The Associations of Maternal Weight Change with Breastfeeding,Diet and Physical Activity During the Postpartum Period

Objective To determine the association between breastfeeding practices, diet and physical activity and maternal postpartum weight. Methods This was a secondary data analysis of a randomized community trial on beneficiaries of the Programa de Desarrollo Humano Oportunidades, recently renamed Prospera (n = 314 pregnant women), without any diseases that could affect body weight. Generalized estimating equations were used to determine the association between postpartum weight change and changes in diet, physical activity and type of breastfeeding. Results The mean postpartum weight change from the first to the third month was 0.6 ± 2.2 kg. Women who breastfed exclusively for 3 months had a 4.1 (SE = 1.9) kg weight reduction in comparison with women who did not provide exclusive breastfeeding or who discontinued breastfeeding before 3 months (p = 0.04). There was no association between postpartum weight change and physical activity (p = 0.24) or energy intake (p = 0.06). Conclusions Exclusive breastfeeding was associated with maternal postpartum weight reduction. These results reinforce the World Health Organization recommendation of exclusive breastfeeding during the first 6 months of life in order to reduce the risk of weight retention or weight gain in postpartum women. It has been well established that exclusive breastfeeding is beneficial for both infants and mothers, but promoting breastfeeding as a strategy to promote postpartum weight loss is of paramount importance, especially in countries like Mexico where excessive weight in women of reproductive age is a public health problem.     

Improved Outcomes for Hispanic Women with Gestational Diabetes Using the Centering Pregnancy<Superscript>©</Superscript> Group Prenatal Care Model

Objective To determine the impact of Centering Pregnancy^©-based group prenatal care for Hispanic gravid diabetics on pregnancy outcomes and postpartum follow-up care compared to those receiving traditional prenatal care. Methods A cohort study was performed including 460 women diagnosed with gestational diabetes mellitus (GDM) who received traditional or Centering Pregnancy^© prenatal care. The primary outcome measured was completion of postpartum glucose tolerance testing. Secondary outcomes included postpartum visit attendance, birth outcomes, breastfeeding, and initiation of a family planning method. Results 203 women received Centering Pregnancy^© group prenatal care and 257 received traditional individual prenatal care. Women receiving Centering Pregnancy^© prenatal care were more likely to complete postpartum glucose tolerance testing than those receiving traditional prenatal care, (83.6 vs. 60.7 %, respectively; p < 0.001), had a higher rate of breastfeeding initiation (91.0 vs. 69.4 %; p < 0.001), had higher rates of strictly breastfeeding at their postpartum visit (63.1 vs. 46.3 %; p = 0.04), were less likely to need medical drug therapy compared to traditional prenatal care (30.2 vs. 42.1 %; p = 0.009), and were less likely to undergo inductions of labor (34.5 vs. 46.2 %; p = 0.014). When only Hispanic women were compared, women in the Centering group continued to have higher rates of breastfeeding and completion of postpartum diabetes screening. Conclusion for Practice Hispanic women with GDM who participate in Centering Pregnancy^© group prenatal care may have improved outcomes.     

American Indian Breastfeeding Attitudes and Practices in Minnesota

Objectives We examined the breastfeeding attitudes and practices in an American Indian population in Minnesota. Methods We interviewed women prenatally (n = 380), at 2-weeks (n = 342) and at 6-months postpartum (n = 256). We conducted multivariable analyses to examine the demographic, behavioral, and attitudinal correlates of breastfeeding initiation and duration. Results Factors positively associated with breastfeeding initiation included positive breastfeeding attitudes and social support for breastfeeding from the woman’s husband/boyfriend and her mother. Factors positively associated with breastfeeding at 2-weeks postpartum were support from the woman’s mother and positive attitudes about breastfeeding. The prenatal use of traditional American Indian medicines and cigarette smoking were both significantly associated with breastfeeding at 6-months postpartum. Conclusions Programs to encourage breastfeeding in American Indian communities may be strengthened with protocols to encourage social support, recognition of the perceived health, developmental, and practical benefits of breastfeeding, and a focus on traditional American Indian health practices.     

