Child Wanted and When? Fertility Intentions,Wantedness, and Child Survival in Rural Northern Ghana

Panel survey data collected in rural northern Ghana asked women about the “wantedness” status of their children. Parous women were asked whether they wanted more children, while those who had never had a child were asked whether they wanted to have children in the future; those who said that they did not want to have any more children in the future were asked whether they wanted to become pregnant when they last became pregnant and, if so, whether they wanted to become pregnant at the time, or would have preferred to be pregnant earlier or later. This article analyzes longitudinal responses to these questions over a 10‐year period. Birth and survival histories of subsequently born children linked to preference data permit investigation of the question: are “wanted” children more likely to survive than “unwanted” children? Hazard models are estimated to determine whether children born to women who indicated that they did not want to have a child at the time they did, or did not want any more children in the future, have a higher risk of mortality relative to children who were reported wanted at the time of pregnancy. Results show no significant differences in adjusted mortality risks between children who were reported to be wanted and those reported to be unwanted.     

Where Is Women's Health in Maternal and Child Health?

Maternal and Child Health Journal -     

Predictors and Correlates of Homework Completion and Treatment Outcomes in Parent–Child Interaction Therapy

Background

Behavioral parent training has been demonstrated to be an effective treatment for child behavior problems; however, lack of parent engagement can limit the effectiveness of treatment. Understanding more about predictors and correlates of a specific measure of parent engagement—homework completion—in parent training can help to improve treatment effectiveness and treatment outcomes.

Objective

We examined predictors of homework completion, as well as the relationship between homework completion, treatment correlates, and treatment outcomes in an open trial of parent–child interaction therapy (PCIT), a behavioral parent training program.

Methods

Participants included 53 families (mean child age = 4.40 years, SD = 1.43) who received PCIT in a community mental health center serving demographically (i.e., SES, ethnicity) diverse families.

Results

Homework completion varied significantly between mothers and fathers but did not vary with other demographic family characteristics. Parents who completed treatment showed a somewhat greater likelihood of completing homework throughout treatment and a significantly greater likelihood of completing homework during the first phase of treatment. Additionally, parents who completed more homework were more likely to report higher levels of treatment satisfaction and showed a trend toward completing treatment in fewer sessions.

Conclusions

Our findings suggest that homework has some benefits for treatment outcomes. Despite the benefits of homework, rates of adherence to homework were variable and below optimal levels. Study findings have implications for further understanding the role of homework in behavioral parent training programs.

     

Public Health Consequences of Terrorism on Maternal–Child Health in New York City and Madrid

Past research provides evidence for trajectories of health and wellness among individuals following disasters that follow specific pathways of resilience, resistance, recovery, or continued dysfunction. These individual responses are influenced by event type and pre-event capacities. This study was designed to utilize the trajectories of health model to determine if it translates to population health. We identified terrorist attacks that could potentially impact population health rather than only selected individuals within the areas of the attacks. We chose to examine a time series of population birth outcomes before and after the terrorist events of the New York City (NYC) World Trade Center (WTC) attacks of 2001 and the Madrid, Spain train bombings of 2004 to determine if the events affected maternal–child health of those cities and, if so, for how long. For percentages of low birth weight (LBW) and preterm births, we found no significant effects from the WTC attacks in NYC and transient but significant effects on rates of LBW and preterm births following the bombings in Madrid. We did find a significant positive and sustained effect on infant mortality rate in NYC following the WTC attacks but no similar effect in Madrid. There were no effects on any of the indicator variables in the comparison regions of New York state and the remainder of Spain. Thus, population maternal–health in New York and Madrid showed unique adverse effects after the terrorist attacks in those cities. Short-term effects on LBW and preterm birth rates in Madrid and long-term effects on infant mortality rates in NYC were found when quarterly data were analyzed from 1990 through 2008/2009. These findings raise questions about chronic changes in the population’s quality of life following catastrophic terrorist attacks. Public health should be monitored and interventions designed to address chronic stress, environmental, and socioeconomic threats beyond the acute aftermath of events.     

