Effectiveness of a Federal Healthy Start Program in Reducing the Impact of Particulate Air Pollutants on Feto-Infant Morbidity Outcomes

We sought to assess (1) the relationship between air particulate pollutants and feto-infant morbidity outcomes and (2) the impact of a Federal Healthy Start program on this relationship. This is a retrospective cohort study using de-identified hospital discharge information linked to vital records, and air pollution data from 2000 through 2007 for the zip codes served by the Central Hillsborough Federal Healthy Start Project in Tampa, Florida. Mathematical modeling was employed to compute minimal Euclidean distances to capture exposure to ambient air particulate matter. The outcomes of interest were low birth weight (LBW), very low birth weight (VLBW), small for gestational age, preterm (PTB), and very preterm birth. We used odds ratios to approximate relative risks. A total of 12,356 live births were analyzed. Overall, women exposed to air particulate pollutants were at elevated risk for LBW (AOR?=?1.24; 95% CI?=?1.07?C1.43), VLBW (AOR?=?1.58; 95% CI?=?1.09?C2.29) and PTB (AOR?=?1.18; 95% CI?=?1.03?C1.34). Analysis by race/ethnicity revealed that the adverse effects of air particulate pollutants were most profound among black infants. Infants of women who received services provided by the Central Hillsborough Federal Healthy Start Project experienced improved feto-infant morbidity outcomes despite exposure to air particulate pollutants. Environmental air pollutants represent important risk factors for adverse birth outcomes, particularly among black women. Multi-level interventional approaches implemented by the Central Hillsborough Federal Healthy Start were found to be associated with reduced likelihood for feto-infant morbidities triggered by exposure to ambient air particulate pollutants.     

Prenatal Care and Risk of Preterm Birth Among Foreign and US-Born Mothers in Michigan

Studies among ethnic minorities suggest that prenatal care (PNC) may be less protective against preterm birth (PTB) among foreign-born relative to US-born mothers. We assessed relations between nativity, PNC inadequacy, and PTB risk over 17 years in one US state. Adjusted multivariable models were fit to assess the potential interaction between nativity and PNC inadequacy as a determinant of PTB. Additionally, we calculated predicted probabilities of PTB by PNC inadequacy, stratified by nativity. In adjusted models of PTB, there was a significant interaction (P _interaction < 0.01) between nativity and PNC inadequacy. US-born mothers who did not use PNC adequately had 2.9% higher predicted probability of PTB than adequate users, which compares to 1.9% difference among foreign-born mothers. While adequate PNC use was lower among foreign-born compared to native born mothers, when accessed, PNC use may be less protective against PTB among foreign-born mothers relative to native-born mothers. Differences in cultural health traditions during pregnancy, or baseline health status between foreign and native-born mothers may mediate our findings.     

Reducing Low Birth Weight Infancy: Assessing the Effectiveness of the Health Start Program in Arizona

This study compares the incidence of low birth weight among mothers enrolled in Arizona’s Health Start program to a sample of non-Health Start mothers with similar medical and social risk factors. A quasi-experimental design was used to match Health Start program participants to non-participants on the basis of similar medical and social risk factors. Health Start program data were linked to birth certificate data to create a sample of 5,480 pregnant women. A logistic regression analysis was conducted to predict the likelihood of having a normal birth weight (i.e., 2,500 g or more). The findings indicate that Health Start mothers had twice as better odds of having a normal birth weight than non-Health Start mothers, even after controlling for gestational age, adequacy of prenatal care, mother’s history of preterm birth, weight gain during pregnancy, alcohol and cigarette use, mother’s age, education and residency. Hispanic women in the program were three times as likely to have a normal birth weight baby when compared to Hispanics who were not in the program and twice as likely as non-participant Whites. And lastly, women in urban settings had better birth outcomes, especially Hispanic women. Evidence suggests that newborn infants of mothers enrolled in the Health Start Program had better birth weight outcomes even after controlling for the effects of possible confounders. However, the program seems to affect Hispanics and non-Hispanic Whites differently; in particular, Hispanics who are in the program demonstrated the best birth outcomes. One possible explanation for the general success of the program could be that program participants reported lower cigarette use during pregnancy. A limitation of this study is that that there could be reporting bias on the part of Health Start participants about their risks to enter into the program, which is difficult to verify.     

The Impact of Birth Spacing on Subsequent Feto-Infant Outcomes among Community Enrollees of a Federal Healthy Start Project

Numerous studies have shown an association between shorter birth intervals, and several adverse fetal outcomes, including low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA). However, there is little evidence on the effectiveness of interconception care on fetal outcomes associated with sub-optimal interpregnancy interval (IPI). The purpose of this study is to examine the influence of the Federal Healthy Start’s interconception care services on IPI and fetal growth outcomes. This is a retrospective cohort study used records from the Central Hillsborough Healthy Start program in Tampa, Florida linked to Florida vital statistics data covering the period 2002–2009. Only first and second pregnancies were considered, and interpregnancy interval (IPI), the exposure of interest, was categorized in months as 0–5, 6–17, 18–23, and ≥24. The following feto-infant morbidities were considered as primary outcomes: LBW, PTB, and SGA. A composite variable coding the presence of any of the aforementioned adverse fetal events was also created. Multivariate logistic regression modeling was applied Overall, mothers with the shortest IPI (0–5 months: AOR = 1.39, 95% CI 1.23–1.56) and longest IPI (≥60 months: AOR = 1.13, 95% CI 1.03–1.23) were at a greater risk for adverse fetal growth outcomes, compared to the referent category (18–23 months). Our findings support the need for inter conception care that addresses IPI and delayed childbearing among women.     

