Association of Household Savings and Expected Future Means with Delivery Using a Skilled Birth Attendant in Ghana and Nigeria: A Cross-Sectional Analysis

Objectives This study examined the association between household savings and related economic measures with utilization of skilled birth attendants (SBAs) at last birth among women living in peri-urban households (n = 381) in Ghana and Nigeria. Methods Data were drawn from the 2011–2014 Family Health and Wealth Study. Multivariable logistic regression models were used to estimate the odds of delivery with an SBA for individual and composite measures of household savings, expected financial means, debt, lending, and receipt of financial assistance, adjusting for demographic and reproductive characteristics. Results Seventy-three percent (73 %) of women delivered with an SBA during their last birth (89 %, Ghana; 63 %, Nigeria), and roughly one third (34 %) of households reported having any in-cash or in-kind savings. In adjusted analyses, women living in households with savings were significantly more likely to deliver with an SBA compared to women in households without any savings (aOR = 2.02, 95 % CI 1.09–3.73). There was also a consistent downward trend, although non-significant, in SBA utilization with worsening financial expectations in the coming year (somewhat vs. much better: aOR = 0.70, 95 % CI 0.40–1.22 and no change/worse vs. much better: aOR = 0.46, 95 % CI 0.12–1.83). Findings were null for measures relating to debt, lending, and financial assistance. Conclusion Coupling birth preparedness and complication readiness strategies with savings-led initiatives may improve SBA utilization in conjunction with targeting non-economic barriers to skilled care use.     

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.     

Women’s Autonomy and Skilled Attendance During Pregnancy and Delivery in Nepal

Objectives This study aims to explore the association between women’s autonomy and skilled attendance during pregnancy and delivery in Nepal. Methods We adopt data from the Nepal Demographic and Health Survey (NDHS, 2011). We include only married women who gave birth in the 5 years preceding the survey (N = 4148). Women’s autonomy was assessed on the basis of four indicators of decision making: healthcare, visiting friends or relatives, household purchases and spending earned money. Each indicator was dichotomized (yes/no) and then summarized into a single variable to measure overall autonomy. Next, we measured health attendance (skilled vs. unskilled) during antenatal and delivery care. The association between women’s autonomy and skilled attendance was analysed using a logistic regression model. Results Most women had a medium (40 %) and high (35 %) level of overall autonomy. The proportion of women accessing skilled providers during antenatal and delivery care was 51 and 36 %. Women with autonomy in healthcare, visiting friends or relatives, making household purchases and spending money earned were associated with a higher likelihood of receiving care from skilled providers during antenatal care and delivery. An elevated probability of access to skilled attendance during antenatal (aOR 1.33; 95 % CI 1.10–1.59) and delivery care (aOR 1.38; 95 % CI 1.12–1.70) was reported among women with higher levels of overall autonomy. Conclusion Women’s autonomy was significantly associated with the maternal health care utilization by skilled attendants. This study will provide insights for policy makers to develop strategies in improving maternal health.     

Postpartum Depression and Anxiety Among Mothers Whose Child was Placed in Care of Child Protection Services at Birth: A Retrospective Cohort Study Using Linkable Administrative Data

Objectives This study examines whether mothers involved with child protection services (CPS) at the birth of their first child had higher rates of postpartum depression and anxiety. Methods A retrospective cohort of mothers whose first child was born in Manitoba, Canada between April 1, 1995 and March 31, 2015 is used. Postpartum depression and anxiety among mothers whose first child was placed in care at birth (n?=?776) was compared with mothers who received services from CPS (but whose children were not placed in care) (n?=?4,270), and a 3:1 matched group of mothers who had no involvement with CPS in the first year of their firstborn’s life (n?=?2,328). Adjusted odds ratios (AOR) of depression and anxiety diagnoses in the first year postpartum were obtained from logistic regression models. Adjusted rate ratios (ARR) of antidepressant use obtained using Poisson models. Results Mothers whose children were taken into care have greater odds of having a postpartum depression or anxiety diagnosis than mothers receiving services (AOR?=?1.31; 95% CI 1.08–1.59) and those not involved with CPS (AOR?=?2.13; 95% CI 1.67–2.73). Among mothers who had a postpartum depression or anxiety diagnosis, mothers whose children were placed in care had significantly higher rates of antidepressant use than mothers receiving services only (ARR?=?2.00; 1.82, 2.19) and mothers who were not involved with CPS (ARR?=?2.42; 95% CI 1.94–3.51). Conclusions for Practice Targeted programs should be implemented to address postpartum mental illness among mothers who are involved with CPS at the birth of their child.     

