within the intermediate endemic
area of 2-7% as per World Health Organization criteria. We found a reasonable HBV infectivity prevalence which could pose a
risk for perinatal infection. Risk factors common to HIV disease were identified.
PUBLIC HEALTH IMPLICATIONS: This study highlights the likehood of perinatal transmssion of Hepatitis B which might
necessitate revision of the existing infant hepatitis vaccination schedule. Integrated package for HIV and Hepatitis B health
education is advocated.
90
EVALUATION OF PRENATAL EXPOSURE AND MECONIUM COLLECTION
METHODS USING SIMULATED COTININE AND BIRTH WEIGHT DATA
Bo Park, MPH, Brian Lee, PhD
Drexel University
BACKGROUND: Prenatal exposures may adversely impact fetal development. In recent studies, meconium samples were
found to be useful in detecting drug abuse during pregnancy. It is unclear whether varying methods of collecting meconium and
preparation for analysis (e.g., collection at different timepoints) influence resulting effect estimates. A better understanding of
meconium collection variability is needed for efficient exposure measurement strategies in designing epidemiological studies.
STUDY QUESTIONS: To determine whether different methods of meconium collection and analysis influence associations
between cotinine measurements and infant birthweight using simulated data.
METHODS: Cotinine measurements from US population data on smoking among women of child bearing age were used to
simulate profiles of multiple exposures across the pregnancy. True cotinine and birthweight associations were simulated
according to empirical distributions in the literature. Observed cotinine-birthweight associations were calculated according to
different meconimum measurement scenarios.
RESULTS: When the total exposure is of interest, early collection alone overestimates the true association while subsequent
collection yields an underestimate. If early gestational exposure is of interest, then mean exposure may adequately capture the
association whereas two later collections underestimates the association. If late gestational exposure is of interest, neither mean
or early collection yield correct measures of association.
CONCLUSIONS: Understanding exposure patterns and the etiological window of relevance are essential in determining when
and how to collect meconium as a biomarker of prenatal exposure.
PUBLIC HEALTH IMPLICATIONS: Meconium may be metabolically inert and may serve as an ideal medium to represent
cumulative gestational exposure during second and third trimester of pregnancy. A better understanding of meconium collection
and analysis method will allow researchers to fully utilize meconium as a biomarker of prenatal exposures.
91
ANALYSIS OF INCREASING CESAREAN BIRTH TRENDS IN LOS ANGELES
COUNTY
Suvas Patel, MPH, Shin Chao, MPH, PhD, Chandra Higgins, MPH, Cynthia Harding, MPH
Los Angeles County Dept. of Public Health
BACKGROUND: Cesarean births are associated with higher medical risks/complications for mothers and babies than vaginal
births. They also impose a greater cost to the health care system. Recent increases in Cesarean birth rates on the national
level prompted a closer examination of the trend in Los Angeles County (LAC).
STUDY QUESTIONS: Is the Cesarean birth trend within LAC similar to the national trend? What characterizes this trend and
what factors drive it?
METHODS: Analysis of State Vital Statistics Birth records was completed to characterize the Cesarean birth trend in LAC from
2000-2010. C-section rates from 2005-2010 were compared to national data by specific indicators (race/ethnicity and age of
mother, and gestational age). To assess whether pregnancy risk influenced c-section rates, data from 2005-2010 was analyzed
by risk group categories in accordance with Healthy People 2020 pregnancy risk designations.
RESULTS: From 2000-2010, the Cesarean birth rate within Los Angeles County increased marginally (1.2% per year) and was
similar to the national trend. LAC C-section rates from 2005-2010 were also similar to national data by specific indicators: Csection rates increased with mother’s age (greatest in 40+ years old), Cesarean rates increased marginally across all
racial/ethnic groups (greatest among African Americans), and rates increased with decreasing gestational age. Analysis by
pregnancy risk categories shows a greater increase in Cesarean births among high risk pregnancies from 2005-2010. The total
Cesarean rate increased 4% from 2005-2010, c-section rates increased 2% among low-risk pregnancies, and rates increased
15% among high-risk pregnancies.
CONCLUSIONS: Recent increases in the Cesarean birth trend within LAC have been marginal with rates mimicking the national
trend. Consideration of pregnancy risk did play a factor in the LAC Cesarean rates. As the proportion of high-risk pregnancies
increased from 2005-2010, so did the Cesarean birth rate; suggesting that the greater proportion of high risk pregnancies may be
driving the increase in Cesarean births.
PUBLIC HEALTH IMPLICATIONS: Cesarean births result in higher medical risks, complications, and increased recovery time
for mothers. Efforts should be made to educate women on how to prepare for a healthy pregnancy and reduce their risk of
having a cesarean delivery.
92
TETANUS TOXOID, REDUCED DIPHTHERIA TOXOID AND ACELLULAR
PERTUSSIS VACCINATION AND INFLUENZA VACCINATION OF
PREGNANT AND POSTPARTUM WOMEN
Sara Paton, PhD, Colleen McCormick, BS, Sherman Alter, MD
Wright State University
BACKGROUND: Pregnancy increases risk for maternal influenza complications and influenza during pregnancy may result in
adverse perinatal or delivery complications. Most hospitalizations and death due to pertussis occur in infants <2 months.
Influenza vaccine (FLUV) given in pregnancy can protect women and newborns. Tetanus toxoid, reduced diphtheria toxoid and
acellular pertussis (Tdap) vaccine administered in late pregnancy or the postpartum period can protect infants from pertussis. We
investigated vaccine use among pregnant women in a large city hospital.
STUDY QUESTIONS: To determine Tdap and FLUV rates in pregnant and postpartum patients and identify factors associated
with failure to vaccinate.
METHODS: Investigators retrospectively reviewed records of all deliveries at Miami Valley Hospital, Dayton, from January 2009
- December 2010. Data reviewed included age, government vs. private insurance, race/ethnicity, and county of residence. The
numbers receiving (a) Tdap prior, during, and within 6 weeks post-delivery, and, (b) seasonal FLUV before or just after delivery
were collected. History of vaccination by other caretakers was unavailable. Descriptive statistics analyzed prevalence of vaccine
administration, demographic characteristics, and timing of vaccination. Chi square was used to detect differences between these
characteristics.
RESULTS: A total of 9122 charts were reviewed. Forty-one percent had government insurance, 57% private. Seventy percent
were white, 23% black, 4% Latino. FLUV was given to 15% (n=1364) with 40% postpartum, 35% in 3rd trimester, 16% in 2nd,
3% in 1st. A second FLUV (H1N1 swine + seasonal) was given to 7%. Tdap was administered to 35% (n=3152) with 95%
vaccinated postpartum (within 10 days). Tdap uptake was significantly greater among women <20 years of age (45%, p<0.027)
and in persons with government insurance (43%, p<0.0001).
CONCLUSIONS: Despite current recommendations, only a minority of pregnant women received FLUV or Tdap during
pregnancy or postpartum. Vaccination rates were increased with certain patient characteristics, but still represented a minority of
the women. Improved strategies will be needed to increase FLUV and Tdap administration in this population.
PUBLIC HEALTH IMPLICATIONS: Additional efforts should target women >20 years of age and patients with private
insurance. Stronger emphasis on prenatal and perinatal FLUV administration and, as recently recommended, prenatal Tdap
might be of benefit.
93
PREVENTING TEEN PREGNANCY IN NORTHEAST FLORIDA: A
COMMUNITY APPROACH
Erin Petrie, BA
Northeast Florida Healthy Start Coalition
PUBLIC HEALTH AREA:
FOCUS: Reproductive health, Family planning
POPULATION: Adolescents
ISSUE: Teens in the Northeast Florida region give birth at a higher rate than those statewide and nationwide. Nearly one in five
teen mothers in the region will give birth again before leaving their teens. Teenage mothers and their babies are consistently
linked with poor health and socioeconomic outcomes.
SETTING: Five-county area in Northeast Florida.
PROJECT: A regional Northeast Florida Teen Pregnancy Task Force was convened to address the high teen pregnancy rate in
Northeast Florida. The Task Force’s year-long work included collection and review of relevant literature and studies on teen
pregnancy; briefings and conversations with health service providers, school district representatives, organizations that serve
teens; and conducting focus groups with teens, which provided guidance about the priority topics that were on the Task Force’s
agenda. The Task Force developed five themes to focus efforts on and completed a community action plan with overall and
priority implementation strategies.
RESULTS: Since the completion of the Task Force process in October 2011, the Task Force has opted to meet every six
months to follow-up on the implementation strategies. At the initial six-month follow-up meeting of the Task Force, five of the 10
priority implementation strategies had been completed. In addition, two local foundations have dedicated funding to implement
specific strategies outlined in the community action plan. The Task Force will form a subcommittee to review and select grant
applications to fund.
BARRIERS: Many of the implementation strategies require substantial resources and collaboration. Due to the current
economic and political climate in the state, identifying funding resources for and developing political support for non-abstinencebased teen pregnancy prevention is difficult and prevents some of the long-term strategies from implementation.
LESSONS LEARNED: A successful task force requires strong partnerships and a pooling of resources.
94
SHORT INTERPREGNANCY INTERVAL, UNINTENDED PREGNANCY, AND
THEIR JOINT RELATIONSHIP WITH POSTPARTUM CONTRACEPTIVE
NONUSE, FLORIDA PRAMS 2008–2009
Ghasi Phillips, ScD, MS, William Sappenfield, MD, MPH, Leticia Hernandez, PhD, Lindsay Womack, MPH
Florida Dept. of Health, University of South Florida, Council of State & Territorial Epidemiologists
BACKGROUND: Short interpregnancy interval (SIPI) and unintended pregnancy (UIP) share common predictors and are strong
indicators of contraceptive nonuse. However, it is unclear whether SIPI and UIP jointly predict postpartum contraceptive nonuse.
STUDY QUESTIONS: Are SIPI and UIP jointly associated with postpartum contraceptive nonuse and with use of specific
postpartum contraceptive methods?
METHODS: We used 2008–2009 Florida Pregnancy Risk Assessment Monitoring System (PRAMS) data linked with birth
certificate records to assess SIPI (<18 months between the previous live birth or pregnancy outcome and the last menstrual
period for the index birth) and UIP (mistimed or unwanted index pregnancy). The three-level exposure variable was categorized
as having: Neither SIPI/UIP (referent); Either SIPI/UIP; and Both SIPI/UIP. We assessed two postpartum outcomes:
contraceptive nonuse (use, nonuse) and use of specific methods (nonuse (referent), sterilization, long-acting reversible methods
(implants and intrauterine devices), condoms, and pills). Binomial and multinomial logistic regressions were used to estimate
weighted and adjusted odds ratios (aOR), 95% confidence intervals (95%CI), and p-values for dose response (p–trend).
RESULTS: Of 1,140 respondents, 42.2% experienced Either SIPI/UIP while 21.5% experienced Both SIPI/UIP. Thirteen percent
reported nonuse. Either SIPI/UIP (aOR=1.06;95%CI:0.66,1.71) and Both SIPI/UIP (aOR=0.69;95%CI:0.35,1.36) were not
associated with overall nonuse. Relative to Neither SIPI/UIP, Either SIPI/UIP was not associated with sterilization
(aOR=1.38;95%CI:0.77,2.46) whereas Both SIPI/UIP was associated with more than twice the odds of sterilization
(aOR=2.69;95%CI:1.20,6.05; p–trend=0.02). While Either SIPI/UIP (aOR=1.34;95%CI:0.64-2.93) and Both SIPI/UIP
(aOR=2.55;95%CI:0.97-6.71) were not associated with long-acting reversible contraceptives, the pattern of association was
similar to sterilization. Compared with Neither SIPI/UIP, the odds of condom use were significantly lower for Either SIPI/UIP
(aOR=0.38;95%CI:0.20,0.73) but not significantly lower for Both SIPI/UIP (aOR=0.44;95%CI:0.17,1.14). No associations were
observed for contraceptive pills.