Bulky DNA Adducts in Cord Blood,Maternal Fruit-and-Vegetable Consumption,and Birth Weight in a European Mother–Child Study (NewGeneris)

Background: Tobacco-smoke, airborne, and dietary exposures to polycyclic aromatic hydrocarbons (PAHs) have been associated with reduced prenatal growth. Evidence from biomarker-based studies of low-exposed populations is limited. Bulky DNA adducts in cord blood reflect the prenatal effective dose to several genotoxic agents including PAHs.Objectives: We estimated the association between bulky DNA adduct levels and birth weight in a multicenter study and examined modification of this association by maternal intake of fruits and vegetables during pregnancy.Methods: Pregnant women from Denmark, England, Greece, Norway, and Spain were recruited in 2006–2010. Adduct levels were measured by the ³²P-postlabeling technique in white blood cells from 229 mothers and 612 newborns. Maternal diet was examined through questionnaires.Results: Adduct levels in maternal and cord blood samples were similar and positively correlated (median, 12.1 vs. 11.4 adducts in 10⁸ nucleotides; Spearman rank correlation coefficient = 0.66, p < 0.001). Cord blood adduct levels were negatively associated with birth weight, with an estimated difference in mean birth weight of –129 g (95% CI: –233, –25 g) for infants in the highest versus lowest tertile of adducts. The negative association with birth weight was limited to births in Norway, Denmark, and England, the countries with the lowest adduct levels, and was more pronounced in births to mothers with low intake of fruits and vegetables (–248 g; 95% CI: –405, –92 g) compared with those with high intake (–58 g; 95% CI: –206, 90 g)Conclusions: Maternal exposure to genotoxic agents that induce the formation of bulky DNA adducts may affect intrauterine growth. Maternal fruit and vegetable consumption may be protective.Citation: Pedersen M, Schoket B, Godschalk RW, Wright J, von Stedingk H, Törnqvist M, Sunyer J, Nielsen JK, Merlo DF, Mendez MA, Meltzer HM, Lukács V, Landström A, Kyrtopoulos SA, Kovács K, Knudsen LE, Haugen M, Hardie LJ, Gützkow KB, Fleming S, Fthenou E, Farmer PB, Espinosa A, Chatzi L, Brunborg G, Brady NJ, Botsivali M, Arab K, Anna L, Alexander J, Agramunt S, Kleinjans JC, Segerbäck D, Kogevinas M. 2013. Bulky DNA adducts in cord blood, maternal fruit-and-vegetable consumption, and birth weight in a European mother–child study (NewGeneris). Environ Health Perspect 121:1200–1206; http://dx.doi.org/10.1289/ehp.1206333     

Clinical, Immunological and Virological Evolution in Patients with CD4 T-Cell Count above 500/mm3: Is there a Benefit to Treat with Highly Active Antiretroviral Therapy (HAART)?

To assess the clinical, immunological and virological evolution in HIV-1 infected patients with CD4 T-cell count above 500/mm3, a historical cohort of 202 untreated and 96 patients treated with HAART was longitudinally studied (median follow-up 36 months). Fourteen untreated and 2 treated patients experienced clinical progression (p = 0.09). The difference between baseline CD4 T-cell count and after 3 years, was -240/mm3 in the untreated group +19/mm3 in the HAART group (p < 10(-3)). A better immunological outcome was significantly associated with a HIV sexual contamination (p = 0.01), HAART (p = 0.01), high baseline CD4 T-cell count (p < 10(-3)) and low baseline HIV viral load (p = 0.01). In the HAART group, the incidence rate of antiretroviral modification due to tolerance difficulties was 0.23+/-0.36/patient year. A sustained undetectable HIV viral load was correlated with a low baseline HIV viral load (p = 0.003) and to be antiretroviral naive (p < 10(-3)). Thus, HAART provide a better immunological outcome in patients with high CD4 T-cell count. However, the CD4 decay slope after 3 years, the risk of therapeutic side-effects and the low risk of clinical progression do not support systematic treatment of those patients.     