Determinants of prenatal anemia in Ethiopia

Background

Anemia is responsible for 20% of maternal mortality worldwide, and it is associated with premature birth, low birth weight, and infant mortality. In Ethiopia, about 22% of pregnant women are anemic. However, literatures are limited, therefore, this study aimed to investigate the prevalence and associated factors of anemia among pregnant women attending antenatal care (ANC) in Asossa Zone Public Health Institutions, northwest Ethiopia.

Methods

A facility based cross-sectional study was conducted from February to March 2016. Data were collected by interviewer administered, pretested and structured questionnaires. A multi-stage sampling technique was used to select 762 pregnant women. The hemoglobin level was determined by taking 5 ml of venous blood using Sahli’s method. A multivariate binary logistic regression model was fitted to identify factors associated with anemia. Adjusted Odds Ratio (AOR) with a 95% Confidence Interval (CI) was computed to show the strength of association and statistical significance was determined at a P-value of <0.05.

Results

The prevalence of anemia was 31.8% [95% CI: 28.9, 35.5]. In the adjusted analysis, maternal age of 30–34 years [AOR = 0.34, 95% CI: 0.14, 0.86], household size of ≥6 [AOR = 4.27, 95% CI: 1.58, 11.45], dietary diversity [AOR = 0.58, 95% CI: 0.38, 0.93], no meat consumption [AOR = 1.80, 95% CI: 1.11, 2.91], not drinking soft beverages [AOR =1.96, 95% CI: 1.19, 3.23], undernutrition [AOR = 7.38, 95% CI: 4.22, 12.91], not consuming fruits [AOR = 3.29, 95% CI: 1.59, 6.82], inter-pregnancy interval of ≥2 years [AOR = 0.59, 95% CI: 0.34, 0.99], and third trimester of pregnancy [AOR = 0.33, 95% CI: 0.20, 0.57] were significantly associated with anemia.

Conclusions

The prevalence of prenatal anemia is high in the Asossa Zone; suggesting a moderate public health concern. Socio-demographic and dietary intake characteristics were significantly associated with anemia. Therefore, improving dietary diversity and animal food consumption are the key to reduce the high burden of anemia. It is also important to strengthen interventions aiming to reduce closed birth interval and teenage pregnancy.

     

Does Preconception Health Differ by Nativity?: Findings from the Los Angeles Mommy and Baby (LAMB) Study

Objectives To compare certain preconception health (PCH) behaviors and conditions among US-born (USB) and foreign-born (FB) mothers in Los Angeles County (LAC), regardless of race/ethnicity, and to determine if any identified differences vary among Asian/Pacific Islanders (API’s) and Hispanics. Methods Data are from the 2012 Los Angeles Mommy and Baby study (n = 6252). PCH behaviors included tobacco use, multivitamin use, unintended pregnancy, and contraception use. PCH conditions comprised being overweight/obese, diabetes, asthma, hypertension, gum disease, and anemia. The relationship between nativity and each PCH behavior/condition was assessed using multivariable logistic regression models. Results USB women were more likely than FB women to smoke (AOR 2.12, 95 % CI 1.49–3.00), be overweight/obese (AOR 1.57, 95 % CI 1.30–1.90), and have asthma (AOR 2.04, 95 % CI 1.35–3.09) prior to pregnancy. They were less likely than FB women to use contraception before pregnancy (AOR 0.59, 95 % CI 0.49–0.72). USB Hispanics and API’s were more likely than their FB counterparts to be overweight/obese (AOR 1.57, 95 % CI 1.23–2.01 and AOR 2.37, 95 % CI 1.58–3.56, respectively) and less likely to use contraception (AOR 0.58, 95 % CI 0.45–0.74 and AOR 0.46, 95 % CI 0.30–0.71, respectively). USB Hispanic mothers were more likely than their FB counterparts to smoke (AOR 2.47, 95 % CI 1.46–4.17), not take multivitamins (AOR 1.30, 95 % CI 1.02–1.66), and have asthma (AOR 2.35, 95 % CI 1.32–4.21) before pregnancy. Conclusions US nativity is linked to negative PCH among LAC women, with many of these associations persisting among Hispanics and API’s. As PCH profoundly impacts maternal and child health across the lifecourse, culturally-appropriate interventions that maintain positive behaviors among FB reproductive-aged women and encourage positive behaviors among USB women should be pursued.     