CONCLUSIONS: Collectively, no clear dose response was observed for postpartum contraceptive use as levels of the exposure
increased. Either SIPI/UIP was associated with lower odds of using condoms, while Both SIPI/UIP was associated with higher
odds of sterilization.
PUBLIC HEALTH IMPLICATIONS: Women who experience either SIPI or UIP, or both may increase their use of highly
effective methods, such as long-acting reversible contraceptives, through enhanced understanding of permanent versus nonpermanent options of contraception.
95
RE-THINKING RESEARCH TECHNIQUE & BUILDING NEW
COLLABORATIVE PARTNERSHIPS: ASSESSING RESEARCH CAPACITY
IN FAMILY/PARENT LED NON-PROFITS ORGANIZATIONS
Jennifer Bolden Pitre, MA, JD
Statewide Parent Advocacy Network
PUBLIC HEALTH AREA:
FOCUS: Children and youth with special health care needs, Chronic disease
POPULATION: Families
ISSUE: This proposal presents an Organizational Research Capacity Assessment Tool designed to assess the Research
Capacity of Family/Parent led Non-Profits (FPNPO). The propose model is the first of its kind, created to raise consciousness
and start a dialog to further advance the possible role, activities and project funding of Parent/Family led Non-profit
organizations(PFNPO)research projects by analyzing the research capacity of PFNPOs and assessing how the activities and
successes of Parent/Family led organizations may be further highlighted through their presentation of research and other
scholarly work.
SETTING: Collaboration amongst Parent/Family led organizations is key to authentic relationship building and community
empowerment. no one can tell the program impact story like Parent/Family led organizations (PFNPO) who actually do
Community-based Participatory Research (CBPR) in the field. There can be no doubt that scholarly publications by actual
members of PFNPOs will lend further credence to the Federal funding of programs and also aid in establishing the ground work
and documented data needed for program sustainability.
PROJECT: Design a tool to assess the organizational research capacity of parent run non-profits and organizations, (3) Pilot the
tool in the Northeast US region, (or Nationally if possible) through Family Voices (4) Analyze the results and provide feedback.
RESULTS: The data supports the proposition that FPNPO arguably have research capacity, but are not reaching their greatest
research and publication potential for some reason. While participants indicate they are funded at appropriate levels, 50 % do not
have a full-time researcher on staff and only 20% have published a scholarly article. This indicates to the author that perhaps
there is not sufficient funding.
BARRIERS: Language, stakeholder reluctance and competition for funding. Outreach to Non-profits is difficult.
LESSONS LEARNED: Parent leaders may do their own Participatory Research.
96
IDENTIFYING EVIDENCE-BASED PRACTICES THAT LEAD TO
IMPROVEMENTS IN MCHB PERFORMANCE MEASURES: A TOOLKIT FOR
STATES
Ellen Pliska, MHS, CPH
Association of State & Territorial Health Officials
PUBLIC HEALTH AREA:
FOCUS: Other
POPULATION: Intergenerational
ISSUE: Association of State and Territorial Health Officials (ASTHO) developed a toolkit to help Title V programs with program
planning and linking program activities to performance measures. Specifically, this approach was designed to help programs
identify and select evidence-based activities that will be more effective in meeting outcome and process measures.
SETTING: Framework and toolkit pilots occurred in Florida and Wisconsin state health departments. The toolkit could help all
state and local MCH programs better plan programs.
PROJECT: This session leads participants to develop a framework to plan and link their state’s Title V program to national and
state performance measures. Designed to help states identify and select evidence-based program activities, the toolkit assists
MCH programs with setting future needs assessments and annual revisions of projects and programs.
RESULTS: The toolkit guides users through the steps needed to develop and use a logic model to help programs visualize the
full range of program activity choices and the process of translating state/local needs into effective program activities and
broader strategies; link program activity choices to the national or state performance measures via identifying intermediate
factors or measures that are amenable to change (by Title V programs); consider factors that may influence implementation of
selected efforts that could affect achieving identified outcomes; and support monitoring and tracking of progress toward
performance measures and goals. The session can help participants make the case for planning and including more robust
lifecourse activities in their programs.
BARRIERS: During the pilot test of the toolkit, some participants were not familiar with logic models. In response, we developed
the tool to teach how basic logic models work.
LESSONS LEARNED: The session guides users to develop and use a logic model to help their programs translate state/local
needs into effective program activities and broader strategies; identify intermediate factors affecting national or state
performance measures that are amenable to change (by Title V programs); and support monitoring and tracking of progress
toward outcome and process measures.
97
STATE HEALTH DEPARTMENT STRATEGIES TO IMPROVE BIRTH
OUTCOMES
Ellen Pliska, MHS, CPH
Association of State & Territorial Health Officials
PUBLIC HEALTH AREA:
FOCUS: Adverse perinatal outcomes, Life course perspective
POPULATION: Infants, Women, Families
ISSUE: In January 2012, HRSA hosted an Infant Mortality Summit for HHS Regions IV and VI. The summit facilitated teams of
6-7 participants, including the state health officer, MCH director, and Medicaid director for each state. Teams developed
strategies to improve birth outcomes and reduce infant mortality from each of the 13 South Eastern states.
SETTING: The HRSA Infant Mortality Summit took place on January 11-13, 2012, in New Orleans, Louisiana. The state team
plans came from Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, North Carolina, Oklahoma, South Carolina,
Tennessee, and Texas.
PROJECT: Analyze similarities and differences in state health department strategies to improve birth outcomes; give attendees
information on how to increase collaboration across multiple departments and organizations; and identify promising practices in
improving birth outcomes in states.
RESULTS: State strategies towards improving birth outcomes and reducing infant mortality included implementing state policies
to eliminate elective C-sections and inductions prior to 39 week gestation; developing a regional campaign to address life course
health, smoking cessation, chronic conditions, and influenza immunizations; and implementing safe sleep campaigns.
BARRIERS: Multi-sector state teams had to decide on state plans to improve birth outcomes in their states and how to
incorporate hospitals, universities, locals, and the private sector into state health department activities.
LESSONS LEARNED: While states selected similar action plans to improve birth outcomes and reduce infant mortality, their
strategies varied between hospital policies, payment mechanisms, multi-sector collaboration, and individual and provider
education.
98
MEDICAL HOME AND PUBLIC HEALTH NURSING PARTNERSHIP
DEMONSTRATES SUCCESS IN CHILDHOOD ASTHMA OUTCOMES
Dona Putnam, MPH, PHN, RN, Patricia Zerounian, MPP, Krista Hanni, MS, PhD
Monterey County Health Dept.
BACKGROUND: In California, asthma is a frequent cause of emergency room visits and hospitalizations making it a costly
disease. In 2009, 44% of Monterey County, California, Latino children aged 0-17 years who had been diagnosed with asthma
had an emergency room visit within the last 12 months.
STUDY QUESTION(S): This study sought to determine if better health outcomes for children diagnosed with peristent asthma
could occur through a medical home and public health nurse home visitation model.
METHODS: A study group of 30 clients (ages 0-17 years, primarily Latino) diagnosed with persistent asthma by their primary
care physician were offered enhanced care including case management and home visits. Parents were surveyed at baseline and
follow-up telephone assessments were made at three and six month post intervention.
RESULTS: At three months post intervention, there was a 25% gain (from 45% to 68%) in the percentage of children who did
not visit the emergency department for treatment of asthma episodes; a 13% decrease (from 40% to 27%) in the percentage of
children who visited the emergency department once or twice for treatment of asthma episodes; a 37% gain (from 31% to 68%)
in the percentage of children who did not miss any school days due to asthma symptoms; and a 21% gain (from 33% to 54%) in
the percentage of children who did not need to use asthma medications during the prior week. The evaluation will continue until
6-month post-intervention to determine if improvements are sustained. Additional data analysis will determine if correlations
exist between patient health outcomes and the number of clinical visits kept during the post-intervention period, and to provide a
cost savings analysis.
CONCLUSIONS: The strategies of the interventions are increasing asthma knowledge and improving functional outcomes.
Clients and parents gained knowledge about how to self-manage asthma symptoms, decreased number of emergency
department visits and decreased the use of asthma medications.
PUBLIC HEALTH IMPLICATIONS: This project has identifed a model of care that will be institutionalized within Monterey
County's Federally Qualifed Health Clinics (FQHC) look alikes as part of a tiered best practice strategy of asthma care.
99
PET OWNERSHIP DECREASES RESPIRATORY RESPONSES TO AIR
POLLUTION IN CHILDREN: THE SEVEN NORTHEASTERN CITIES (SNEC)
STUDY
Zhengmin Qian, MD, PhD, Guang-Hui Dong, PhD, Miao-Miao Liu, MD, Da Wang, MD. Wan-Hui Ren, PhD, Maayan
Simckes, BS, Qiang Gu, MD, PhD, Jing Wang, PhD, Alan Zelicof, MD, Edwin Trevathan, MD, MPH
St. Louis University School of Public Health, China Medical University School of Public Health, Shenyang Environmental
Monitoring Center
BACKGROUND: Evidence indicates that pet ownership and exposure to ambient air pollution are both important factors for
respiratory symptoms and asthma in children. Few studies have examined the potential interaction of air pollution and pet
ownership on respiratory health effects. Little is known about whether or not pet ownership modifies the relationship between air
pollutants and respiratory symptoms and asthma in children.
STUDY QUESTION(S): Does pet ownership modify the associations between ambient air pollution concentrations and
prevalence of respiratory symptoms and asthma in Chinese children?
METHODS: We conducted a large cross-sectional study in the seven northeastern cities (SNEC) in China. We recruited 30,149
children, aged 2-to-12 years from 25 districts of the SNEC. Parents of the children completed questionnaires that characterized
the children’s histories of respiratory symptoms and illnesses and associated risk factors. We measured average ambient annual
exposures to particulate matter with an aerodynamic diameter =10 µm (PM10), sulfur dioxide (SO2), nitrogen dioxide (NO2), and
ozone (O3) in monitoring stations in each of the 25 study districts.
RESULTS: Among children without pets at home, there were statistically significant associations between both recent
exacerbations of asthma among physician-diagnosed asthmatics and respiratory symptoms and all pollutants examined. Odds
ratios (ORs) ranged from 1.12 [95% confidence interval (CI), 1.00-1.26] to 1.41 (95%CI, 1.24-1.61) per 31µg/m3 for PM10,
whereas, among children with pets at home, there were no effects or small effects for either asthma or the symptoms. The
interactions between dog ownership and PM10, SO2, NO2, and O3 were statistically significant, such that children with a dog at
home had lower reporting of both current asthma and current wheeze.
CONCLUSIONS: Pet ownership may decrease the air pollution effects on respiratory symptoms and asthma among Chinese
children.
PUBLIC HEALTH IMPLICATIONS: The present study, along with future variants adjusted to address the limitations, should be
conducted in other environments with a different population and a study design. In the long term, if evidence continues to point
towards protective capabilities of animal exposure, there may be the potential for an entirely new branch of respiratory medicine
encompassing the use of animal therapy.
100
EDUCATING POLICY MAKERS ABOUT LOCAL MCAH NEEDS AND
PROGRAMS: BARRIERS AND STRATEGIES
Jennifer Rienks, PhD, MS, Katherine Gillespie, MA, MPH
University of California San Francisco - Family Health Outcomes Project
BACKGROUND: California’s elimination of all state funding for local Maternal, Child and Adolescent Health (MCAH) Programs
and threatened cuts to the federal Title V MCH block grant underscore the importance of educating policy makers about the
services delivered and benefits produced by these programs.
STUDY QUESTION(S): To what degree are California’s local MCAH Directors educating policy makers at local, state, and
national levels and what are the barriers and possible strategies to overcome these barriers?
METHODS: The Family Health Outcomes Project at UCSF, in conjunction with MCAH Action Policy Committee, developed an
online survey for local MCAH Directors. The survey was completed 46 out of 61 MCAH Directors (75% response rate). Basic
frequencies were computed for quantitative data.