Reducing infant mortality in the United States through "Healthy Start"

The author reviews current trends in infant mortality in the United States. Attention is given to the importance of early prenatal care and to the behavioral and cultural factors related to differences in infant mortality rates among ethnic groups.     

Evaluating the Healthy Start program. Design development to evaluative assessment

The national evaluation of the federally funded Healthy Start program involved translating a design for a process and outcomes evaluation and standard maternal and infant data set, both developed prior to the national evaluation contract award, into an evaluation design and client data collection protocol that could be used to evaluate 15 diverse grantees. This article discusses the experience of creating a process and outcomes evaluation design that was both substantively and methodologically appropriate given such issues as the diversity of grantees and their community-based intervention strategies; the process of accessing secondary data sources, including vital records; the quality of client level data submissions; and the need to incorporate both qualitative and quantitative approaches into the evaluation design. The relevance of this experience for the conduct of other field studies of public health interventions is discussed.     

Reducing the Use of Emergency Medical Resources Among Head Start Families: A Pilot Study

The objective of this study was to determine whether self-care training with Head Start parents can improve their ability to manage the healthcare needs of their children measured by utilization of emergency department (ED) and physician services. Four hundred and six families in Head Start agencies were included in the study. Parents were given a low-literate self-help book entitled What To Do When Your Child Gets Sick. The study design included using multiple-choice, pre-and post-intervention survey data. In a six month follow-up, parents who received the book reported a 48% reduction in ED visits and a 37.5% reduction in clinic visits. More research is needed to determine if this self-care tool and additional training can have a significant impact on inappropriate use of medical resources.     

Reducing Fat in Preschool Meals: Description of the Foodservice Intervention Component of Healthy Start

Healthy Start is a 3–year demonstration and education research project to evaluate the effectiveness of a coronary heart disease risk reduction program in Head Start centers in New York State. The primary goal of the program is to demonstrate that it is possible and safe to reduce young children's intake of fat to desirable levels. The development and initial implementation of the nutrition intervention component of the program are described in this report. Nutrition intervention includes nutrition education for the children's care givers and modifications in the foodservice operation in each of the study's six intervention sites. Recommendations are provided to guide educators in future research and practice.     

Reducing Stress Among Mothers in Drug Treatment: A Description of a Mindfulness Based Parenting Intervention

Background Parenting women with substance use disorder could potentially benefit from interventions designed to decrease stress and improve overall psychosocial health. In this study we assessed whether a mindfulness based parenting (MBP) intervention could be successful in decreasing general and parenting stress in a population of women who are in treatment for substance use disorder and who have infants or young children. Methods MBP participants (N?=?59) attended a two-hour session once a week for 12 weeks. Within-group differences on stress outcome measures administered prior to the beginning of the MBP intervention and following the intervention period were investigated using mixed-effects linear regression models accounting for correlations arising from the repeated-measures. Scales assessed for pre-post change included the Perceived Stress Scale-10 (PSS) and the Parenting Stress Index-Short Form (PSI). Results General stress, as measured by the PSS, decreased significantly from baseline to post-intervention. Women with the highest baseline general stress level experienced the greatest change in total stress score. A significant change also occurred across the Parental Distress PSI subscale. Conclusions Findings from this innovative interventional study suggest that the addition of MBP within treatment programs for parenting women with substance use disorder is an effective strategy for reducing stress within this at risk population.     

Preterm Birth and Receipt of Postpartum Contraception Among Women with Medicaid in North Carolina

Maternal and Child Health Journal - To compare receipt of contraception and method effectiveness in the early postpartum period among women with and without a recent preterm birth (PTB). We used...     

Defining the Role of the Community Health Worker within a Federal Healthy Start Care Coordination Team

Introduction Federal and state policies often require utilization of evidence-based home visiting programs. Measurement of specified interventions is important for tracking program implementation and achieving program outcomes. Thus, the Strong Beginnings program worked to define community health worker (CHW) interventions, a core service of the program to improve maternal and child health. Methods A workgroup consisting of CHWs, supervisors and other program staff was created in order to develop and define specific CHW interventions within a nurse or social worker care team. Basic interventions were first compared to the nurse or social worker care coordinator home visiting interventions by risk topic. The evaluator then grouped each CHW intervention into categories per risk domain using thematic analysis and assigned a CHW core function or role based on literature review findings. The workgroup confirmed the results. The workgroup then continued discussions to further enhance CHW interventions per risk domain once the general structure was created. Results The workgroup identified seven core functions and 28 maternal and child health risk topics to be addressed by the CHW. The process resulted in a detailed document of program interventions that the CHWs use to guide care. Conclusions The process helped CHWs feel more valued with their role in team care. The specified interventions will help others understand the CHW role within the care team, ensure consistent interventions are delivered across program partners, provide a foundation to better understand how specific CHW contributions are related to health outcomes, and support program sustainability.     