Affluent-Born White Mother’s Descending Neighborhood Income and Infant Mortality: A Population-Based Study

Objectives To determine whether affluent-born White mother’s descending neighborhood income is associated with infant mortality rates (<?365 day, IMR). Methods Stratified and multilevel logistic regression analyses were completed on the Illinois transgenerational dataset of singleton births (1989–1991) to non-Latina White mothers (1956–1976) with an early-life residence in affluent neighborhoods (defined as the fourth quartile of income distribution). The breadth of descending neighborhood income was defined by mother’s neighborhood income at the time of delivery. Results Infants of White mothers (n?=?4890) who did not suffer descending neighborhood income by the time of delivery had a first-year mortality rate of 5.1/1,000. Infants of White mothers who experienced minor (n?=?5112), modest (n?=?2158), or extreme (n?=?339) descending neighborhood income had IMR of 6.5/1,000, 14.4/1,000, and 11.8/1,000, respectively; RR [95% CI]?=?1.3 [0.8, 2.1], 2.8 [1.7, 4.8], and 2.3 [0.8, 6.6], respectively. The incidence of young maternal age, inadequate prenatal care utilization, and cigarette smoking rose as descending neighborhood income increased, p?<?0.01. In multilevel logistic regression models, the adjusted (controlling for selected individual-level co-variates) OR [95% CI] of infant mortality for White women with an early-life residence in affluent neighborhoods who subsequently experienced minor or modest to extreme (versus absent) descending neighborhood income equaled 1.0 [0.6, 1.8] and 2.1 [1.1, 3.8] respectively. Conclusions White mother’s modest to extreme descending neighborhood income from early-life residence in affluent neighborhoods is associated with a twofold greater risk of infant mortality independent of selected biologic, medical, and behavioral characteristics.     

Attachment to Conventional Institutions and Adolescent Rapid Repeat Pregnancy: A Longitudinal National Study Among Adolescents in the United States

Introduction There is limited research on rapid repeat pregnancies (RRP) among adolescents, especially using nationally representative samples. We examine distal factors—school, family, peers, and public/private religious ties—and their associations with RRP among adolescent mothers. Methods Guided by social development theory, we conducted multivariate logistic regression analyses, adjusted for sociodemographic characteristics, to examine associations between RRP and attachment to school, family, peers, and religion among 1158 female respondents from the National Longitudinal Study of Adolescent to Adult Health (Add Health) who reported at least one live birth before age 20. Results Attachments to conventional institutions were associated with lower likelihood of RRP. Adolescent mothers who had a stronger relationship with their parents had reduced odds of RRP (adjusted odds ratio [aOR] 0.83, 95 % CI 0.71–0.99). Increased odds of RRP were associated with anticipating fewer negative social consequences of sex (aOR 1.18, 95 % CI 1.02–1.35), never praying (versus praying daily; aOR 1.47, 95 % CI 1.10–1.96), and never participating in church-related youth activities (versus participating once a week; 1.04, 95 % CI 1.01–1.07). Discussion After an adolescent birth, social support from family, peers, and the community can benefit young mothers. Private aspects of religiosity may be especially important. Understanding the processes by which these distal factors are linked to the likelihood of RRP is needed to create multifaceted intervention programs that provide diverse methods of support customized to specific circumstances of adolescent mothers.     

Protective Assets for Non-use of Alcohol,Tobacco and Other Drugs among Urban American Indian Youth in Oklahoma

Objective This study explored associations between nine youth assets and tobacco, alcohol and other drug non-use among participating American Indian adolescents. Methods Data from 134 American Indians, ages 13–19 years, participating in an inner-city youth asset study, were analyzed. Individual logistic regression analyses were conducted, controlling for demographic variables, with nine youth assets as the independent variables and alcohol, tobacco and other drug non-use as the dependent variables. Results Among American Indian youth, nearly 79% reported not using alcohol in the past 30 days. The prevalence of tobacco non-use was somewhat lower than that of alcohol, with 71% reporting not using tobacco in the past 30 days. For other drug non-use, 87% reported not using other drugs in the past 30 days. The non-parental adult role models asset was significantly associated with non-use of alcohol (OR = 4.4, 95% CI 1.5–13.3), tobacco (OR = 7.5, 95% CI 2.2–25.6), and other drugs (OR = 5.0, 95% CI 1.5–16.8). The use of time (religion) asset was also significantly associated with alcohol non-use (OR = 2.8, 95% CI 1.1–7.2). The family communication asset was associated only with other drug non-use (OR = 3.1, 95% CI 1.02–9.4). For tobacco non-use, an interaction was observed between family structure and the good health practices (exercise/nutrition) asset. Among youth in single-parent households, the odds of tobacco non-use were 4.4 times greater among those who possessed the good health practices (exercise/nutrition) asset. Conclusions Despite the relatively small sample size of American Indian youth, these results suggest an important role for specific youth assets in the prevention of substance abuse among American Indian youth.     