RESULTS: When asked how often they sent a letter, electronic message, made a phone call, or met with a policy maker at the
local, state or national level, the majority of MCAH directors had done none of these things. Among those who took any action,
on a local level they were most likely to have met with a policy maker (39%), and on state and national levels were most likely
to send an electronic message (state: 33%, national: 35%). Enlisting others to advocate for MCAH issues was more common
(50% at the local and state levels). Barriers to educating policy makers include the need for approval from a supervisor (89%);
not being allowed to meet with policy makers (approximately 83%), too much other work (87%), and needing to take time off
work to meet with policy makers (85%). The most popular strategies to help communicate with policy makers are providing
Directors with sample letters and emails (85%), materials such as fact sheets developed specifically for policy makers (83%) and
specific scripts for what to say when making a phone call (78%).
CONCLUSIONS: Local MCAH Directors frequently experience barriers to educating policy makers which is reflected in the low
level of contact and communication at all levels.
PUBLIC HEALTH IMPLICATIONS: To ensure ongoing support for and adequate funding of local MCAH programs, effort are
needed to reduce barriers and build local MCAH Director capacity to educate policy makers.
101
FACTORS ASSOCIATED WITH POSTPARTUM SMOKING RELAPSE
FOLLOWING CESSATION DURING PREGNANCY IN HAWAII – DATA FROM
THE HAWAII PREGNANCY RISK ASSESSMENT MONITORING SYSTEM,
2009-2010
Emily Roberson, MPH
Hawaii Dept. of Health
BACKGROUND: Maternal smoking postpartum is associated with poor health outcomes for mother and infant. The Hawaii
Pregnancy Risk Assessment Monitoring System (PRAMS) provides detailed data on underrepresented racial/ethnic groups. In
2009 new survey questions were added which provide additional information regarding perinatal smoking.
METHODS: Hawaii PRAMS data from 3180 respondents were used to estimate prevalence of postpartum smoking relapse
following cessation during pregnancy. Data were weighted to be representative of all pregnancies resulting in live births in
Hawaii in 2009 and 2010. Logistic regression was used to estimate adjusted associations of demographic, clinical and behavioral
factors with postpartum smoking relapse. The final model included maternal age, race/ethnicity, education, household income
and whether the mother had quit smoking before or after starting prenatal care (early vs. late quitting).
RESULTS: Of the 21.7% (95%CI: 19.9-23.6) of recently-pregnant women in Hawaii who reported smoking cigarettes in the
three months before pregnancy, 60.2% (95%CI: 55.4-64.8) reported quitting by their last trimester. However, 39.6% (95%CI:
33.9-45.7) of women who quit during pregnancy relapsed postpartum. Prevalence of postpartum smoking relapse was highest
among women who had less than a high school education (63.6%; 95%CI: 43.5-79.8), had an annual household income less
than $10,000 (52.2%; 95%CI: 39.3-64.9) and were Japanese (50.8%; 95%CI: 31.2-70.1). The significant predictors of
postpartum smoking relapse were: Japanese ethnicity (ref: Caucasian; aOR 3.0; 95%CI: 1.1-8.0), annual income less than
$50,000 ($10,000-49,999: aOR 2.7; 95%CI: 1.4-5.5; <$10,000: aOR 2.7; 95%CI: 1.1-6.5), and quitting smoking after prenatal
care began (aOR 2.2; 95%CO: 1.2-3.9).
CONCLUSIONS: Prevalence estimates of postpartum smoking relapse differed by demographic characteristics in Hawaii.
Significantly associated factors in the multivariable model were Japanese ethnicity, income less than $50,000 annually, and
quitting smoking after starting prenatal care.
PUBLIC HEALTH IMPLICATIONS: This research is part of a collaboration between the Hawaii PRAMS and Tobacco programs.
Determining what factors are associated with postpartum smoking relapse can help inform healthcare providers as well as those
developing and operating smoking cessation programs.
102
ESTIMATING THE NUMBER AND UNDERSTANDING THE
CHARACTERISTICS OF AMISH BIRTHS IN WISCONSIN
Angela Rohan, PhD, Jessica Seay, MPH, Murray Katcher, MD, PhD
Wisconsin Division of Public Health, Centers for Disease Control & Prevention
BACKGROUND: Wisconsin has the fourth largest Amish population in the US. Identifying Amish births and encouraging
community participation in screening programs is important because of traditional concerns about cost and invasiveness of
medical treatment. Amish status is not available on the birth certificate.
STUDY QUESTION(S): Can a method be developed to estimate the number and geographic distribution of births that may occur
to Amish women using vital records data? Do the characteristics and outcomes associated with these births differ from other
births in Wisconsin?
METHODS: Distinguishing characteristics of births that may have occurred to Amish women were identified using literature
review and expert input. Using this information an algorithm was developed to identify probable Amish (PA) births as those with
the following cluster of maternal characteristics: non-Hispanic, white, 18+ years of age, elementary-level education, and married.
The geographic distribution of these results was compared with the location of Amish settlements in the state using a Pearson
correlation. Characteristics of PA versus other Wisconsin births were compared using chi-square tests.
RESULTS: For 2005-2009, 880 average annual births in Wisconsin were identified as PA births using the above algorithm
(1.2% of all births). The number of PA births was highly correlated with the number of Amish settlements by county (Pearson
r=0.87). Characteristics significantly (p<0.0001) more prevalent among PA versus non-PA births included elementary-level
paternal education (91.0% vs. 0.5%); interpregnancy interval <24 months (81.1% vs. 46.0%); and out-of-hospital birth (81.0% vs.
0.8%). Characteristics significantly (p<0.0001) less prevalent among PA versus non-PA births were cesarean delivery (6.9% vs.
25.1%), receipt of first trimester prenatal care (20.0% vs. 84.3%), smoking during pregnancy (1.9% vs. 14.4%), medical doctor
birth attendant (21.9% vs. 92.2%), and low birth weight (3.4% vs. 7.1%) or preterm (5.6% vs. 11.2%) birth.
CONCLUSIONS: The selected algorithm provides an estimate of the number of PA births in Wisconsin, and characteristics and
outcomes that distinguish these births from other Wisconsin births. Next steps include working with partners to further validate
the algorithm.
PUBLIC HEALTH IMPLICATIONS: Understanding the number, characteristics, and geographic distribution of Amish births
could contribute to outreach and program planning and provides a foundation to examine Amish screening rates.
103
ASSOCIATION BETWEEN PHYSICAL ACTIVITY AND POSTPARTUM
WEIGHT RETENTION FROM A POPULATION-BASED STUDY
Kenneth Rosenberg, MD, MPH, Chia-Hua Yu, MBI
Oregon Office of Family Health
BACKGROUND: Women who retain pregnancy weight gain are at increased risk of diabetes and other health problems.
STUDY QUESTIONS: Is physical activity associated with decreased risk of retaining pregnancy weight gain?
METHODS: The Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) is a stratified, population-based survey of
women who have recently had a live birth. PRAMS respondents receive a follow-back survey (PRAMS-2) shortly after their
child's second birthday. Data are from 1302 respondents who had live births in 2004-2005 (re-interviewed 2006-2008 with no
intervening pregnancy); weighted response rate 43.5%. Physical activity was defined as engaging in at least 30 minutes of
physical activity at least once a week. Significant weight retention was defined as retaining more than 5kg, calculated by
subtracting the pre-pregnancy weight reported in PRAMS from the weight reported in PRAMS-2. Multivariate logistic regression
in Stata was used for the analysis.
RESULTS: 79.4% of respondents reported partaking in at least 30 minutes of physical activity at least once a week in the month
prior responding to the PRAMS-2 survey. 32.3% of women retained more than 5 kg (~11 lbs) from a previous pregnancy.
Overall, women who engaged in at least one day of physical exercise per week were less likely to retain pregnancy weight
(adjusted odds ratio: 1.73; 95% confidence interval: 1.04-2.86), after controlling for parity.
CONCLUSIONS: Engaging in at least 30 minutes of physical activity at least once a week is significantly associated with
decreased risk of retaining pregnancy weight gain?
PUBLIC HEALTH IMPLICATIONS: To help women lose pregnancy weight gain, women need to learn about the importance of
physical activity and be able to find opportunities for physical activity. We also need to learn more about how change in diet
interacts with changes in physical activity to help women return to a healthy weight after pregnancy. We also need to explore
how long-term physical activity changes affect women’s risk of diabetes, heart disease and other chronic diseases.
104
IMPROVING RELATIONSHIPS BETWEEN OREGON TRIBAL HEALTH
AUTHORITIES AND THE OREGON PRAMS PROGRAM
Kenneth D. Rosenberg, MD, MPH, Kathryn Broderick, MPA
Oregon Office of Family Health, Oregon Health Authority
PUBLIC HEALTH AREA:
FOCUS: Health equity, Social justice, Immunization
POPULATION: Infants, Women
ISSUE: The Oregon PRAMS program has collaborated with the Northwest Portland Area Indian Health Board but not directly
with individual tribes. Therefore, most Oregon Tribal Health Authorities have limited awareness of Oregon PRAMS and other
data resources available from the Oregon Public Health Division.
SETTING: Oregon’s 9 federally recognized tribes.
PROJECT: In response to a national effort to increase surveillance for H1N1 influenza among American Indian and Alaska
Native (AI/AN) pregnant women, Oregon was provided with supplemental PRAMS funds. The plan to increase the response rate
for PRAMS among this population required making presentations about PRAMS to tribal health staff to inform them about this
MCH data resource and enlist their assistance in encouraging women to respond. State staff attended several meetings and
convened a number of conference calls with tribal representatives while attempting to hire an American Indian program
coordinator who would ultimately assemble a Tribal Advisory Committee for the project. One additional project element being
pursued includes determining breastfeeding and tobacco (quit and stayed quit) rates among AI/AN women.
RESULTS: We have identified representatives in 5 of the largest Oregon tribes and one urban Indian organization interested in
collaborating on the use of MCH data. We will soon be hiring a fulltime program coordinator to continue meeting with tribal health
staff, inform them of existing data resources, and develop analyses that will help them in their work.
BARRIERS: Oregon government had a hiring freeze which delayed hiring a program coordinator by 4 months. Although MCH
surveillance is an interest of many tribal health leaders, it is not their highest concern.
LESSONS LEARNED: (1) CDC and state health department timelines may not coincide with tribal timelines; (2) contacts with
tribal health staff should, as much as possible, be face-to-face; (3) tribal health staff are stretched thin so collaborative projects
need to address high priority issues specific to their own tribes.
105
FATHER INVOLVEMENT DURING PREGNANCY IN A BLACK COMMUNITY:
IDENTIFYING PERCEPTIONS AND EXPECTATIONS
Jamila Seaton, BS, Natalie Rella, BA, Erica Coates, BA, Adejoke Ogunrinde, MBBS, Atalie Ashley, BA
University of South Florida
BACKGROUND: In Florida, the rate of infant mortality among the Black population has been consistently higher than the rate
among the White population. The disparity in Hillsborough County is more severe where the Black infant mortality rate is more
than 3 times higher than the White infant mortality rate. Research has explored various factors that affect infant mortality, and
paternal involvement (PI) during pregnancy has emerged as a potential mechanism through which birth outcomes may be
improved. However, little is known about PI during pregnancy. In order to develop culturally competent research questions and
intervention strategies, it is essential to understand the perceptions of PI within the Black community to address infant health
disparities.
STUDY QUESTIONS: What language is used by the Black community in Hillsborough County to: reference paternal
involvement, the expectations they have for the father of their child, and the support desired from or provided by the father?
METHODS: In this study, a Community- Based Participatory Research approach was employed to discern the language and
expectations that characterize PI in the Black community while identifying types of support desired from a father. Participants
were recruited from the East Tampa community, and 38 residents, over the age of 18, participated in 10 focus groups.