Prenatal and Postnatal Fruit and Vegetable Intake Among US Women: Associations with WIC Participation

Objective Evaluate variation in fruit and vegetable intake by Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation and poverty status among pregnant, and postpartum women participating in the Infant Feeding Practice Study II (IFPSII). Methods IFPSII (2005–2007) followed US women from third trimester through 1 year postpartum through mailed questionnaires measuring income, WIC participation, breastfeeding; and dietary history questionnaires (DHQ) assessing prenatal/postnatal fruit and vegetable consumption. Poverty measurements used U.S. Census Bureau Federal Poverty thresholds to calculate percent of poverty index ratio (PIR) corresponding to WIC’s financial eligibility (≤185 % PIR). Comparison groups: WIC recipients; WIC eligible (≤185 % PIR), but non-recipients; and women not financially WIC eligible (>185 % PIR). IFPSII participants who completed at least one DHQ were included. Intake variation among WIC/poverty groups was assessed by Kruskal–Wallis tests and between groups by Mann–Whitney Wilcoxon tests and logistic regression. Mann–Whitney Wilcoxon tests examined postnatal intake by breastfeeding. Results Prenatal vegetable intake significantly varied by WIC/poverty groups (p = 0.04) with WIC recipients reporting significantly higher intake than women not financially WIC eligible (p = 0.02); association remained significant adjusting for confounders [odds ratio 0.66 (95 % confidence interval: 0.49–0.90)]. Prenatal fruit and postnatal consumption did not significantly differ by WIC/poverty groups. Postnatal intake was significantly higher among breastfeeding than non-breastfeeding women (fruit: p < 0.0001; vegetable: p = 0.006). Conclusions for Practice Most intakes did not significantly differ by WIC/poverty groups and thus prompts research on WIC recipient’s dietary behaviors, reasons for non-participation in WIC, and the influence of the recent changes to the WIC food package.     

Intimate Partner Violence Associated with Postpartum Depression,Regardless of Socioeconomic Status

Objective This study examined whether socioeconomic status moderated the association between intimate partner violence (IPV) and postpartum depression among a community-based sample of women. Defining the role of poverty in the risk of postpartum depression for IPV victims enables prioritization of health promotion efforts to maximize the effectiveness of existing maternal-infant resources. Methods This cross-sectional telephone-survey study interviewed 301 postpartum women 2 months after delivery, screening them for IPV and depression [using Edinburgh Postnatal Depression Scale (EPDS)]. Socioeconomic status was defined by insurance (Medicaid-paid-delivery or not). This analysis controlled for the following covariates, collected through interview and medical-record review: demographics, obstetric history, prenatal health and additional psychosocial risk factors. After adjusting for significant covariates, multiple linear regression was conducted to test whether socioeconomic status confounded or moderated IPV’s relationship with EPDS-score. Results Ten percent of participants screened positive for postpartum depression, 21.3 % screened positive for current or previous adult emotional or physical abuse by a partner, and 32.2 % met poverty criteria. IPV and poverty were positively associated with each other (χ² (1) = 11.76, p < .001) and with EPDS score (IPV: beta 3.2 (CI 2.0, 4.5) p < .001, poverty: beta 1.3 (CI 0.2, 2.4) p = .017). In the multiple linear regression, IPV remained significantly associated, but poverty did not (IPV: adjusted beta 3.1 (CI 1.8, 4.3) p < .001, poverty: adjusted beta 0.8 (CI ?0.3, 1.9) p = .141), and no statistically significant interaction between IPV and poverty was found. Conclusions Study findings illustrated that IPV was strongly associated with postpartum depression, outweighing the influence of socioeconomic status upon depression for postpartum women.     