Relationship Between Current Substance Use and Unhealthy Weight Loss Practices Among Adolescents

Objectives To determine the relationship between current substance use and unhealthy weight loss practices (UWLP) among 12-to-18 year olds. Methods Participants were 12-to-18 year olds who completed the 2013 Youth Risk Behavior Survey in Florida (N = 5620). Current alcohol, tobacco, and marijuana use was self-reported based on last 30-day use. UWLP was defined based on self-report of at least one of three methods to lose weight in last 30-days: (1) ≥24 h of fasting, (2) diet pill use, and (3) laxative use/purging. The reference group included those with no reported UWLP. Logistic regression models adjusted for age, gender, race/ethnicity, academic performance, age-sex-specific body mass index percentiles, and perceived weight status were fitted to assess relationships between UWLP and current substance use. Results About 15 and 41 % of adolescents reported ≥1 UWLP and use of ≥1 substance in the last 30-days, respectively. Over half (60.1 %) of adolescents who reported substance use engaged in UWLP (p < 0.0001). The prevalence of current alcohol use (50.6 %) was the highest among those who reported UWLP, followed by marijuana (31.9 %), tobacco (19.7 %), and cocaine (10.5 %) use. Adolescents who reported current tobacco [adjusted odds ratio (AOR) 2.7, 95 % confidence interval (CI) 2.1–3.6], alcohol (AOR 2.2, 95 % CI 1.9–2.6), or marijuana (AOR 2.1, 95 % CI 1.7–2.5) use had significantly higher odds of UWLP compared to their non-user counterparts. Conclusions This cross-sectional study shows that substance use and UWLP behaviors are likely to co-exist in adolescents. Further studies are necessary to determine the temporal relationship between substance use and UWLP. It is recommended that intervention programs for youth consider targeting these multiple health risk behaviors.     

Undernutrition Among Infants and Children in Nepal: Maternal Health Services and Their Roles to Prevent it

Objectives Appropriate infant and young child feeding (IYCF) for children aged 6–23 months includes adequate dietary diversity, appropriate meal frequency, and continued breastfeeding. Mothers receiving antenatal care (ANC) and postnatal care (PNC) may adopt better IYCF. This study examined the association of ANC or PNC attendance with IYCF and child nutrition status. Methods A cross-sectional study was performed on 400 mother–child pairs in rural Nepal. Mothers were interviewed about their history of ANC and PNC attendance and IYCF; the height and weight of their children were measured. IYCF was measured with infant and child feeding index (ICFI) aggregating scores of dietary diversity, meal frequency, continued breastfeeding, and dietary variety. Lower ICFI scores indicated poorer IYCF practices. Multiple regression and logistic regression examined the association of ANC and PNC attendance with ICFI scores and undernutrition, respectively. Results Absence of ANC (β = ?1.01, P = 0.011) and absence of PNC (β = ?1.01, P = 0.011) were negatively associated with ICFI scores. Additionally, absence of ANC was positively associated with underweight (AOR 3.37; 95 % CI 1.42–9.92 for children 6–11 months, AOR 3.43; 95 % CI 1.41–8.32 for children 12–23 months) and stunting (AOR 6.51; 95 % CI 2.11–20.10 for children 6–11 months, AOR 3.32; 95 % CI 1.50–7.31 for children 12–23 months). Similarly, children tended to be underweight and stunted if their mothers did not receive any PNC. Conclusion Absence of ANC and PNC were associated with poor IYCF, underweight, and stunting in children.     