Participants included men (n=14) and women (n=24). Codes were developed a priori, categorizing broad themes and constructs
found in current research. Each focus group session was recorded, transcribed and coded; codes were entered into ATLAS.ti
software for analysis.
RESULTS: Descriptions of physical support, emotional support, and support from others were provided by over 80% of
participants; responsible actions, commitment, and parental cooperation by over 70% of the participants; and other related
themes by over 87% of the participants. Fathers’ upbringing and intentions of pregnancy were also associated with PI.
CONCLUSIONS: Support, responsibility, relationship, barriers and other related themes were prominent domains, and fathers
desired multilevel support.
PUBLIC HEALTH IMPLICATIONS: The results have implications that include exploration of parental cooperation and
pregnancy intention. In addition, the study revealed the need to develop father-friendly programs and provision of father-specific
mentorship and support services.
106
PRACTICAL PEDIATRICS: INTEGRATING CLINICAL KNOWLEDGE INTO
COMMUNITY TOBACCO PREVENTION
Regina Shaefer, MPH, Kiran Patel, MPH, CHES,
American Academy of Pediatrics, Organization
PUBLIC HEALTH AREA:
FOCUS: Chronic disease, Community collaboration
POPULATION: Children, Adolescents, Families
ISSUE: In 2010, the American Academy of Pediatrics (AAP) was funded through the Communities Putting Prevention to Work
(CPPW) initiative to provide technical assistance (TA) to communities working to decrease smoking prevalence, teen initiation,
and secondhand smoke (SHS) exposure. As a national TA provider, AAP worked to bridge the gap between clinical expertise
and local tobacco control. While electronic resources were available, the AAP specifically sought to provide communities with
access to tobacco control expert physicians.
SETTING: CPPW-funded communities across the United States focusing on tobacco prevention and control
PROJECT: Involving healthcare providers in tobacco control efforts can show strong results; however, many communities did
not have the resources or connections to link directly with local physicians. After identifying this gap, the AAP worked to connect
CPPW communities with local and national physician experts and advocates through state AAP chapters and the AAP tobacco
faculty expert panel.
RESULTS: Physician involvement has made an impact in several communities. In Philadelphia, a local pediatrician testified to
help increase fines for retailers selling tobacco to minors. The Philadelphia Department of Health later hosted another Academy
expert to educate pediatricians about their role in cessation at a low-income, urban hospital. In San Jose (CA) physicians,
nurses, social workers, dietitians, and other public health staff attended sessions focused on understanding the effects of
tobacco. These are just two of several examples that highlight the impact physicians can have on policy, systems, and
environment change related to tobacco control.
BARRIERS: The short funding period and coordination of TA across organizations proved to be a challenge. The AAP worked
to overcome these issues by offering the medical/clinical perspective.
LESSONS LEARNED: While the CPPW initiative has ended, linking state and local public health advocates with AAP chapters
and national pediatric leaders is a sustainable practice. Public health departments can continue to initiate and advance
relationships with the clinicians in their communities with the support of the AAP. The Academy is currently evaluating the value
of these fostered partnerships. Preliminary results showing the impact on involving physicians in local tobacco control efforts will
be available in time to present at the meeting.
107
PREDICTORS OF VACCINATION CARD RETENTION OF CARETAKERS OF
CHILDREN UNDER FIVE YEARS OF AGE IN KARACHI, PAKISTAN
Sana Sheikh, MBBS, Asad Ali
The Aga Khan University
BACKGROUND: Low card retention has been a barrier in accurately estimating the vaccine uptake. Vaccine coverage surveys
have to use both parental recall and vaccine card review but parental recall has been questionable to estimate vaccine coverage.
STUDY QUESTION: What are the predictors of vaccination card retention among care takers of 12-59 months old children in
Karachi, Pakistan.
METHODS: It was an analytical cross-sectional study in Karachi. Households were randomly selected through multistage
cluster sampling technique. 504 eligible children 12-59 months of age from these households were enrolled. Questionnaire was
administered to caretakers to gather information of child’s vaccination status through vaccination card or by recall and sociodemographic characteristics. Statistical analysis was done by SPSS 19 using logistic regression.
RESULTS: Among 462 vaccinated children, caretakers of only 33% provided vaccination card. Odds of card retention decrease
if caretaker has large size of household (> 5 people sharing one room) (AOR0.27, 95% CI (.09, .79) and if has child of four to five
years of age (AOR .54 (.30, .97). Gender of child, parental education and access to electronic media were not significant
predictors in our study.It would have been interesting to look at some other variables such as number of children < five years of
age, difference between vaccinating from public and private sector, ever been a part of education intervention on vaccination and
reasons for not keeping card safely.
CONCLUSIONS: Our study showed that vaccine card retention for children 12-59 months of age was low (33%) in Karachi.
There is a need to educate caretakers of young children regarding importance of vaccination card keeping and to disseminate
this information through vaccine providers. Improving vaccine card retention will help in accurately estimating vaccine coverage
and to inform health policy makers and designing interventions to improve vaccine uptake.
PUBLIC HEALTH IMPLICATIONS: Finding of our study gave an insight of why vaccine cards are not kept safely. Policy makers
can focus on these factors and design interventions to educate parents on importance of card keeping which will be later helpful
in accurately estimating vaccine uptake.
108
ASPECTS OF MATERNAL HEALTH IN PAREWADIN VILLAGE OF NEPAL
Suman Singh, DM
B.P. Koirala Institute of Health Sciences
BACKGROUND: The health care during pregnancy and at the time of delivery is important. Nepal is committed to a threefourths reduction in maternal mortality ratio (MMR) by the year 2015. The MMR in Nepal is still 281 deaths per 100,000 births.
Nepal is a country of diversity. The studies about the maternal health in Nepal have not characterized the aspect of maternal
health in Parewadin village. Basic needs of living particularly health and education still remain unmet.
STUDY QUESTIONS: What are the aspects of maternal health for Parewadin village of Nepal?
METHODS: A cross sectional study was done in Parewadin village of Dhankuta district of Nepal. House to house visits were
done in randomly selected wards of the village to enroll the eligible 244 married women (15-49 years) giving birth within 5 years
preceding the visit. They were interviewed using semi-structured questionnaire. Data analysis was done in SPSS 12 version for
proportion, percentage and Chi-square test. Selection of the study units was limited to those happened to be available at the time
of data collection.
RESULTS: Majority of women (60%) married below the age of 20 years. About 29% of the mothers were illiterate. More than
62% women were living below the poverty line. Only 29% had 4 or more antenatal care (ANC) visits. Home delivery constituted
86% of deliveries. Around 52% mothers did not use delivery kit. About 56% women were unaware of warning signs of
pregnancy. More than 74 % women had no prepared-plan for delivery. Only 23% women attended 1 PNC visit. Literacy of the
mothers significantly affected the number of births, ANC visits and the knowledge regarding the warning signs of pregnancy (p <
0.05).
CONCLUSIONS: ANC visit is low. Literacy affects births, ANC visits and awareness of danger signs of pregnancy. PNC visit is
less practiced. Many women don’t have prepared-plan for delivery. Home delivery is common.
PUBLIC HEALTH IMPLICATIONS: The current study could alert administrators to organize better services so as to reduce the
maternal morbidity and mortality at the particular community level.
109
CESAREAN DELIVERY IN SOUTH CAROLINA: AN ANALYSIS OF BIRTH
CERTIFICATE AND PREGNANCY RISK ASSESSMENT MONITORING
SYSTEM (PRAMS) DATA
Michael Smith, MSPH, Daniela Nitcheva, PhD, Kristin Simpson, MSW, MPA, Shae Sutton, PhD
South Carolina Dept. of Health & Environmental Control
BACKGROUND: Though a cesarean delivery can be a life-saving operation, reducing the rate of cesarean deliveries among
low-risk women giving birth for the first time to 23.9% and reducing repeat cesareans for low-risk women to 81.7% are Healthy
People 2020 goals.
STUDY QUESTIONS: What are the trends and risk factors associated with cesarean deliveries in South Carolina? Furthermore,
what are mother-reported reasons for cesarean deliveries in South Carolina?
METHODS: South Carolina birth certificate data are used to assess trends in cesarean delivery among 950,168 low-risk women
delivering live births from 1989-2009. Bivariate (Chi-square) and multivariate (logistic regression) methods are used to assess
risk factors for cesarean delivery using data from 682 women delivering live births and completing PRAMS surveys in 2009.
Finally, the prevalence of reasons for cesarean delivery reported in PRAMS by the mother is considered.
RESULTS: The prevalence of cesarean delivery among low-risk deliveries was consistently around 20% from 1989-1999,
before increasing steadily from 20.6% in 1999 to 31.4% in 2009. Over 91% of low-risk women with a previous cesarean had a
repeat cesarean in 2009, well above the Health People 2020 goal. Controlling for other factors, women that were underweight,
overweight, obese, or had education beyond high school had greater odds of having a cesarean delivery. Meanwhile, mothers
19 years of age or younger had lesser odds of cesarean delivery than older mothers. The most commonly reported reason for a
cesarean delivery was having had a previous cesarean (39.1%), while less than 6% of women reported that wanting to schedule
their delivery or not wanting to have a vaginal delivery were reasons for their cesarean delivery.
CONCLUSIONS: There has been a substantial increase in the prevalence of cesarean delivery in South Carolina in the last ten
years, mirroring national trends. However, the vast majority of women delivering via cesarean in South Carolina in 2009 report a
medical indication or a previous cesarean as the reason for their cesarean delivery.
PUBLIC HEALTH IMPLICATIONS: Efforts to eliminate non-medically indicated cesarean deliveries are essential, but may not
result in the attaining of the Healthy People 2020 goals in South Carolina.
110
LOCAL HEALTH DEPARTMENT COLLABORATIONS IN MATERNAL,
CHILD, AND ADOLESCENT HEALTH
Laura Snebold, MPH, Jessica Carda-Auten, MPH, L. Michele Issel, PhD, RN, Carolyn J. Leep, MS, MPH, Christine
Brickman Bhutta, PhD,, Hale Thompson, Nathalie Robin, MPH, Arden Handler, DrPH
National Association of County & City Health Officials, University of Illinois at Chicago School of Public Health,
BACKGROUND: Since the start of the recession, many local health departments (LHDs) have faced budget cuts and reduced
revenues. The financial crisis at the local level is affecting maternal, child, and adolescent health (MCAH) services, which have
historically constituted a large portion of LHD services/programs. At the same time, the life course approach, which requires
partnerships beyond health, has been embraced by the MCH field. Yet, we know little about the LHD collaborations that ensure
the delivery of key MCAH services/programs.
STUDY QUESTION(S): What is the nature and extent of current and desired collaborations between LHDs and other entities?
METHODS: An online survey was conducted in April-May 2012, using a sample of National Association of County and City
Health Officials (NACCHO) members stratified by size of the LHD and randomly selected within strata. Of the 546 LHDs invited
to participate, 269 returned usable surveys (49%). Respondents were mostly from LHDs serving populations of fewer than
50,000 (n=137,51%). All data were collected via a secure link to an online questionnaire designed in Qualtrics. LHDs pilot tested
the survey and informed the list of 21 potential collaborators. Respondents indicated their current collaborations and their desire
for new collaborators. For ease of analysis, the list of 21 collaborators was divided into: government, health, non-health, and
colleges/universities. All analyses are performed in STATA.
RESULTS: The mean number of collaborations between LHDs and government agencies is 205.25 (n=246), dropping to 163.14
for non-health agencies, 140.38 for health agencies, and 122.00 for colleges/universities. The top 5 entities with which LHDs are
not currently collaborating, but want to collaborate: colleges/universities (35); local recreation departments (31); religious
institutions (29); hospitals-emergency departments (25); hospitals-administration (20).
CONCLUSIONS: Collaboration may be a key strategy to meet the needs of MCAH in stressful economic times. These
preliminary results also demonstrate that LHDs are leveraging and seeking myriad opportunities for collaboration, which may
foster a life course approach to MCAH.