Evidence for a Complex Relationship Among Weight Retention,Cortisol and Breastfeeding in Postpartum Women

Objective To assess the relationship between cortisol slope, a biologic marker of stress, and postpartum weight retention. Methods We included 696 women in a secondary analysis from a multi-site study conducted using principles of community-based participatory research to study multi-level sources of stress on pregnancy outcomes. As a stress marker, we included salivary cortisol slope; the rate of cortisol decline across the day. Pre-pregnancy weight and demographic data were obtained from the medical records. At 6 months postpartum, patients were weighed and returned saliva samples. We built stepwise regression models to assess the effect of demographic variables, cortisol slope and cortisol covariates (wake time, tobacco use and breastfeeding) on postpartum weight retention. Results 45.5 % of participants were African American, 29.2 % White, and 25.3 % Hispanic. Of the Hispanic women 62.5 % were Spanish speaking and 37.5 % were English speaking. In general, participants were young, multiparous, and overweight. Postpartum, almost half (47.6 %) of women studied retained >10 lbs. In multivariable analysis including age, pre-pregnancy BMI and public insurance, cortisol slope was significantly associated with weight retention (β = ?1.90, 95 % CI = 0.22–3.58). However, when the model was adjusted for the cortisol covariates, breastfeeding (β = ?0.63, 95 % CI = ?1.01 to ?0.24) and public insurance (β = 0.62, 95 % CI = 0.20–1.04) were the two strongest correlates of weight retention. Conclusions for Practice The association between cortisol slope and postpartum weight retention appears to be influenced breastfeeding status.     

Associations Between Peer Counseling and Breastfeeding Initiation and Duration: An Analysis of Minnesota Participants in the Special Supplemental Nutrition Program for Women,Infants, and Children (WIC)

Background Peer counseling (PC) has been associated with increased breastfeeding initiation and duration, but few analyses have examined the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) model for peer counseling or the continuation of breastfeeding from birth through 12 months postpartum. Objectives Identify associations between Minnesota WIC Peer Breastfeeding Support Program services and breastfeeding initiation and continuation. Methods Retrospective analysis of observational data from the Minnesota WIC program’s administrative database of women who gave birth in 2012 and accepted a PC program referral prenatally (n?=?2219). Multivariate logistic regression and Cox regression models examined associations between peer services and breastfeeding initiation and continuation of any breastfeeding. Results Among women who accepted referral into a PC program, odds of initiation were significantly higher among those who received peer services (Odds Ratio (OR): 1.66; 95% CI 1.19–2.32), after adjusting for confounders. Women who received peer services had a significantly lower hazard of breastfeeding discontinuation from birth through 12 months postpartum than women who did not receive services. (Hazard Ratio (HR) month one: 0.45; 95% CI 0.33–0.61; months two through twelve: 0.33; 95% CI 0.18–0.60). The effect of peer counseling did not differ significantly by race and ethnicity, taking into account mother’s country of origin. Conclusion for practice Receipt of peer services was positively associated with breastfeeding initiation and continued breastfeeding from birth through 12 months postpartum. Making peer services available to more women, especially in communities with low initiation and duration, could improve maternal and child health in Minnesota.     

Effects of Group Prenatal Care on Food Insecurity during Late Pregnancy and Early Postpartum

Objective This study compared the effects of group to individual prenatal care in late pregnancy and early postpartum on (1) women’s food security and (2) psychosocial outcomes among food-insecure women. Methods and Results We recruited 248 racially diverse, low-income, pregnant women receiving CenteringPregnancy? group prenatal care (N = 124) or individual prenatal care (N = 124) to complete surveys in early pregnancy, late pregnancy, and early postpartum, with 84 % completing three surveys. Twenty-six percent of group and 31 % of individual care participants reported food insecurity in early pregnancy (p = 0.493). In multiple logistic regression models, women choosing group versus individual care were more likely to report food security in late pregnancy (0.85 vs. 0.66 average predicted probability, p < 0.001) and postpartum (0.89 vs. 0.78 average predicted probability, p = 0.049). Among initially food-insecure women, group participants were more likely to become food-secure in late pregnancy (0.67 vs. 0.35 individual care average predicted probability, p < 0.001) and postpartum (0.76 vs. 0.57 individual care average predicted probability, p = 0.052) in intention-to-treat models. Group participants were more likely to change perceptions on affording healthy foods and stretching food resources. Group compared to individual care participants with early pregnancy food insecurity demonstrated higher maternal-infant attachment scale scores (89.8 vs. 86.2 points for individual care, p = 0.032). Conclusions Group prenatal care provides health education and the opportunity for women to share experiences and knowledge, which may improve food security through increasing confidence and skills in managing household food resources. Health sector interventions can complement food assistance programs in addressing food insecurity during pregnancy.     