Determinants and perceptions of the utilization of tetanus toxoid immunization among reproductive-age women in Dukem Town,Eastern Ethiopia: a community-based cross-sectional study

Background

Maternal and neonatal tetanus (MNT) is still the major public health problem in about 25 countries, mainly in Africa and Asia. However, the utilization of intervention strategies, like tetanus toxoid (TT) immunization remains low in these countries. In Ethiopia, only 49% of the pregnant mothers received TT2+ in 2016. This study was designed to evaluate perceptions and factors affecting the utilization of TT immunization among reproductive-age women in Dukem town, Eastern Ethiopia, 2016.

Methods

We conducted a community-based cross-sectional study from May to October 2016. A simple random sampling method was employed to select samples of 422 women. Data were collected using a, pretested semi-structured and a face-to-face interviewer-administered questionnaire. We entered data in to Epi Info version 7 and analyzed them by SPSS version 20 software. Odds ratios and a 95% CI at 0?<?0.05 p-value were calculated to ascertain the significance of associations.

Results

Response rate was 98.6% (N?=?416). Mean age with standard deviation was 29.25±?5.11 years, and average family size was 4.19. Our study showed the utilization of TT immunization was 39.2% (N?=?163). Of the participants, 33.9% (N?=?141) had never been vaccinated. ANC follow up service [AOR: 2.56, 95% CI: (1.18, 5.49)], distance from health facilities [AOR: 2.27, 95% CI: (1.27, 4.09)], knowing vaccination date [AOR: 1.98, 95% CI: (1.23, 3.18)], having a TV set in the house [AOR: 1.80, 95% CI: (1.11, 2.917)], maternal education [AOR: 1.41, 95% CI: (1.84, 2.30), and place of delivery [AOR: 1.19, 95% CI: (1.00, 1.43)] were factors significantly associated with the utilization of TT immunization.

Conclusions

This study indicated the utilization of TT immunization was low. ANC service follow up, distance from health facilities, knowing vaccination date, having a TV in the house, mothers’ educational status, and place of delivery were significant predictors. Our study suggests that policymakers and other stakeholders should consider the need for increasing access to maternal education, like basic adult education, ANC follow up services, providing accessible health facilities, improving varieties of communication media, promoting female occupational status, and providing appropriate vaccination cards.

     

Impact of Maternal Glucose and Gestational Weight Gain on Child Obesity over the First Decade of Life in Normal Birth Weight Infants

Objective To determine, among children with normal birth weight, if maternal hyperglycemia and weight gain independently increase childhood obesity risk in a very large diverse population. Methods Study population was 24,141 individuals (mothers and their normal birth weight offspring, born 1995–2003) among a diverse population with universal GDM screening [50-g glucose-challenge test (GCT); 3 h. 100 g oral glucose tolerance test (OGTT) if GCT+]. Among the 13,037 full-term offspring with normal birth weight (2500–4000 g), annual measured height/weight was ascertained between ages 2 and 10 years to calculate gender-specific BMI-for-age percentiles using USA norms (1960–1995 standard). Results Among children who began life with normal birth weight, we found a significant trend for developing both childhood overweight (>85 %ile) and obesity (>95 %ile) during the first decade of life with both maternal hyperglycemia (normal GCT, GCT+ but no GDM, GDM) and excessive gestational weight gain [>40 pounds (18.1 kg)]; p < 0.0001 for both trends. These maternal glucose and/or weight gain effects to imprint for childhood obesity in the first decade remained after adjustment for potential confounders including maternal age, parity, as well as pre-pregnancy BMI. The attributable risk (%) for childhood obesity was 28.5 % (95 % CI 15.9–41.1) for GDM and 16.4 % (95 % CI 9.4–23.2) for excessive gestational weight gain. Conclusions for Practice Both maternal hyperglycemia and excessive weight gain have independent effects to increase childhood obesity risk. Future research should focus on prevention efforts during pregnancy as a potential window of opportunity to reduce childhood obesity.     

Small-for-Gestational-Age Births are Associated with Maternal Relationship Status: A Population-Wide Analysis