PUBLIC HEALTH IMPLICATIONS: LHDs may need support from national organizations and state health agencies to maintain
and develop new partnerships. Such collaborations may increase the ability of entire communities to promote the health of
women, children, adolescents, and families.
111
HEALTH PLAN APPROACHES TO PRECONCEPTION HEALTH
Claire Speeding, MPH, CHES, Kathryn Santoro, MA
National Institute for Health Care Management Foundation
BACKGROUND: Research has shown that improving women’s access to preconception and interconception care has the
potential to improve reproductive health outcomes and thus reduce the financial, emotional and physical burdens associated with
infant mortality and prematurity. Lack of access to health insurance has been documented as a barrier to receipt of
preconception care. The Affordable Care Act will provide more women of childbearing age access to health insurance, and
health plans are poised to impact the health of millions of women. Research surrounding health insurers and their philanthropic
foundations’ efforts regarding the promotion of preconception care is scarce.
STUDY QUESTIONS: Is preconception health a priority for Blue Cross Blue Shield health plans/foundations and what are their
strategies for increasing access to preconception care?
METHODS: NIHCM Foundation conducted studies of nine health insurers/foundations via in-depth phone interviews. The
interviews lasted approximately one hour and were guided by a structured instrument. Content analysis was used to group
insurers according to type of preconception health activities and program impacts. The study was limited by the small sample
size and the non-random selection of plan/foundation participants.
RESULTS: NIHCM Foundation staff found that health plans are engaging in innovative approaches to preconception health
including: strengthening preconception health as a component of maternity programs; utilizing new media such as video
storytelling, social media and other interactive health communication approaches; funding community efforts that incorporate
preconception health messages into prevention messaging; and promoting health literacy as early as adolescence so that
women can make appropriate health decisions and adopt healthy behaviors. NIHCM found that health insurers/foundations face
barriers to promoting preconception care; some reported positive initial response to their preconception programs with one
program yielding a measurable increase in knowledge among participants.
CONCLUSIONS: Health insurers and their foundations are investing in programs and services that encourage women to seek
preconception care. Health insurers/foundations can continue to support the proliferation of preconception health information by
investing in innovative health communication approaches.
PUBLIC HEALTH IMPLICATIONS: Other health plans, foundations, community organizations and government agencies can
learn from health plans/ foundations’ experiences implementing preconception health programs and explore partnerships with
health plans/foundations.
112
OBSTETRIC PROVIDER SHORTAGE AND MALDISTRIBUTION IN GEORGIA
Bridget Spelka, BA, Adrienne Zertuche, MD, MPH, Pat Cota, RN, MS, Andrew Dott, MD, MPH, Roger Rochat, MD
Emory University School of Medicine, Rollins School of Public Health, Georgia Obstetrical & Gynecological Society
BACKGROUND: Georgia has the nation’s highest maternal mortality rate, the tenth highest infant mortality rate, and a declining
obstetrician/gynecologist workforce. Access to obstetric care is directly linked to maternal and infant health outcomes; yet,
existing statewide obstetrician/gynecologist rates mask both obstetric-specific care shortages and regional variation in access to
services.
STUDY QUESTIONS: The Georgia Maternal and Infant Health Research Group (1) assessed the state’s obstetric provider
workforce to identify service-deficient areas and (2) created a statewide map of obstetric provider shortages to illustrate
geographical variation in access to care.
METHODS: We identified 63 birthing facilities in the 82 Primary Care Service Areas (PCSAs) outside metropolitan Atlanta and
interviewed the nurse manager at each to assess obstetric provider workforce and to survey each delivering professional’s age,
sex, and expected year of departure. We applied annual delivery rates of 155 deliveries per obstetrician (OB), 100 per certified
nurse midwife (CNM), and 70 per family practice physician (FP) to convert the range of obstetric providers into OB equivalents.
Using facility births and computed OB equivalents (contemporary and 2020 estimates), we calculated current and projected
average annual deliveries per provider (AADP) for each PCSA, categorizing its obstetric provider workforce as “adequate” if
AADP <144, “at risk” if 144<= AADP <166, and “deficient” if AADP <=166. Results were mapped using ArcGIS.
RESULTS: Of the 82 surveyed Georgia PCSAs, 52% (43) are deficient in obstetric care; 16% (13) have a shortage and 37%
(30) lack obstetric providers entirely. There are no delivering FPs in 89% (73) of PCSAs and no CMNs in 70% (56). If Georgia
fails to recruit new delivering providers, 75% (58/77) of PCSAs will have deficient or no obstetric care by 2020.
CONCLUSIONS: The obstetric provider shortages in many areas of Georgia hinder women’s access to prenatal care and labor
and delivery services. The care-deficient areas will soon expand if recruitment and retention of delivering professionals does not
improve.
PUBLIC HEALTH IMPLICATIONS: Targeted initiatives that address the growing obstetric provider shortage can bolster
Georgia’s efforts to improve its grave maternal and infant mortality rates.
113
PREDICTING DISCREPANCY IN CHILD BEHAVIOR SCORESBETWEEN
MOTHER-CHILD AND TEACHER-CHILD RATINGS; DOES MOTHER KNOW
BEST?
Sarah Stone, MPH, Matthew Speltz, PhD, Brent Collett, PhD, Martha Werler, ScD
Boston University School of Public Health (Dept. of Epidemiology), University of Washington (Dept. of Psychiatry & Behavioral
Sciences), Slon
BACKGROUND: Studies of childhood behavior problems can utilize reports by parents and teachers. However,
correspondence across respondents tends to be low (i.e., r<0.30) and discrepancies can obfuscate interpretation. Furthermore,
discrepancies may be associated with other demographic or clinical characteristics.
STUDY QUESTION(S): Do indicators of socioeconomic status (SES) predict parent-teacher discrepancies in non-clinically
referred children?
METHODS: In data from 469 children aged 5-12 years who were controls in prior studies of craniofacial anomalies, we
evaluated SES indicators (maternal age, education and income) relative to score discrepancies between mother and teacher
reports on the Achenbach System of Empirically Based Assessments. Both reports use T-scores (M=50, SD=10) for
Externalizing, Internalizing and Total Problems scores. We examined maternal age as continuous and categorized maternal
education and family income (<=12 vs >12 years and <$35,000 vs >=$35,000, respectively). We created 3 variables of
discrepancy: 'Mother>Teacher' (mother's score >=10 points exceeding teacher's), 'Teacher>Mother' (teacher's score >=10 points
exceeding mother's), and 'non-discrepant' for comparison (discrepancy <10 points). We used multivariable logistic regression,
controlling for maternal race, psychiatric use in pregnancy and number of children under age 18 at home, to identify associations
between SES indicators and score discrepancies. Limitations include lack of data on teacher's race and mother's current health.
RESULTS: Family income <$35,000 was independently associated with score discrepancies; mothers reported more child
behavior problems than did teachers by >=10 points for both Externalizing Problems (OR=3.19, 95% CI 1.63 to 6.25, n=85
mothers) and Internalizing Problems (OR=2.39, 95% CI 1.26 to 4.53, n=110 mothers). We were unable to evaluate maternal
mental health at the time of behavior ratings, which may confound the association between increased odds of Mother>Teacher
discrepancies and lower family income.
CONCLUSIONS: Maternal age and education were not associated with reporting discrepancies, but mothers with lower family
income were almost three times as likely to have identified more problems in their child than the child's teacher.
PUBLIC HEALTH IMPLICATIONS: These results suggest that relying on only maternal or teacher report of child behavior may
have misclassification of outcomes that is dependent on SES and could produce biased results.
114
FOOD-INSECURITY CONTRIBUTES TO OBESITY AMONG
COLORADOCHILDREN AND PREGNANT WOMEN
Rickey Tolliver, MPH, Alyson Shupe, MSW, PhD
Colorado Dept. of Public Health & Environment
BACKGROUND: The United States Department of Agriculture’s measure of hunger is “food-insecurity” which is defined as lack
of access to enough food to fully meet the basic needs at all times due to lack of financial resources. Studies have shown that
food-insecure children are at higher risk of stunted early development, physical health problems, and behavioral challenges.
Research also demonstrates that food-insecurity can lead to weight gain because the least expensive food options are typically
high in calories and low in nutrients. Food-insecurity can also lead to greater weight gain and complications for women during
pregnancy including physical health problems such as gestational diabetes and mental health complications such as anxiety and
depression.
STUDY QUESTIONS: Is there a relationship between food-insecurity and obesity among Colorado children and pregnant
women?
METHODS: Data from the 2008-2010 Colorado Child Health Survey (CHS) and The Pregnancy Risk Assessment Monitoring
System (PRAMS) were utilized for this study. Responses from 4,277 CHS surveys were weighted to reflect behaviors and
experiences for all Colorado children between the ages of 1 and 14 years. Results from 5,973 PRAMS surveys were weighted to
reflect the experiences of all Colorado mothers giving birth.
RESULTS: Overall, 13.9% of Colorado children were obese and 26.9% lived in food-insecure households. Children who lived in
food-insecure households were more likely to be obese (aOR=1.4;p=0.02). Additionally, 19% of pregnant women were obese
and 10.0% were food-insecure. Women who were food-insecure were more likely to be obese (aOR=1.9; p=0.0004).
CONCLUSIONS: There is a link between food-insecurity and being obese, regardless of how contradictory these problems may
seem.
PUBLIC HEALTH IMPLICATIONS: The paradox between food-insecurity and obesity may be explained by the fact that highcalorie, processed foods often are less expensive than fresh fruits, vegetables, and high-fiber products. Additionally, we cannot
ignore the implications that food-insecurity poses to diet-sensitive chronic diseases such as hypertension hyperlipidemia, and
diabetes.
115
ESTIMATES OF SMOKING PREPREGNANCY, DURING PREGNANCY, AND
QUITTING DURING PREGNANCY: COMPARISON BETWEEN TWO
POPULATION-BASED DATA SOURCES
Van Tong, MPH, Patricia Dietz, DrPH, MPH, Sherry Farr, PhD, Denise D’Angelo, MPH, Lucinda England, MD, MSPH
Centers for Disease Control & Prevention
BACKGROUND: Healthy People 2020 goals include reducing the prevalence of smoking before and during pregnancy and
increasing cessation during pregnancy. Most states can measure progress in achieving these goals using two population-based
data sources, the Pregnancy Risk Assessment Monitoring System (PRAMS) and the 2003 revision of the birth certificate (BC).
STUDY QUESTIONS: How do estimates of prepregnancy and prenatal smoking prevalence and quitting smoking during
pregnancy differ using the PRAMS questionnaire and the 2003 revised BC?
METHODS: We analyzed data from 10,485 PRAMS participants who delivered live births in 2008 in eight states using the 2003
revised BC. PRAMS, a confidential and anonymous survey administered in the postpartum period, collects information on
smoking before, during, and after pregnancies ending in a live birth, and the mother’s data are linked to her infant’s BC. The BC
collects data on smoking status during the 3 months before pregnancy and during the first, second, and third trimesters. We
calculated self-reported prepregnancy and prenatal smoking prevalence (based on the BC, PRAMS, and the two data sources
combined), and the percentage of women who quit smoking during pregnancy based on BC and PRAMS. Two-sided t-tests were
used to compare BC and PRAMS estimates.
RESULTS: Prepregnancy smoking prevalence estimates were 17.3% from BC, 24.4% from PRAMS, and 25.4% on one or both
data sources. Prenatal smoking prevalence estimates were 11.3% from BC, 14.0% from PRAMS, and 15.2% on one or both data
sources. The percentages of prepregnancy smokers who indicated quitting smoking by the last 3 months of pregnancy were
35.1% from BC and 42.6% from PRAMS. The PRAMS estimates of prepregnancy, prenatal, and quitting smoking during
pregnancy were statistically higher than the corresponding BC estimates (t-tests, p<0.05).
CONCLUSIONS: PRAMS reported higher prevalences of smoking before and during pregnancy than did the revised BC.