Evaluation of an Integrated Services Program to Prevent Subsequent Pregnancy and Birth Among Urban Teen Mothers

This article details the evaluation of a clinical services program for teen mothers in the District of Columbia. The program's primary objectives are to prevent unintended subsequent pregnancy and to promote contraceptive utilization. We calculated contraceptive utilization at 6, 12, 18, and 24 months after delivery, as well as occurrence of subsequent pregnancy and birth. Nearly seven in ten (69.5%) teen mothers used contraception at 24 months after delivery, and 57.1% of contraceptive users elected long-acting reversible contraception. In the 24-month follow-up period, 19.3% experienced at least one subsequent pregnancy and 8.0% experienced a subsequent birth. These results suggest that an integrated clinical services model may contribute to sustained contraceptive use and may prove beneficial in preventing subsequent teen pregnancy and birth.     

A Single-Blind,Parallel Design RCT to Assess the Effectiveness of SMS Reminders in Improving ART Adherence Among Adolescents Living with HIV (STARTA Trial)

PurposeThe study evaluated the feasibility, acceptability, and efficacy of interactive and tailored short message reminders on antiretroviral therapy adherence among adolescents (15–19 years) living with HIV in southwest Nigeria.MethodsThe study was a single-blind, parallel-design (ratio 1:1), and multicenter RCT of 209 medication-non-adherent adolescents living with HIV at HIV clinics in two states in southwest Nigeria. The research assessed ART adherence using the visual analog scale, viral suppression, pill count, and ACTG scores; the feasibility of the intervention by the SMS delivery and response (overall and individual) rates; and acceptability using self-report, willingness to continue receiving the intervention, and desire for its scale-up.ResultsA total of 17,690 text messages were sent while 10,119 (57.2%) got delivered to the participants. Out of 9,216 responses that were received from the study participants, 8,781 (95.3%) indicated acceptability of the intervention.The end-of-study log₁₀ of viral load values between control and intervention groups had a mean difference of 0.66 (95% CI 0.26–1.06) and p-value of .001. Also, the unadjusted odds ratio of undetected viral load (≤20 copies/ml) was 1.356 (1.039–1.771) with a p-value of .002. However, the intervention had no effect on subjective measures of antiretroviral therapy adherence.ConclusionsThe use of interactive and tailored short message reminders to enhance antiretroviral therapy adherence among adolescents has good potential. It seems feasible, highly acceptable, and possibly leads to improved viral load count. It is likely that the associated antiretroviral therapy adherence enhances viral suppression and, therefore, improves outcomes in adolescent HIV.     

Birth Outcomes Among Older Mothers in Rural Versus Urban Areas: A Residence‐Based Approach

Purpose: We examined the association between rural residence and birth outcomes in older mothers, the effect of parity on this association, and the trend in adverse birth outcomes in relation to the distance to the nearest hospital with cesarean‐section capacity. Methods: A population‐based retrospective cohort study, including all singleton births to 35+ year‐old women in British Columbia (Canada), 1999‐2003. We compared birth outcomes in rural versus urban areas, and between 3 distance categories to a hospital (<50, 50‐150, >150 km). Outcomes included labor induction, cesarean section, stillbirth, perinatal death, preterm birth (<37 weeks), small‐for‐gestational‐age, large‐for‐gestational‐age, and neonatal intensive care unit admission. We used multivariate regression to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Findings: Among the 29,698 subjects, 11.5% lived in rural areas; 5% lived within 50‐150 km; and 1.1% lived >150 km from a hospital. Rural women were at lower risk of primary and repeat cesarean section (OR = 0.9, CI: 0.9‐1.0; OR = 0.7, CI: 0.6‐0.9) and small‐for‐gestational‐age (OR = 0.8, CI: 0.7‐0.9) births; they were at increased risk for perinatal death (OR = 1.5, CI: 1.1‐2.1) and large‐for‐gestational‐age (OR = 1.1, CI: 1.1‐1.2) births. The association was stronger among multiparous versus primiparous women. No differences in emergency cesarean section, preterm birth, or neonatal intensive care admission were found, regardless of parity. Perinatal mortality increased with distance from hospital; OR = 1.5 (CI: 1.1‐2.1) per distance category. Conclusions: Older women in rural versus urban areas had a lower rate of cesarean section and increased risk of perinatal death. The risk of perinatal death increased with the distance to hospital. Further studies need to evaluate the contribution of underlying perinatal risks, access to care, and decision making regarding referral and transport.