Evaluating Iowa Severe Maternal Morbidity Trends and Maternal Risk Factors: 2009–2014

Objectives To describe statewide SMM trends in Iowa from 2009 to 2014 and identify maternal characteristics associated with SMM, overall and by age group. Methods We used 2009–2014 linked Iowa birth certificate and hospital discharge data to calculate SMM based on a 25-condition definition and 24-condition definition. The 24-condition definition parallels the 25-condition definition, but excludes blood transfusions. We calculated SMM rates for all delivery hospitalizations (N?=?196,788) using ICD-9-CM diagnosis and procedure codes. We used log-binomial regression to assess the association of SMM with maternal characteristics, overall and stratified by age groupings. Results In contrast to national rates, Iowa’s 25-condition SMM rate decreased from 2009 to 2014. Based on the 25-condition definition, SMM rates were significantly higher among women <20 years and >34 years compared to women 25–34 years. Blood transfusion was the most prevalent indicator, with hysterectomy and disseminated intravascular coagulation (DIC) among the top five conditions. Based on the 24-condition definition, younger women had the lowest SMM rates and older women had the highest SMM rates. SMM rates were also significantly higher among racial/ethnic minorities compared to non-Hispanic white women. Payer was the only risk factor differentially associated with SMM across age groups. First trimester prenatal care initiation was protective for SMM in all models. Conclusions High rates of blood transfusion, hysterectomy, and DIC indicate a need to focus on reducing hemorrhage in Iowa. Both younger and older women and racial/ethnic minorities are identified as high risk groups for SMM that may benefit from special consideration and focus.     

Seasonal influenza vaccine supply and target vaccinated population in China, 2004–2009

To better understand the gap between limited influenza vaccine supply and the target population for vaccination in China, we conducted a retrospective survey to quantify the production capacity, supply and sale of seasonal trivalent inactive vaccine (TIV) from the 2004–2005 through the 2008–2009 season, and estimated the target population who should receive annual influenza vaccine. The maximum domestic capacity to produce TIV was 126 million doses in 2009. A total of 32.5 million doses of TIV were supplied in 2008–2009, with an average annual increase rate of 18% from 16.9 million in 2004–2005. This represents an amount sufficient to vaccinate 1.9% of Chinese population. The average number of doses of TIV for sale by province ranged from <5 to 108 per 1000 people. The differences are explained in part by level of economic development but also influenced by local reimbursement policies in some provinces. Based on national recommendations, we estimated a target population of 570.6 million or 43% of the total population. Supply and domestic production capacity for influenza vaccine is currently insufficient to vaccinate the estimated target population in China. The Government of China should consider measures to improve domestic production capacity of influenza vaccine, expand successful promotional campaigns, and add cost subsidies in high risk groups to further encourage influenza vaccine usage.     

Temporal Trends in Social Disparities in Maternal Smoking and Breastfeeding in Canada, 1992–2008

A steady decrease in maternal smoking during pregnancy and a steady increase in breastfeeding rates have been observed in Canada in the past two decades. However, the extent to which all socioeconomic classes have benefited from this progress is unknown. Therefore, this study was undertaken to determine: (1) whether progress achieved benefited the entire population or was limited to specific strata; and (2) whether disparities among strata decreased, stayed the same, or increased over time. We used data from the National Longitudinal Survey of Children and Youth, which enrolled children aged 0–3 years between 1994 and 2008. Data collected at entry was analyzed in a cross-sectional manner. Between birth years 1992–1996 and 2005–2008, smoking during pregnancy decreased from 11.5 % (95 % CI 10.0–13.0 %) to 5.2 % (95 % CI 4.1–6.3 %) among mothers with a college or university degree and from 43.0 % (95 % CI 38.8–47.2 %) to 38.6 % (95 % CI 32.9–44.2 %) among those with less than secondary education. During the same period, the rate of breastfeeding initiation increased from 83.8 % (95 % CI 81.9–85.6 %) to 91.5 % (95 % CI 90.2–92.8 %) among mothers with a college or university degree and from 63.1 % (95 % CI 58.9–67.4 %) to 74.7 % (95 % CI 69.8–79.7 %) among those with less than secondary education. The risks of smoking and of not breastfeeding remained significantly higher in the least educated category than in the most educated throughout the study period, and these associations remained statistically significant after controlling for maternal age. Gaps between the least and the most educated mothers narrowed for breastfeeding but widened for smoking during pregnancy.     

Behavioral Economics: The Key to Closing the Gap on Maternal, Newborn and Child Survival for Millennium Development Goals 4 and 5?