PRAMS reported a higher percentage of women who quit smoking during pregnancy; however, this is due to the substantial
number of women indicated as prepregnancy smokers on PRAMS, but not on the BC.
PUBLIC HEALTH IMPLICATIONS: States implementing PRAMS and the revised BC should consider information from both
sources when developing population-based estimates of smoking before and during pregnancy.
116
DOVE: THE ASSOCIATION BETWEEN MATERNAL EXPOSURE TO
INTIMATE PARTNER VIOLENCE (IPV) AND BEING BORN SMALL FOR
GESTATIONAL AGE (SGA)
Ifeyinwa Udo, MS, Jeanne Alhusen, PhD, CRNP, Linda Bullock, PhD, RN, FAAN, Phyllis Sharps, PhD, RN, FAAN
Morgan State University, Johns Hopkins University School of Nursing, University of Virginia
BACKGROUND: IPV during pregnancy affects 9% to 17% of women in the US. IPV significantly impacts maternal physical and
mental health, with abused women reporting increased rates of depression and PTSD over their non-abused counterparts. The
impact of IPV extends to health consequences for the neonate with a demonstrated direct association between the mother’s
violence experience and low birth weight and preterm birth (PB). Less is known about the association between maternal
exposure to IPV and the risk for having an SGA baby. SGA fetuses are at increased risk of PB, and developmental and
behavioral problems in childhood.
STUDY QUESTIONS: Is maternal experience of Intimate Partner Violence during pregnancy associated with being born Small
for Gestational Age (SGA)?
METHODS: This longitudinal mixed-methods study examined the association between baseline violence scores of pregnant
abused women participating in the Domestic Violence Enhanced Home Visitation Program (DOVE; RO1NROO9093, NINR/NIH),
and their risk of delivering SGA babies. 119 women (mean age 22.5 years) from rural Missouri and 75 women (mean age 26.0)
from Baltimore (urban). Baseline violence and SGA status were determined by the Severity of Violence Against Women Scale
(SVAWS) and birth data respectively. Bivariate and multivariate logistic regression analyses were used to determine the
association between IPV and risk of SGA.
RESULTS: 19% of study neonates were classified as SGA with rates slightly higher in urban neonates as compared to rural
neonates (23% versus 17 %, p<0.05). Maternal sexual abuse was significantly associated with having a SGA neonate in urban
neonates in the unadjusted model (OR=1.16, p= 0.03, 95% CI =1.01-1.53). This association was attenuated after adjusting for
other confounders. Infant’s gender, mother’s employment status and age were significantly associated with delivering a SGA
neonate in the urban neonates.
CONCLUSIONS: Future research should examine the types and severity of violence that women experience in relation to birth
outcomes.
PUBLIC HEALTH IMPLICATIONS: Reducing infant mortality has been identified as a major public health objective. IPV
structured interventions may reduce prevalence of IPV and the consequent health effects on fetuses and neonates , ultimately
reducing infant mortality rates.
117
BUILDING BRIDGES FOR ADOLESCENT SEXUAL HEALTH THROUGH
STATE-LOCAL COLLABORATION
Maritza Valenzuela, MPH
Association of Maternal & Child Health Professionals (AMCHP)
PUBLIC HEALTH AREA:
FOCUS: Life course perspective, Reproductive health
POPULATION: Adolescents
ISSUE: In this time of increasingly shrinking public health dollars, partnerships and collaboration become even more critical to
improving health outcomes for MCH populations. Partnerships between Health and Education are recognized by national
education and health organizations as essential to improving health outcomes for children and adolescents, and are increasingly
recognized as critical to closing the achievement gap in schools. However, more successful models of health and education
collaborations are needed, particularly those that bridge the divide between state and local agencies.
SETTING: The project is currently underway in Houston, TX. The partners in the project are state and local health and
education professionals. The population expected to benefit from the activities are school-aged youth in Houston (and Texas).
PROJECT: The Building Bridges for Adolescent Sexual Health Through State-Local Collaboration project’s goal is to strengthen
the ability of state and local departments of health and education to improve sexual health for school aged youth in Houston and
Texas. The project is supported by the Association of Maternal and Child Health Programs (AMCHP), the National Association of
County and City Health Officials (NACCHO), and CDC’s Division of Adolescent and School Health. Drawing on existing
relationships in Texas, AMCHP and NACCHO reached out to their respective members at the state and local levels, along with
education agency partners, to identify opportunities for programs.
RESULTS: While in its early stages, the project has already succeeded in bringing key leaders from each agency to the table;
identifying shared priorities as well as individual strengths and assets; and developing a collective vision that will drive
collaborative efforts moving forward. To continue moving towards that vision, partners will next identify and recruit appropriate
partners from inside and outside their agencies and develop, implement, and evaluate a plan of action for achieving their
common vision for sexual health for youth in Houston and Texas.
BARRIERS: This presentation will outline the project process, share barriers identified by the partners and how they were
addressed, and review lessons learned that can inform other efforts to advance health-education partnerships across agencies.
LESSONS LEARNED: This presentation will outline the project process, share barriers identified.
118
NATIONAL AND REGIONAL PRECONCEPTION HEALTH INITIATIVES:
WORKING TOGETHER TO IMPROVE THE HEALTH OF YOUNG WOMEN
AND MEN
Sarah Beth Verbiest, DrPH, MSW, MPH
UNC Center for Maternal & Infant Health
PUBLIC HEALTH AREA:
FOCUS: Preconception health
POPULATION: Women
ISSUE: The US continues to have high rates of preterm birth, LBW and birth defects with high rates of infant and maternal
morbidity and mortality. Improving the health of women of childbearing age prior to conception is essential to changing these
trends. Millions of women don't receive evidence-based prevention services, primary care and treatment due to a lack of health
coverage/limited access to quality care. Many women don't benefit from clinical and community services and resources that
could improve their health for a lifetime and help them have healthy babies when, and if, they choose to do so.
SETTING: The Initiative on Preconception Health and Health Care serves a national audience and the Every Woman Southeast
Coalition serves 9 states in the Southeast US. Much of the work undertaken by these groups focuses on developing tools,
resources, partnerships and policies to support leaders across the country in their efforts to improve the health and well-being of
young women/men.
PROJECT: The National Initiative on PCHHC and its partners around the country remain focused on improving the knowledge,
attitudes and behaviors of men and women related to preconception health; eliminating disparities in adverse birth outcomes;
and assuring that all women of CBA receive the services they need to achieve high levels of wellness, including the reduction of
risks among women who have had prior adverse birth outcomes. The National Initiative accomplishes many activities through its
Workgroups (Consumer, Clinical, Public Health, Policy/Finance and Research/Surveillance) all of which have contributed to the
new 2012-14 Preconception Strategic Plan. EWSE works through a series of networks across the Southeast.
RESULTS: This presentation will review the major accomplishments of the National Initiative on PCHHC and describe the
activities underway over the next two years to continue to push this work forward nationally and in the southeast.
BARRIERS: Lack of funding and national focus on other issues, overcome through volunteers and commitment.
LESSONS LEARNED: Participants will be able to describe existing and new/upcoming preconception health tools/resources,
including evidence based and promising practices. They will be able to apply these resources to their programs and connect with
National efforts.
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A QUALITY IMPROVEMENT PROGRAM FOR TOBACCO CESSATION
AMONG WOMEN OF REPRODUCTIVE AGE IN NORTH CAROLINA
Sarah Beth Verbiest, DrPH, MSW, MPH
UNC Center for Maternal & Infant Health
PUBLIC HEALTH AREA:
FOCUS: Adverse perinatal outcomes, Chronic disease
POPULATION: Infants, Women, Families
ISSUE: Tobacco use by women contributes to many devastating and costly poor health outcomes. Smoking among women of
reproductive age is particularly dangerous given the potential for negative birth outcomes and multigenerational harm.
SETTING: You Quit Two Quit is a tobacco cessation quality improvement project targeting low socioeconomic status women of
childbearing age within six North Carolina counties. This work builds on three years of successful pilot projects that took place in
four NC health departments.
PROJECT: YQTQ is implemented by the UNC CMIH in partnership with the Women and Tobacco Coalition for Health, the NC
Division of Public Health Tobacco Prevention and Control Branch, and Community Care of the Lower Cape Fear, funded by the
Federal Office of Women’s Health. YQTQ implements the evidence-based best practices outlined in the U.S. DHHS’s Public
Health Service Clinical Practice Guideline.
RESULTS: Over the past four years, You Quit Two Quit has built a foundation of tobacco cessation training, outreach and
awareness across the state. The project has a tobacco use identification system in 16 practices; provides education, resources,
and feedback to the entire provider team to promote intervention; and provides resources to women to support them in their
cessation process. Outcomes are measured through chart audits, data summaries, Medicaid billing records, case management
documentation, data about referrals to the Quitline, interviews with providers and staff, training evaluations, and follow-up calls to
women who indicated interest in quitting. The project assesses harm reduction, quit attempts, periods of abstinence, cessation
and referral to behavioral health. This project will serve as a catalyst to expand this work to reach practices and women across
NC.
BARRIERS: Electronic medical records, billing and poor mental health among poor young women have presented barriers.
Policy changes, record work-arounds and setting up a system for behavioral health referrals have been effective.
LESSONS LEARNED: Behavioral health is critically important in tobacco cessation as is incorporating harm reduction into
project message and strategy. Establishing clear systems for screening/treatment, educating all providers on cessation
counseling, and creating a consistent, personalize and streamlined system with feedback loops for practices is key.
120
STATE-BASED GEOGRAPHIC PATTERNS IN RATES OF PARENTREPORTED DIAGNOSIS AND TREATMENT OF ADHD
Susanna Visser, MS, Joseph Holbrook, PhD
Centers for Disease Control & Prevention
BACKGROUND: Research reflects geographic differences in the prevalence and medication treatment of attentiondeficit/hyperactivity disorder (ADHD), with the highest rates found in the South and Midwest. Two national surveys currently
allow for state-based analysis of ADHD diagnosis and treatment. State-based geographic analysis of ADHD indicators could
serve to expand what is known about the service use of the estimated 5.4 million children with ADHD.
STUDY QUESTION(S): What are the state-based patterns in parent-reported rates of current ADHD diagnosis and treatment
among two samples: a national sample of US children and a national sample of children with special healthcare needs?
METHODS: Data from the 2007 National Survey of Children’s Health (NSCH) and the 2009 National Survey of Children with
Special Healthcare Needs (NS-CSHCN) were used to generate weighted state-based estimates for parent-reported ADHD
indicators: current ADHD diagnosis and medication treatment and past year counseling from NSCH’s national sample of
children; and past year behavioral therapy and dietary supplement use from NS-CSHCN’s sample of children with special
healthcare needs. ArcGIS software was used to generate US maps of these estimates for geographic analysis at the state level.
RESULTS: Geographic patterns of current ADHD diagnosis and treatment were similar to each other, reflecting an increasing
gradient of prevalence from West to Southeast. An increasing gradient from East to West was observed for behavioral therapy,
suggesting an inverse relationship between medication use and behavioral therapy for ADHD. No consistent geographic patterns
were observed for dietary supplements or counseling.
CONCLUSIONS: Sociodemographic characteristics associated with ADHD diagnosis and treatment, cultural preferences for
ADHD treatment, and service availability may play a role in the geographic patterns noted in this study. Well-accepted diagnostic
and medication treatment protocols and the extensive provision of, and insurance coverage for, these health services may
partially explain the more consistent geographic pattern of these indicators.
PUBLIC HEALTH IMPLICATIONS: Geographic patterns in the use of ADHD treatments may help guide future investigations of
the availability and use of services for children with ADHD. This may be particularly important, given the recent AHRQ
recommendation that behavioral therapy be the first-line treatment for young children with ADHD.