Objectives To examine the association between maternal relationship status during pregnancy and infant birth outcomes. Methods Observational study of the National Longitudinal Survey of Youth 1979, a nationally representative sample of 12,686 men and women between the ages of 14 and 21. We used data from surveys of women reporting childbirth between 1979 and 2004. Relationship status was defined as relationship with an opposite-sex partner in the child’s birth year. Relationship stability was defined as the consistency in relationship status in the 1 year before, of, and after the child’s birth. Childbirth outcome included small-for-gestational age (SGA) infant. We applied random effects logistic regression models to assess the association between relationship status and stability and childbirth outcome—adjusting for maternal race, infant sex, history of miscarriage, employment, maternal age, multiparity, cohort-entry year, household poverty status, and tobacco use. Results The study included 4439 women with 8348 live births. In fully adjusted models, term SGA infants were more commonly born to partnered women (AOR 1.81; 95 % CI 1.20–2.73) and unmarried women (AOR 1.82; CI 1.34–2.47; LRT p value 0.0001), compared to married women. SGA infants were also more commonly born in unstable relationships (AOR 1.72; 95 % CI 1.14–2.63; LRT p value 0.01) compared to stable relationships. Conclusions for Practice Maternal relationship status and stability during pregnancy is independently associated with risk of SGA infant birth.     

Characteristics of Low-income Racial/Ethnic Minority Pregnant Women Screening Positive for Alcohol Risk

The current study examined the prevalence and characteristics associated with alcohol risk among low-income, predominantly racial/ethnic minority pregnant women in an urban area. We surveyed 225 pregnant women receiving nutritional care. Twenty-six percent screened positive for alcohol risk. Current smoking status (AOR 2.9, p = 0.018, 95 % CI [1.2, 7.0]) and a history of marijuana use (AOR 3.1, p = 0.001, 95 % CI [1.6, 6.2]) were the strongest predictors of alcohol risk status. This study underscores the need for screening for alcohol risk, smoking, and illicit drug use among low-income, racial/ethnic minority pregnant women and highlights the usefulness of the TWEAK in identifying alcohol risk in WIC settings.     

Women’s Use of Health Care in the First 2 Years Postpartum: Occurrence and Correlates

Objectives We sought to determine rates and correlates of accessing health care in the 2 years following delivery among women at an urban academic medical center. Methods We used electronic medical records, discharge, and billing data to determine the occurrence of primary care, other non-primary outpatient care, emergency department visits, and inpatient admissions among women delivering at a single medical center who had a known primary care affiliation to that medical center over a 5 year period. We explored sociodemographic, clinical, and health care-related factors as correlates of care, using bivariate and multivariable modeling. Results Of 6216 women studied, most (91 %) had had at least one health care visit in the window between 2 months and 2 years postpartum (the “late postpartum period”). The majority (81 %) had had a primary care visit. Factors associated with use of health care in this period included a chronic medical condition diagnosed prior to pregnancy (adjusted odds ratio (AOR) 1.42, 95 % CI [1.19, 1.71]), prenatal care received in an urban community health center (AOR 1.35 [1.06, 1.73]), having received obstetric (AOR 1.90 [1.51, 2.37]), primary (AOR 2.30 [1.68, 3.23]), or other non-primary outpatient care (AOR 2.35 [1.72, 3.39]) in the first 2 months postpartum, and living closer to the hospital [AOR for residence >17.8 miles from the medical center (AOR 0.74 [0.61, 0.90])]. Having had an obstetrical complication did not increase the likelihood of receipt of care during this window. Conclusions for Practice Among women already enrolled in a primary care practice at our medical center, health care utilization in the late postpartum period is high, but not universal. Understanding the characteristics of women who return for health care during this window, and where they are seen, can improve transitions of care across the life course and can provide opportunities for important and consistent interconception and well-woman messaging.     

Neighborhood Disadvantage and Neighborhood Affluence: Associations with Breastfeeding Practices in Urban Areas

Objective To estimate the associations between neighborhood disadvantage and neighborhood affluence with breastfeeding practices at the time of hospital discharge, by race-ethnicity. Methods We geocoded and linked birth certificate data for 111,596 live births in New Jersey in 2006 to census tracts. We constructed indices of neighborhood disadvantage and neighborhood affluence and examined their associations with exclusive (EBF) and any breastfeeding in multilevel models, controlling for individual-level confounders. Results The associations of neighborhood disadvantage and affluence with breastfeeding practices differed by race-ethnicity. The odds of EBF decreased as neighborhood disadvantage increased for all but White women [Asian: Adjusted odds ratio (AOR) 0.82 (95% confidence interval (CI) 0.69–0.97); Black: AOR 0.77 (95% CI 0.70–0.86); Hispanic: AOR 0.78 (95% CI 0.70–0.86); White: AOR 0.99 (95% CI 0.91–1.08)]. The odds of EBF increased as neighborhood affluence increased for Hispanic [AOR 1.19 (95% CI 1.08–1.31)] and White [AOR 1.12 (95% CI 1.06–1.18)] women only. The odds of any breastfeeding decreased with increasing neighborhood disadvantage only for Hispanic women [AOR 0.85 (95% CI 0.79–0.92)], and increased for White women [AOR 1.16 (95% CI 1.07–1.26)]. The odds of any breastfeeding increased as neighborhood affluence increased for all except Hispanic women [Asian: AOR 1.31 (95% CI 1.13–1.51); Black: AOR 1.19 (95% CI 1.07–1.32); Hispanic: AOR 1.08 (95% CI 0.99–1.18); White: AOR 1.30 (95% CI 1.24–1.38)]. Conclusions Race-ethnic differences in associations between neighborhood disadvantage and affluence and breastfeeding practices at the time of hospital discharge indicate the need for specialized support to improve access to services.     