Employing Community Voices: Informing Practice and Programming through Camden Healthy Start Focus Groups

Objectives Women living in communities with low-socioeconomic status, substandard healthcare, and ongoing exposure to social disparities encounter barriers to healthcare, often making it difficult to access health services. Barriers may stem from provider interactions with clients, conditions of the healthcare facility, or even language barriers. This prompts a call for providers to be keenly aware of the obstacles women encounter when attempting to access services. Methods In an effort to facilitate better access to services, Camden Healthy Start conducted six focus groups. Thirty-nine women between the ages of 22–56 participated. A total of 39 questions were posed to participants about health behavior, health services, pregnancy, reproductive health, and barriers to accessing services. Each 2 h session was audio recorded, translated and transcribed. Following the format of the Women’s Health: Attitudes and Practices in North Carolina Focus Group Research, responses were analyzed and themes emerged. Results This article discusses characteristics of healthcare services and cultural insensitivity that impact women’s access and act as barriers to care. The results signal the need for Healthy Start to apply a more relational engagement when providing services. Consideration for Practice Relational engagement includes getting to know the client as a person first, respecting their rights to autonomy in the decision making process, and demonstrating an understanding of the client’s culture and inclusion of their voices in the conversation.     

Association of Bisphenol A Exposure with Breastfeeding and Perceived Insufficient Milk Supply in Mexican Women

Introduction Estrogen inhibits lactation and bisphenol A (BPA) is a high production environmental estrogen. We hypothesize an inhibitory effect of BPA on lactation and aim to analyze the association between third trimester pregnancy urinary BPA and breastfeeding rates 1 month postpartum. Methods Odds ratios (OR) and 95 % confidence intervals (95 % CI) of breastfeeding and perceived insufficient milk supply (PIM) in relation to maternal peripartum urinary BPA concentrations were calculated in 216 mothers. Results 97.2 % of mothers in the lowest BPA tertile were breastfeeding at 1 month postpartum, compared to 89.9 % in highest (p = 0.01). Adjusted ORs (95 % CI) for not breastfeeding at 1 month were 1.9 (0.3, 10.7) and 4.3 (0.8, 21.6) for second and third BPA tertiles, respectively, compared to the lowest (p = 0.06, trend). 4.2 % reported PIM in the lowest BPA tertile, compared to 8.7 % in the highest (p = 0.03). Adjusted ORs (95 % CI) for PIM were 1.8 (0.4, 7.7) and 2.2 (0.5, 9.5), for the second and third BPA tertiles, respectively, compared to the lowest (p = 0.29, trend). Discussion These results suggest an association between maternal BPA exposure and decreased breastfeeding.     

WIC Participation and Breastfeeding at 3 Months Postpartum

Objectives Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been associated with lower breastfeeding initiation and duration. This study examines breastfeeding-related factors among WIC participants and nonparticipants that might explain these previous findings. Methods Respondents to the 2007 Infant Feeding Practices Study II who were income-eligible for WIC were categorized as follows: no WIC participation (No-WIC); prenatal participation and infant entry while ≥60 % breastfeeding (WIC BF-high); prenatal participation and infant entry while <60 % breastfeeding (WIC BF-low). Percent breastfeeding was the number of breast milk feeds divided by the total number of liquid feeds. Using propensity scores, we matched WIC BF-high respondents to No-WIC respondents on demographic and breastfeeding factors. We used logistic regression to estimate the impact of WIC participation on breastfeeding at 3 months postpartum in the matched sample. Within-WIC differences were explored. Results Of 743 income-eligible respondents, 293 never enrolled in WIC, 230 were categorized as WIC BF-high, and 220 as WIC BF-low. Compared to matched No-WIC respondents, WIC BF-high respondents had increased odds of breastfeeding at 3 months, though this difference was not statistically significant (OR 1.92; 95 % CI 0.95–3.67; p value 0.07). WIC BF-high respondents were more similar on breastfeeding-related characteristics to No-WIC respondents than to WIC BF-low respondents. Conclusions for Practice Accounting for prenatal breastfeeding intentions and attitudes, we find no negative association between WIC participation and breastfeeding at 3 months postpartum. This is in contrast to prior studies, and highlights the importance of understanding within-WIC differences.     