121
MOTOR VEHICLE CRASHES AND ADVERSE PREGNANCY OUTCOMES
AMONG PREGNANT DRIVERS IN NORTH CAROLINA
Catherine Vladutiu, MPH, Charles Poole, ScD, Stephen Marshall, PhD, Carri Casteel, PhD, M. Kathryn Menard, MD, MPH,
Harold Weiss, PhD
University of North Carolina at Chapel Hill, University of Otagu – New Zealand
BACKGROUND: Motor vehicle crashes are the leading cause of hospitalized maternal injury and injury-related mortality among
pregnant women in the United States. However, little is known about the effect of crashes on adverse fetal outcomes and
obstetric conditions.
STUDY QUESTION(S): Are motor vehicle crashes associated with adverse pregnancy outcomes?
METHODS: We assembled a cohort of 878,546 pregnant women who delivered a live or stillborn singleton infant in North
Carolina from 2001-2008. Pregnant drivers in crashes were identified by probabilistically linking live birth and fetal death records
with state crash reports. We used Poisson regression to estimate rate ratios for the association between crashes (modeled as a
time-dependent exposure) and adverse pregnancy outcomes (i.e., preterm birth, stillbirth, placental abruption, and premature
rupture of the membranes or PROM), adjusting for gestational age, maternal age, parity, prenatal care, prenatal tobacco and
alcohol use.
RESULTS: In 2001-2008, 2.9% of pregnant women were drivers involved in at least one motor vehicle crash during pregnancy
(n=25,168). Of the pregnant drivers in crashes, 3.1% were in two or more crashes during the same pregnancy. Pregnant drivers
had elevated rates of preterm birth (adjusted rate ratio, RR=1.07, 95% confidence interval, CI, 1.03, 1.11), stillbirth (RR=1.06,
95% CI 0.88, 1.27), placental abruption (RR=1.14, 95% CI 0.98, 1.33), and PROM (RR=1.13, 95% CI 1.04, 1.22) following their
first crash, compared to no crashes. Pregnant drivers had even higher rates of preterm birth (RR=1.16, 95% CI 0.94, 1.44),
stillbirth (RR=4.68, 95% CI 2.77, 7.91), placental abruption (RR=2.20, 95% CI 1.18, 4.09) and PROM (RR=1.48, 95% CI 0.96,
2.27), following their second or subsequent crashes, compared to no crashes.
CONCLUSIONS: Multiple crashes while driving during pregnancy are associated with elevated rates of several adverse
pregnancy outcomes. Additional research is needed to explore the impact of crash severity and vehicle safety devices (e.g.,
seatbelts, airbags) on these outcomes.
PUBLIC HEALTH IMPLICATIONS: Clinicians should be aware of the effects of crashes during pregnancy and willing to advise
pregnant women about these risks. By increasing awareness of this important public health issue, we can work towards
improving motor vehicle safety for pregnant women and their fetuses.
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MATERNAL RISK FACTORS FOR CHILDHOOD OBESITY
Melissa Vonderbrink, MPH
Ohio Dept. of Health
BACKGROUND: Childhood obesity in the U.S. has tripled since 1980; 20% of children between 6 and 11 years old were obese
in 2008 compared with 7% in 1980. As they age, obese children are at risk for chronic health conditions including hypertension
and diabetes. The causes of childhood obesity are difficult to pin-point. Environment, genetics, diet, and physical activity are
interwoven, making isolating the effects of one variable problematic. Research indicates that the mother’s health and behaviors
before and during pregnancy play an important role in her child’s obesity risk.
STUDY QUESTION(S): How do the health and behavior of Ohio mothers with a recent live birth appear on known risk factors for
childhood obesity?
METHODS: Ohio PRAMS data from 2009-2010 were used to produce descriptive statistics on maternal risk factors for
childhood obesity. Weighted survey methods were employed to calculate percentages and 95% confidence intervals for prepregnancy BMI, smoking during pregnancy, breastfeeding, and physical activity before pregnancy stratified by various maternal
characteristics.
RESULTS: 46.9% (95%CI: 44.4-49.4) of mothers were overweight or obese before pregnancy. This was higher among nonHispanic black mothers (54.4%; 95%CI: 50.5-58.3) than non-Hispanic white mothers (45.9%; 95%CI: 42.9-49.0). 16.3% (95%CI:
13.7-19.3) reported smoking during the last 3 months of pregnancy. Women on Medicaid and those whose pregnancy was
unintended were among those most likely to smoke (32.2%; 95%CI: 28.8-35.8 and 24.8; 95%CI: 21.7-28.3 respectively). 73.6%
(95%CI: 71.3-75.9) of mothers ever breastfed their infant. Mothers with less than 12 years of education were less likely to
breastfeed than those with more than 12 years (52.9%; 95%CI: 45.9-59.8 and 83.0%; 95%CI: 80.3-85.3 respectively). 38.0%
(95%CI: 35.6-40.5) reported exercising at least 3 days per week before pregnancy. 27.3% (95%CI: 21.6-33.9) of mothers with
less than 12 years of education reported this amount of exercise.
CONCLUSIONS: Risk factors for childhood obesity are evident in the health and behaviors of Ohio mothers. Those at greatest
risk are minorities and women with low socioeconomic status.
PUBLIC HEALTH IMPLICATIONS: Targeting mothers at risk and implementing programs to help maintain a healthy weight,
increase physical activity, avoid smoking, and providing support to breastfeed are important steps to reduce childhood obesity.
123
CUMULATIVE POOR PSYCHOSOCIAL AND BEHAVIORAL HEALTH
AMONG LOW-INCOME POSTPARTUM WOMEN AT 6 WEEKS
POSTPARTUM
Lorraine Walker, EdD, MPH, Bobbie Sterling, PhD, Sarah Guy, MSN
University of Texas at Austin
BACKGROUND: Women postpartum may confront psychosocial and behavioral health issues that adversely affect maternal
and child health. Because these health issues affect young populations, they are an important aspect of early disease prevention
in public health. To date many studies have emphasized one or more of these postpartum issues, such as, depression, poor
body image, smoking, poor diet, sedentary lifestyle, or drug or alcohol use. Rarely have these issues been examined together
with an eye to identifying risk factors for poor psychosocial and behavioral health across these domains.
STUDY QUESTIONS: The purpose of this study was to identify risk factors for cumulative poor psychosocial and behavioral
health at 6 weeks postpartum, when maternity-related care in programs such as Medicaid usually ends.
METHODS: We conducted a secondary analysis of low-income women in the Austin New Mothers Study, a longitudinal multiethnic study of the first postpartum year. We included 419 cases with available data at 6 weeks postpartum on 5 self-report
health variables: depressive symptoms; body image dissatisfaction; diet and activity behaviors; substance use behaviors
including smoking, alcohol, and illicit drugs; and general self-care behavior. Cumulative poor health scores constituted the sum of
health variables on which women fell into the lowest tertiles. Risk factors included nine demographic and obstetric variables.
Limitations included use of self-report data. Linear regression was used for analysis.
RESULTS: Cumulative poor heath scores ranged from 0 to 5 with this distribution, respectively, 25%, 30%, 20%, 13%, 9%, and
3%. Risk factors accounted for a small but significant amount of the variance (8%) in cumulative poor health scores (F = 3.9, p =
.000). Exclusive breastfeeding (beta -.18) and Hispanic ethnicity (beta = -.50) were significantly associated with lower cumulative
poor health scores, and parity with significantly higher ones (beta = .35).
CONCLUSIONS: More than half of low-income women had 2 or more domains in which they experienced poor psychosocial or
behavior health with parity increasing such risk.
PUBLIC HEALTH IMPLICATIONS: Risk factors were not strong predictors of poor cumulative psychosocial or behavior health.
Direct assessment of psychosocial or behavior health may be needed to advance public health goals for maternal and child
health.
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ANALYSIS THE INFLUENCE OF CHILDCARE WORKERS’ INFECTIOUS
DISEASE KNOWLEDGE ON KINDERGARTEN INFECTIOUS DISEASE
CUMULATIVE INCIDENCE IN 2011 IN FENGTAI DISTRICT, BEIJING, CHINA
Ruiping Wang, MSc, Meng Zhang, Liangliang Cui, Qian Zhang, Huilai Ma, Iijie Zhang
Chinese Field Epidemiology Training Program, Shanghai Songjiang CDC
BACKGROUND: In recent years, kindergarten infectious disease incidence grows rapidly in China. CDC school hygiene office
and education bureau disease control office have implemented various infectious disease knowledge education and training
program to boost kindergarten childcare workers’ infectious knowledge. it’s uncertain whether the infectious knowledge can
transform into healthy behavior and finally lower kindergarten’s infectious disease incidence.
STUDY QUESTION(S): Whether infectious disease knowledge training can decrease kindergarten infectious disease incidence.
METHODS: During December 2011, 327 childcare workers of 38 kindergartens in Fengtai district were surveyed face to face by
random cluster sampling. Infectious knowledge and healthy behavior were collected by questionnaires and kindergarten
infectious diseases information was from ‘China CDC Information System’. We accounted for the complex survey design in the
data analysis.
RESULTS: The average infectious disease knowledge score of 38 kindergarten childcare workers is 80 (95% confidence
interval [CI]:77-83), the average health behavior score is 77 (95%CI: 73-81), and the average kindergarten infectious disease
cumulative incidence of 2011 is 4.1 per 100 person years (95%CI: 2.8-5.4). With the increasing of infectious knowledge score,
childcare workers’ healthy behavior score increase (r=0.61, p<0.01), and with the increase of healthy behavior score, the
kindergarten infectious disease cumulative incidence in 2011 decreases (r=-0.43, p<0.01).
CONCLUSIONS: Conducting infectious disease knowledge education and training among kindergarten childcare workers is
effective. Good infectious knowledge can improve healthy behavior and lower kindergarten’s infectious disease incidence in
some extent.
PUBLIC HEALTH IMPLICATIONS: Educational agencies and healthcare institutions should deeply focus on infectious disease
knowledge training and education, which lower kindergarten’s infectious disease incidence in some extent.
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THE FIRST STEP IN KNOWLEDGE TRANSLATION: MOVING MISSISSIPPI
PRECONCEPTION HEALTH INDICATORS FROM DATA TO PRACTICE
Lauren A. White, BS, Larry L. Smith, PhD, Juanita Graham, DNPc, MSN, RN, Connie L. Bish, MS, PhD, MPH
Mississippi State Dept. of Health
PUBLIC HEALTH AREA:
FOCUS: Preconception health, Reproductive health
POPULATION: Women
ISSUE: Optimal preconception health (PCH) may improve maternal and infant outcomes, including infant mortality, a priority
issue in Mississippi (MS). In 2010, an expert panel of maternal health experts recommended 45 indicators to monitor the
preconception health of women in state or local health agencies’ jurisdictions. Surveillance of the preconception health of
Mississippi women will provide knowledge for women’s health program planning.
SETTING: The Mississippi State Department of Health (MSDH) Preconception Health website was developed to house data
and summary factsheets relevant to the preconception health of Mississippi women. The intended audiences included program
planners, grant writers, and other public health and community workers involved in women’s health.
PROJECT: Recommended data systems (e.g., census, vital records, Behavioral Risk Factor Surveillance System, Pregnancy
Risk Assessment Monitoring System) were used to evaluate the preconception health of MS women among 10 domains (e.g.,
general health status, social determinants of health, health care, reproductive health and family planning, tobacco, alcohol &
substance use, nutrition and physical activity, mental health, emotional and social support, chronic conditions, and infections).
Domain-specific factsheets and tables of response frequencies for each indicator were posted to the MSDH Preconception
Health Website.
RESULTS: Reliable indicators of MS women’s preconception health were established in the first step of knowledge translation
from data systems to program planners.
BARRIERS: Initially, lack of funding limited analytic support and development of the website, but heightened state focus on
infant mortality prevention pathways assembled champions who volunteered time and resources. A campaign to publicize the
website will also require support.