Millennium Development Goals (MDGs) 4 and 5 set ambitious targets to reduce maternal, newborn and child mortality by 2015. With 2015 fast approaching, there has been a concerted effort in the global health community to “close the gap” on the MDG targets. Recent consensus initiatives and frameworks have refocused attention on evidence-based, low-cost interventions that can reduce mortality and morbidity, and have argued for additional funding to increase access to and coverage of these life-saving interventions. However, funding alone will not close the gap on MDGs 4 and 5. Even when high-quality, affordable products and services are readily available, uptake is often low. Progress will therefore require not just money, but also advances in health-related behavior change and decision-making. Behavioral economics offers one way to achieve real progress by improving our understanding of how individuals make choices under information and time constraints, and by offering new approaches to make it easier for individuals to do what is in their best interest and harder to do what is not. We introduce five behavioral economic principles and demonstrate how they could boost efforts to improve maternal, newborn, and child health in pursuit of MDGs 4 and 5.     

Community Poverty and Trends in Racial/Ethnic Survival Disparities Among People Diagnosed With AIDS in Florida, 1993–2004

Objectives. We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.Methods. We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.Results. Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996–1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.Conclusions. Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.The HIV/AIDS epidemic has disproportionately affected the non-Hispanic Black population in the United States. In 2008, an estimated 545 000 non-Hispanic Blacks were living with HIV/AIDS.1 The estimated prevalence of HIV infection for 2008 among non-Hispanic Blacks was 18.2 per 1000 population, more than 7 times higher than the estimated rate for non-Hispanic Whites (non-Hispanic Whites; 2.4 per 1000).1 Non-Hispanic Blacks as a group not only have a higher prevalence of HIV/AIDS, but once infected also have a lower survival rate. The 3-year survival rate in the United States for people diagnosed with AIDS between 2001 and 2005 was 80% among non-Hispanic Blacks compared with 84% for non-Hispanic Whites, 83% for Hispanics, and 88% for Asians,2 further contributing to the disparities in the HIV mortality rate of 16.8 per 100 000 among non-Hispanic Blacks compared with 1.6 per 100 000 among non-Hispanic Whites during 2007.3 Race/ethnicity is a fundamentally social as opposed to a biological construct,4,5 and survival disparities between non-Hispanic Blacks and non-Hispanic Whites have not generally been seen in settings with universal health care access such as in the Veterans Administration health care system,6 the military health care system,7 or a health maintenance organization.8 Therefore, potentially modifiable social explanations for the observed racial/ethnic disparities in survival should be examined.A most remarkable advance in medical treatment in the past century was the development of highly active antiretroviral therapy (HAART). It led to a significant improvement in survival from HIV/AIDS, 9–12 but racial/ethnic disparities in HIV/AIDS survival remain2, 13–16 and in New York City appeared to widen.17 Despite these well-recognized health disparities, there is a critical gap in the knowledge about why the disparity exists. Two population-based studies, both in San Francisco, California (a city that has provided free HIV care for those who cannot afford it), found that Black race was no longer associated with survival between 1996 and 2001 after controlling for neighborhood socioeconomic status (SES), and that this SES effect seemed to be related to HAART use.18,19 However, in a study using HIV surveillance data from 33 states, racial/ethnic disparities in 5-year survival after HIV diagnosis between 1996 and 2003 persisted after adjusting for county-level SES and other factors.20 The objective of this study was to describe the racial/ethnic disparities in AIDS survival in Florida among people diagnosed with AIDS between 1993 and 2004 (a period spanning the time before and during the widespread availability of HAART) and to determine if these disparities decrease after controlling for community-level SES.     

Changes in Caries Experience,Untreated Caries,Sealant Prevalence,and Preventive Behavior Among Third-Graders in New York State, 2002–2004 and 2009–2012