Obese Mothers have Lower Odds of Experiencing Pro-breastfeeding Hospital Practices than Mothers of Normal Weight: CDC Pregnancy Risk Assessment Monitoring System (PRAMS), 2004–2008

Objectives This study examines the extent to which a mother’s pre-pregnancy body mass index (BMI) category is associated with her exposure to pro-breastfeeding hospital practices. Methods Data from the 2004–2008 CDC PRAMS were analyzed for three states (Illinois, Maine, and Vermont) that had administered an optional survey question about hospital pro-breastfeeding practices. Results Of 19,145 mothers surveyed, 19 % were obese (pre-pregnancy BMI ≥ 30). Obese mothers had lower odds than mothers of normal weight of initiating breastfeeding [70 vs. 79 % (unweighted), p < 0.0001]. Compared with women of normal weight, obese mothers had lower odds of being exposed to pro-breastfeeding hospital practices during the birth hospitalization. Specifically, obese mothers had higher odds of using a pacifier in the hospital [odds ratio (OR) 1.31, 95 % confidence interval (CI) (1.17–1.48), p < 0.0001] and lower odds of: a staff member providing them with information about breastfeeding [OR 0.71, 95 % CI (0.57–0.89), p = 0.002], a staff member helping them breastfeed [OR 0.69, 95 % CI (0.61–0.78), p < 0.0001], breastfeeding in the first hour after delivery [OR 0.55, 95 % CI (0.49–0.62), p < 0.0001], being given a telephone number for breastfeeding help [OR 0.65, 95 % CI (0.57–0.74), p < 0.0001], rooming in [OR 0.84, 95 % CI (0.73–0.97), p = 0.02], and being instructed to breastfeed on demand [OR 0.66, 95 % CI (0.58–0.75), p < 0.0001]. Adjusting for multiple covariates, all associations except rooming in remained significant. Conclusions Obesity stigma may be a determinant of breastfeeding outcomes for obese mothers. Breastfeeding support should be improved for this at-risk population.     

Infant Mortality Lessons Learned from a Fetal and Infant Mortality Review Program

Objective To review fetal and infant deaths from women enrolled in Indianapolis Healthy Start using the National Fetal and Infant Mortality Review (FIMR) methods to provide strategies for prevention. Methods: Marion County Public Health Department (MCPHD) FIMR staff identified and reviewed 22 fetal and infant deaths to Indianapolis Healthy Start program participants between 2005 and 2012. Trained FIMR nurses completed 13 of 20 maternal interviews and compiled case summaries of all deaths from the MCPHD FIMR database.. Results Case review teams identified a total of 349 family strengths, 219 contributing factors, and made 220 recommendations for future pregnancies. FIMR deliberation values for Healthy Start program participant deaths were similar to other infant deaths in Marion County during the same time period. Common themes that emerged from the reviews included lack of social support, absence of paternal involvement, substance abuse, non-compliance, and poor health behaviors leading to chronic health conditions that complicated many pregnancies. Conclusions A number of the infant deaths in this review could have been prevented with preconception and inter-conception education and by improving the quality and content of prenatal care.     

Healthcare Utilization in the Postpartum Period Among Illinois Women with Medicaid Paid Claims for Delivery, 2009–2010