Predictors of Health Care Seeking Behavior During Pregnancy,Delivery, and the Postnatal Period in Rural Tanzania

Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are the World Health Organization recommendations for women to optimize maternal health outcomes. This study examines maternal compliance with the full recommended maternal health visits in rural Tanzania with the goal of illuminating interventions to reduce inequalities in maternal health. Methods Analysis included 907 women who had given birth within two years preceding a survey of women of reproductive age. Multinomial logistic regression was used to assess the influence of maternal, household, and community-level characteristics on four alternative classes defining relative compliance with optimal configuration of maternal health care seeking behavior. Results Parity, wealth index, timeliness of ANC initiation, nearest health facility type, religion, and district of residence were significant predictors of maternal health care seeking when adjusted for other factors. Multiparous women compared to primiparous were less likely to seek care at the high level [RRR 0.16, 95 % confidence interval (CI) 0.06–0.46], at the mid-level (RRR 0.22, 95 % CI 0.09–0.58), and the mid-low level (RRR 0.27, 95 % CI 0.09–0.80). Women in the highest wealth index compared to those in the poorest group were almost three times more likely to seek the highest two levels of care versus the lowest level (high RRR 2.92, 95 % CI 1.27–6.71, mid-level RRR 2.71, 95 % 1.31–5.62). Conclusion Results suggest that efforts to improve the overall impact of services on the continuum of care in rural Tanzania would derive particular benefit from strategies that improve maternal health coverage among multiparous and low socioeconomic status women.     

Barriers to using skilled birth attendants’ services in mid- and far-western Nepal: a cross-sectional study

Background

Skilled birth attendants (SBAs) provide important interventions that improve maternal and neonatal health and reduce maternal and neonatal mortality. However, utilization and coverage of services by SBAs remain poor, especially in rural and remote areas of Nepal. This study examined the characteristics associated with utilization of SBA services in mid- and far-western Nepal.

Methods

This cross-sectional study examined three rural and remote districts of mid- and far-western Nepal (i.e., Kanchanpur, Dailekh and Bajhang), representing three ecological zones (southern plains [Tarai], hill and mountain, respectively) with low utilization of services by SBAs. Enumerators assisted a total of 2,481 women. All respondents had delivered a baby within the past 12 months. We used bivariate and multivariate analyses to assess the association between antenatal and delivery care visits and the women’s background characteristics.

Results

Fifty-seven percent of study participants had completed at least four antenatal care visits and 48% delivered their babies with the assistance of SBAs. Knowing the danger signs of pregnancy and delivery (e.g., premature labor, prolonged labor, breech delivery, postpartum hemorrhage, severe headache) associated positively with four or more antenatal care visits (OR?=?1.71; 95% CI: 1.41-2.07). Living less than 30 min from a health facility associated positively with increased use of both antenatal care (OR?=?1.44; 95% CI: 1.18-1.77) and delivery services (OR?=?1.25; CI: 1.03-1.52). Four or more antenatal care visits was a determining factor for the utilization of SBAs.

Conclusions

Less than half of the women in our study delivered babies with the aid of SBAs, indicating a need to increase utilization of such services in rural and remote areas of Nepal. Distance from health facilities and inadequate transportation pose major barriers to the utilization of SBAs. Providing women with transportation funds before they go to a facility for delivery and managing transportation options will increase service utilization. Moreover, SBA utilization associates positively with women’s knowledge of pregnancy danger signs, wealth quintile, and completed antenatal care visits. Nepal’s health system must develop strategies that generate demand for SBAs and also reduce financial, geographic and cultural barriers to such services.