LESSONS LEARNED: A web-based resource with data and prepared fact sheets provides women’s health program
stakeholders with resources to prepare grants, disseminate state data, and target areas of adequate and inadequate health
among reproductive aged MS women.
126
THE ASSOCIATION BETWEEN SUGAR SWEETENED BEVERAGES AND
DENTAL CARIES AMONG THIRD GRADE STUDENTS IN GEORGIA
Jocelyn Wilder, MPH, Kristin Rankin, PhD, Arden Handler, DrPH, Linda Kaste, DDS, PhD, Thesesa Chapple-McGruder,
PhD
University of Illinois at Chicago, Georgia Dept. of Health
BACKGROUND: According to national data, 58% of thirds graders have caries experience (CE). Tooth decay is the most
prevalent infectious disease among children. An association between sugar and caries development has previously been found,
however there have been conflicting results from research examining the relationship between sugar sweetened beverages
(SSB) consumption and the prevalence of dental caries.
STUDY QUESTION(S): We hypothesize that as daily intakes of sugar sweetened beverages (SSB) increases, so will the
association with increased CE.
METHODS: The 2010 Georgia Third Grade Oral Health Study, conducted by the Georgia Department of Public Health and
Department of Education explored the association between increasing daily consumption of SSB and CE. Data were weighted
for probability of selection and non-response to reflect Georgia’s third grade population. Log binomial regression was used to
assess this relationship due to the non-rare outcome. Study limitations were the use of free/reduced lunch eligibility as a proxy
for household income and mother's tooth loss as a proxy for household behavior around dental hygiene. Additionally the
supplemental parent's survey was not available is Spanish.
RESULTS: Fifty-two percent of Georgia’s third graders have caries experience. Children‘s prevalence of caries increased by
22% for each serving increase of SSB controlling for race/ethnicity, gender, age and geographical location. Caries experience
increased as one daily consumption of SSB increased (p<.001). Daily serving consumption of SSB differed significantly by
race/ethnicity, geographical location and SES variables.
CONCLUSIONS: Increased consumption of SSB may put children at an increased risk of developing dental caries possibly
abating the benefits of fluoridation, improved oral hygiene and increased preventive dental visits. Additionally care and
interventions targeting caries development would increase the quality of life for children and would likely reduce obesity among
children.
PUBLIC HEALTH IMPLICATIONS: Tooth decay is a chronic disease among children which hampers their quality of life.
Behaviors that contribute to development of caries need to be identified. Dental Care is essential and consistent preventive care
would improve children's overall health, reinforce health messaging and likely reduce caries in future generations. Care and
interventions targeting caries development would likely reduce obesity among children.
127
PEER SUPPORT, CASE MANAGEMENT AND REFERRALS?:
UNDERSTANDING BEST PRACTICES AS EVIDENCED IN THREE DIVERSE
PROGRAMS WORKING WITH WOMEN IN THE NICU
Jeffry Will, PhD, Irma Hall, MS, Timothy Cheney, MS
UNF Center for Community Initiatives
PUBLIC HEALTH AREA:
FOCUS: Adverse perinatal outcomes, Health equity
POPULATION: Infants, Women
ISSUE: The March of Dimes Florida Chapter funded three multi-year demonstration projects that provide comprehensive
pre/interconception health services, education, and referrals to women who have an infant in a Neonatal Intensive Care Center
or have recently experienced a fetal or infant death. The overarching goal is to develop a replicable model for comprehensive
interconception health care for high-risk women, with a particular emphasis on women living in rural communities. Programs for
these women begin prior to the infant’s discharge from the hospital and follow the women for as long as possible. The goal is to
develop a model of interconception health that can be incorporated into the existing system of care without putting an excessive
burden on existing resources.
SETTING: The three sites for the study are Jacksonville, Tampa, and Broward County Florida. The population expected to
benefit from the programs are those women who have an infant in a Neonatal Intensive Care Center or have recently
experienced a fetal or infant death
PROJECT: The programs evaluated in this project provided services to women who have had an infant in the neonatal intensive
care unit (NICU). While all three programs focus on women who have experienced a loss or have had an infant in the NICU, the
service approaches, target services, and other processes are quite diverse.
RESULTS: Overall, site assessments indicate that each of the locations was successful in recruiting clients, and saw successful
“outcomes” vis-à-vis the programs’ respective approaches. It was also clear that each of the sites could have gained by
“melding” some of the processes of the other programs into a “best practices” model for future program implementation.
BARRIERS: Primary barriers included access to women, attrition and access.
LESSONS LEARNED: Multi-dimensional programs are more successful than single focus ones.
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SURVEILLANCE OF PRECONCEPTION INDICATORS IN BRFSS:
EMERGING TRENDS IN THE 21ST CENTURY
Pamela Xaverius, PhD, Joanne Salas, MPH
St. Louis University School of Public Health
BACKGROUND: A groundswell of activity has occurred in the 21st century regarding preconception health, in conjunction with
the growing evidence that preconception care can modify behavioral and medical risk factors known to impact pregnancy
outcomes.
STUDY QUESTIONS: This manuscript assesses emerging trends in the 21st century in preconception health indicators among
women of reproductive age.
METHODS: Secondary analysis of cross-sectional data from the Behavioral Risk Factor Surveillance Survey (BRFSS), 20032010. Data are collected in the United States. Subjects were a sample of non-institutionalized, 18-44 year old, non-pregnant,
women (n = 547,177) grouped into two categories: 2003-2006 (n = 275,630) and 2007-2010 (n = 271,547). Preconception
indicators between two time periods, before 2006 and after 2006. Indicators were selected based upon recommendations by the
Public Health Work Group of the Centers of Disease Control and Prevention Preconception Health and Health Care Initiative
team, including alcohol use, tobacco use, self-reported health, fruit and vegetable intake, mental distress, social/emotional
support, physical activity, chronic conditions (i.e., obesity, diabetes, asthma, and high blood pressure), clinical care, and social
determinants. Overall crude prevalence odds ratios (cPOR) and adjusted prevalence odds ratios (aPOR) were calculated.
RESULTS: When odds ratios were adjusted for demographic characteristics, significant improvements were found for any
alcohol use (aOR 0.90, CI 0.88-0.92), heavy alcohol use (aOR 0.94, CI 0.89, 0.98), smoking (aOR 0.84, CI 0.81-0.86), eating
five or more daily servings of fruits and vegetables (aOR 1.04, CI 1.01, 1.07), moderate/vigorous activity (aOR 1.05, CI 1.01,
1.08), social/emotional support (aOR 1.05, CI 1.02-1.09), and having had an influenza shot in the last year (aOR 1.68, CI 1.641.73) in the 2007-2010 timeframe. In contrast, binge alcohol use (aOR 1.20, CI 1.16-1.24) having a chronic condition (aOR 1.16,
CI 1.13-1.19), and self-reported good health (aOR 0.94, CI 0.90, 0.97) significantly worsened.
CONCLUSIONS: The health of women of reproductive age has worsened, with significant increases in chronic conditions and
binge alcohol use. Focused efforts are needed to reverse this trend back towards national goals.
PUBLIC HEALTH IMPLICATIONS: As the 21st century continues to unfold, more work is needed in educating women,
providers, and public health advocates regarding improved health before pregnancy.
129
CHALLENGES OF AN INTERPREGNANCY CARE PROGRAM IN THE
MISSISSIPPI DELTA
Ayae Yamamoto, ScM, Alisha Lalani, BA, Connie Bish, MPH, PhD
Harvard School of Public Health, Mississippi State Dept. of Health
PUBLIC HEALTH AREA:
FOCUS: Adverse perinatal outcomes, Environment
POPULATION: Infants, Women
ISSUE: Very low birth weight (VLBW) infants comprise 2.3% of all births in Mississippi (MS), but account for 53% of all infant
deaths. The Delta Infant Mortality Elimination (DIME) program, which was modeled after an interpregnancy care (IPC) program
at Grady Hospital (Atlanta, Georgia), was implemented in Mississippi to reduce repeat VLBW through IPC that included case
management of social and physiological factors of women who previously had a VLBW infant.
SETTING: The issue of VLBW infants disproportionately impacts African American infants and mothers. The DIME program
targeted African American women living in 18 counties of the MS Delta (rural Northwestern MS). The success of the DIME
program as a translational research program will likely be influenced by how the program was customized for implementation in
MS.
PROJECT: Evaluation consultants assessed program documents and interviewed key stakeholders and program
implementation staff to formulate an evaluation plan with particular attention to whether fidelity to the original Grady Program
protocol might influence evaluability of the program’s success.
RESULTS: The team found that implementation of the DIME protocol was complicated by participants being exposed to more
than one case manager, and that this variable may have influenced participant retention. Additionally, case managers for the
DIME women varied between health department nurses, social workers and lay care providers referred to as “resource mothers”.
BARRIERS: Program policies developed to meet existing MS State Department of Health (MSDH) Field Service protocols,
reductions in funding, and restrictions and requirements placed by funders contributed to implementation practices in DIME that
differed from the original Grady protocol. Additionally, communication challenges between the program planners at MSDH
headquarters and field offices led to variability in service provision at both MSDH clinics and contracted health centers or private
providers, and inconsistent service documentation by case managers.
LESSONS LEARNED: Pre-intervention assessment might have identified barriers to a case management program in a rural
setting. MSDH policies and procedures could be enhanced to include data collection methodology for evaluation variables.
130
OBSTETRIC CARE IN GEORGIA: TRANSLATING RESEARCH INTO
POLITICAL ACTION
Adrienne DeMarais Zertuche, MD, MPH, Bridget Spelke, Pat Cota, RN, MS, Andrew Dott, MD, MPH, Roger Rochat, MD
Emory Dept. of Gynecology & Obstetrics, Emory University School of Medicine, Georgia Obstetrical & Gynecological Society,
Emory University – Rollins School of Public Health
PUBLIC HEALTH AREA:
FOCUS: Health equity, Social justice
POPULATION: Infants, Women
ISSUE: Many Georgia state legislators lack information on the causes, magnitude, and consequences of their state’s obstetric
provider shortages. The legislature’s last 12 yearly budget approvals have resulted in a 37% decline in Medicaid’s obstetric
reimbursements, which pay for 60% of Georgia births. Moreover, legislators have not revisited tort reform since the Georgia
Supreme Court overturned the General Assembly’s compensation cap in early 2010.
SETTING: House Bill 954, introduced during the 2012 Georgia General Session, sought to ban pregnancy terminations past 20
weeks “embryonic age” (sic), but it offered no exception for rape, incest, mental illness, or fetal condition and stipulated up to 10
years in prison for physician noncompliance. Legislators across the abortion spectrum needed information on Georgia’s
obstetric services and outcomes to understand how this criminalization of standard practices may harm local obstetricians,
mothers, and infants.
PROJECT: The Georgia Maternal and Infant Health Research Group (GMIHRG) created personalized cards for all 234
legislators, which described Georgia’s insufficient obstetric capacity with maps of services, stories from obstetricians, and districtspecific provider burden statistics. Two Republican leaders – the House Health and Human Services Chair and the Senate
Majority Whip – agreed to distribute the cards to their colleagues.
RESULTS: House Bill 954 passed the House, but GMIHRG’s cards caught the attention of a Republican Senator from southern
Georgia, concerned about the dwindling obstetric services available to his pregnant constituents. Motivated by GMIHRG’s
materials, he led a bipartisan coalition in the proposal and passage of an amendment granting a termination exception for fetal
abnormalities incompatible with life. The amended bill passed both chambers and will become Georgia law in 2013. According
to the House Minority (Democratic) Leader, GMIHRG’s cards were the primary impetus for the medical futility amendment.
BARRIERS: In predominantly socially and politically conservative Georgia, abortion bills can divide legislators’ votes along party
lines, with little attention to proposal specifics or potential consequences.
LESSONS LEARNED: Using creative, personalized, and factual materials to educate legislators about obstetric capacity can be
an effective method to develop bipartisan support on controversial maternal and infant health issues in Georgia and throughout
the United States.
131