ObjectiveThis study assessed changes in caries experience, untreated caries, sealant prevalence, and preventive behavior among third-grade children in New York State to monitor progress toward state health objectives.MethodsWe analyzed children''s data from the 2002–2004 (n=10,865) and 2009–2012 (n=6,758) New York State Oral Health Survey. We calculated differences in weighted percentages and 95% confidence intervals for caries experience, untreated caries, sealant prevalence, and preventive behavior. We used logistic regression procedures to assess the independent effects and interaction terms on dental caries experience.ResultsThe percentage of children with dental caries and untreated caries decreased from 54.1% and 33.0% in 2002–2004 to 45.2% and 23.6% in 2009–2012, respectively. While this decrease was not uniform across income subgroups, the prevalence of sealants, a key measure of the use of preventive services, increased significantly from 16.7% to 36.0% among lower-income children.ConclusionsMeasurable improvement in reducing dental caries prevalence among third-grade children has been made in New York State, but this improvement was not uniform across subgroups. Specifically, disease prevalence among lower-income children remained high, underscoring the need to strengthen existing programs and identify additional policy and programmatic interventions.Researchers generally agree that the prevalence and severity of dental caries among U.S. and New York State (NYS) school-age children declined steadily from the 1970s to the 1990s. Although this trend has continued for older children in more recent years, this trend is uncertain among younger children aged 2–8 years.^1–3 Findings from analyses of 1988–1994 and 1999–2004 national surveys show that declines in dental caries observed in earlier decades among younger children may have plateaued or dental caries may even be increasing among subgroups of younger children.⁴ Because of the persistent higher disease rate, especially in low-income groups, prevention of tooth decay among children has become the focus of many prevention efforts.^5,6 Since 2001, the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration have provided grants and technical assistance to NYS to strengthen the infrastructure and capacity to promote fluoridation and improve its quality, as well as to strengthen school-based preventive and early treatment programs.Changes have also been made to increase insurance coverage for dental services and improve annual dental visits.^7,8 Child Health Plus, the state Children''s Health Insurance Program (CHIP), was implemented in 1997 to provide public health insurance for near-poor children from families previously not eligible for Medicaid. According to a U.S. Government Accounting Office report, nationally, Medicaid and CHIP beneficiaries, children in particular, showed increases in the use of dental services (from 28% in 1996 to 37% in 2010), but still visited the dentist less frequently than privately insured children (58% in 2010).⁹ In NYS, the Medicaid program enhanced the fee structure for dental procedures in 2000. In addition, professional organizations, advocacy groups, and foundations have made a concerted effort to promote prevention and access to care. The professional recommendation to initiate first dental visit shifted from age 3 to age 1 around 2003.¹⁰ To assess the collective effect of these and other efforts in NYS, we examined data on caries experience, untreated caries, sealant prevalence, and preventive behavior among third-grade children from the 2002–2004 and 2009–2012 NYS Oral Health Survey.     

Novel Cyclovirus in Human Cerebrospinal Fluid,Malawi, 2010–2011

To identify unknown human viruses, we analyzed serum and cerebrospinal fluid samples from patients with unexplained paraplegia from Malawi by using viral metagenomics. A novel cyclovirus species was identified and subsequently found in 15% and 10% of serum and cerebrospinal fluid samples, respectively. These data expand our knowledge of cyclovirus diversity and tropism.     

Rural–Urban Trends and Patterns in Cervical Cancer Mortality, Incidence, Stage, and Survival in the United States, 1950–2008

This study examined disparities in cervical cancer mortality rates among US women in metropolitan and non-metropolitan areas from 1950 through 2007. Inequalities in incidence, stage of disease at diagnosis, and patient survival were analyzed during 2000–2008. Age-adjusted mortality, incidence, and 5-year relative survival rates were calculated for women in metropolitan and non-metropolitan areas, and differences in relative risks were tested for statistical significance. Log-linear regression was used to analyze annual rates of change in mortality over time. During the last five decades, women in non-metropolitan areas had significantly higher cervical cancer mortality than those in metropolitan areas. Disparities persisted against a backdrop of consistently declining mortality rates. Throughout 1969–2007, both white and black women in non-metropolitan areas maintained significantly higher cervical cancer mortality rates than their metropolitan counterparts. Among black women, cervical cancer mortality declined at a faster pace in metropolitan than in non-metropolitan areas. In both metropolitan and non-metropolitan areas, black women had twice the mortality rate of white women. During 2000–2008, white, black, and American Indian women in non-metropolitan areas had significantly higher cervical cancer incidence rates than their metropolitan counterparts. Survival rates were significantly lower in non-metropolitan areas, particularly among rural black women. The 5-year survival rate for black women diagnosed with cervical cancer was 50.8% in non-metropolitan areas, compared with 60.2% for black women and 71.0% for white women in metropolitan areas. Disparities in survival existed after controlling for disease stage. Rural–urban disparities in cervical cancer have persisted despite steep declines in incidence and mortality rates.