Purpose Postpartum care can provide the critical link between pregnancy and well-woman healthcare, improving women’s health during the interconception period and beyond. However, little is known about current utilization patterns. This study describes the patterns of postpartum care experienced by Illinois women with Medicaid-paid deliveries. Methods Medicaid claims for women delivering infants in Illinois in 2009–2010 were analyzed for the receipt, timing and patterns of postpartum care, as identified through International Classification of Diseases Revision 9—Clinical Modification and Current Procedural Terminology© codes for routine postpartum care (43.4 % of visits), other postpartum services (e.g., depression screening, family planning), and other office visits for non-acute care. Results Over 90,000 visits to 55,577 women were identified, with 81.1 % of women experiencing any care during the first 90 days postpartum. Approximately 40 % had one visit, while 31 and 29 % had two and three or more visits, respectively. Thirty-four percent had their first visit <21 days postpartum, while 56 % had the first visit between 21 and 56 days postpartum. Compared with non-Hispanic whites, African-Americans had lower rates of receiving any care (73.6 vs. 86.5 %), fewer visits (48.0 vs. 33.5 % with only one visit), and later first visits (13.6 vs. 7.3 %, >56 days). Conclusions for Practice The vast majority of Illinois women with Medicaid-paid deliveries interact with the healthcare system during the first 3 months postpartum, though not always for a routine postpartum visit. Strategies to optimize postpartum health should encourage a higher level of coordination among services and linkage to well-woman care to improve subsequent women and infants’ health outcomes.     

A Behavioral Intervention to Reduce Excessive Gestational Weight Gain

Objectives Excessive gestational weight gain (GWG) is a key modifiable risk factor for negative maternal and child health. We examined the efficacy of a behavioral intervention in preventing excessive GWG. Methods 230 pregnant women (87.4 % Caucasian, mean age = 29.2 years; second parity) participated in the longitudinal Glowing study (clinicaltrial.gov #NCT01131117), which included six intervention sessions focused on GWG. To determine the efficacy of the intervention in comparison to usual care, participants were compared to a matched contemporary cohort group from the Arkansas Pregnancy Risk Assessment Monitoring Survey (PRAMS). Results Participants attended 98 % of intervention sessions. Mean GWG for the Glowing participants was 12.7 ± 2.7 kg for normal weight women, 12.4 ± 4.9 kg for overweight women, and 9.0 ± 4.2 kg for class 1 obese women. Mean GWG was significantly lower for normal weight and class 1 obese Glowing participants compared to the PRAMS respondents. Similarly, among those who gained excessively, normal weight and class 1 obese Glowing participants had a significantly smaller mean weight gain above the guidelines in comparison to PRAMS participants. There was no significant difference in the overall proportion of the Glowing participants and the proportion of matched PRAMS respondents who gained in excess of the Institute of Medicine GWG guidelines. Conclusions for Practice This behavioral intervention was well-accepted and attenuated GWG among normal weight and class 1 obese women, compared to matched participants. Nevertheless, a more intensive intervention may be necessary to help women achieve GWG within the Institute of Medicine’s guidelines.     

Breastfeeding and Exposure to Past,Current, and Neighborhood Violence

Objectives Breastfeeding has short- and long-term health benefits for children and mothers, but US breastfeeding rates are suboptimal. Exposure to violence may contribute to these low rates, which vary by race/ethnicity. We studied: (1) whether patterns of violence exposure differ by race/ethnicity and (2) whether these patterns are associated with breastfeeding outcomes. Methods We conducted a secondary analysis of data drawn from self-report surveys completed by a convenience sample of low-income postpartum women (n?=?760) in upstate New York. Latent class analysis was used to identify groups of women with similar responses to seven violence measures, including childhood physical and/or sexual violence, experience of partner violence during or just after pregnancy (physical, emotional, verbal), and neighborhood violence (perceived or by ZIP code). Logistic regression and survival analysis were utilized to determine if classes were associated with breastfeeding initiation, duration, and exclusivity, controlling for demographics. Results Exposure to at least one form of violence was high in this sample (87%). We identified 4 classes defined by violence exposure (combining current and historical exposures). Violence exposure patterns differed between racial/ethnic groups, but patterns were inconsistently associated with breastfeeding plans or outcomes. For White women, history of violence exposure increased the likelihood of earlier breastfeeding cessation. By contrast, among Black women, history of violence exposure increased the likelihood of having a breastfeeding plan and initiating breastfeeding. Conclusions for Practice Some differences between violence exposure classes are likely due to the correlation between race/ethnicity and socioeconomic status in the community studied. Additional studies are warranted to better understand how exposure to violence is related to breastfeeding and how best to support women making decisions about intention, initiation, and duration of breastfeeding.