Health beliefs and parenting attitudes influence breastfeeding patterns among low-income African-American women.

OBJECTIVE: To describe breastfeeding initiation among 210 urban African-American mothers with inadequate prenatal care. METHODS: This study is a case-control study of postpartum mothers recruited from four large urban hospitals. RESULTS: Mothers who chose to breastfeed were more educated, employed before birth, married, and using contraception postnatally. Regression model analysis controlling for demographic differences revealed that breastfeeding was significantly associated with a higher perception of severity of illness and higher confidence in the ability of health care to prevent illness. Breastfeeding mothers were less likely to reverse parent-child roles and had a lower perception of hassle from their infant's behavior. When comparing mothers who breastfed longer than 8 weeks to those who did not breastfeed, breastfeeding mothers had high scores related to empathy toward infants on the Adult-Adolescent Parenting Inventory as well as a low perception of hassle on the Parenting Daily Hassle. The perception of existing formal or informal social support did not influence breastfeeding behavior. CONCLUSION: Personal attributes of low-income urban mothers such as health beliefs and parental attitudes may play a role in the initiation and duration of breastfeeding. Low-income African-American mothers may be influenced in their choice to breastfeed by supportive messages from physicians and nurses delivering care to mothers and their newborns. Emphasis should be placed on the role breastfeeding can play in preventing childhood illnesses.     

Reducing Psychosocial and Behavioral Pregnancy Risk Factors: Results of a Randomized Clinical Trial Among High-Risk Pregnant African American Women

Objectives. We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, secondhand smoke exposure, depression, and intimate partner violence).Methods. Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-up.Results. Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021).Conclusions. In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.Adverse pregnancy outcomes are particularly common among women who are members of racial/ethnic minority groups.^1–4 African American infants are 3.4 times more likely than are White infants to die in the neonatal period, a disadvantage that persists even when mothers have appropriately early and equal access to prenatal care.⁵ In Washington, DC, death rates among non-Hispanic African American infants remain unacceptably high (17.0 per 1000 live births in 2005) despite an overall decline in infant mortality from 18.6 per 1000 live births in 1992 to 14.0 per 1000 births in 2005.⁶ Psychosocial and behavioral risks are recognized as potential contributors to poor reproductive outcomes.^7–9 Poverty,¹⁰ limited social support,¹¹ smoking,¹² illicit drug use,¹³ depression,¹⁴ anxiety,^14,15 and intimate partner violence (IPV)^16,17 are all associated to varying degrees with pregnancy complications, premature and low-birthweight deliveries, stillbirths, and infant mortality.There is increasing recognition of the role of primary care in screening, diagnosis, and treatment of behavioral, mental health, and psychosocial concerns,^18–27 because of the significant association between medical morbidity and behavioral and mental health problems.²⁸ Although interventions involving primary care providers may have limited success, they can be cost-effective.^18,24 Because access to and use of behavioral and mental health care remain problematic, especially among members of underserved minority groups,^29–32 making such care available through primary care services may avert missed opportunities.Prenatal care may be a venue to address behavioral and mental health issues that can potentially affect the health of pregnant women and their unborn children.³³ The guidelines of the American College of Obstetrics and Gynecology and the American Academy of Pediatrics^34,35 suggest ways primary care providers can screen for behavioral and psychosocial risk factors. Despite these guidelines, many providers still fail to screen pregnant women,^35–38 with screening rates varying according to type of provider,^36,39 risk factors,³⁶ population group,⁴⁰ and provider risk perceptions.⁴¹ Furthermore, when implemented, psychosocial and behavioral interventions have been only moderately successful.^42,43Such inconsistent results may arise from multiple factors, including differences in study design, participant engagement, and intervention content or implementation, including approaches that address only 1 of multiple, co-occurring psychosocial or behavioral risk factors. Behavioral and psychosocial factors associated with poor pregnancy outcomes are related to and serve as risk factors for one another⁴⁴; therefore, an alternative approach would be to provide an intervention simultaneously addressing multiple psychosocial and behavioral risk factors among pregnant women, as has been done in relation to other health risks.^45–47A recent study focusing on 3569 Medicaid-eligible pregnant women examined the effects of the Prenatal Plus Program in Colorado with respect to smoking, inadequate prenatal weight gain, and “psychosocial problems” (defined as “significant or severe stress as a result of personal or family safety needs, lack of support systems, or an inability to meet basic needs”).^48(p1955) Women who had at least 10 Prenatal Plus visits were more likely than were women who did not to reduce these risks; in addition, only 7.0% of women who resolved all of their risks delivered low-birthweight infants, whereas 13.2% of those who resolved none of their risks did so. In spite of these promising results, the nonexperimental nature of the Colorado study may have created unquantifiable biases favoring the intervention.Moreover, only 4% of all births in Colorado, and 7% of Prenatal Plus deliveries, occurred among African American women, the group at greatest risk of adverse pregnancy outcomes. Thus, further experimental investigations in which rigorous randomized trial designs are used to assess vulnerable African American women are needed to better appreciate the potential merits of an integrated intervention focusing on psychosocial and behavioral risk factors during pregnancy.We conducted a randomized clinical trial testing the efficacy of an integrated intervention targeting multiple behavioral and psychosocial risk factors among pregnant African American women in the District of Columbia. The risk factors we chose to address were cigarette smoking, secondhand smoke exposure, depression, and IPV.     

Pregnancy intentions and happiness among pregnant black women at high risk for adverse infant health outcomes

CONTEXT: Unintended pregnancy is associated with risk behaviors and increased morbidity or mortality for mothers and infants, but a woman's feelings about pregnancy may be more predictive of risk and health outcomes than her intentions. METHODS: A sample of 1,044 black women who were at increased risk were enrolled at prenatal care clinics in the District of Columbia in 2001-2003. Bivariate and multivariate analyses assessed associations between pregnancy intentions or level of happiness about being pregnant and multiple psychosocial and behavioral risk factors, and identified correlates of happiness to be pregnant. RESULTS: Pregnancy intentions and happiness were strongly associated, but happiness was the better predictor of risk. Unhappy women had higher odds than happy women of smoking, being depressed, experiencing intimate partner violence, drinking and using illicit drugs (odds ratios, 1.7-2.6). The odds of being happy were reduced among women who had other children or a child younger than two, who were single or did not have a current partner, who had had more than one sexual partner in the past year and who reported that the baby's father did not want the pregnancy (0.3-0.6). In contrast, the odds of being happy were elevated among women who had better coping strategies (1.03), who had not used birth control at conception (1.6) and who had 1-2 household members, rather than five or more (2.1). CONCLUSIONS: Additional psychosocial screening for happiness about being pregnant and for partner characteristics, particularly the father's desire to have this child, may help improve prenatal care services and prevent adverse health outcomes.     

An Integrated Randomized Intervention to Reduce Behavioral and Psychosocial Risks: Pregnancy and Neonatal Outcomes

While biomedical risks contribute to poor pregnancy and neonatal outcomes in African American (AA) populations, behavioral and psychosocial risks (BPSR) may also play a part. Among low income AA women with psychosocial risks, this report addresses the impacts on pregnancy and neonatal outcomes of an integrated education and counseling intervention to reduce BPSR, as well as the contributions of other psychosocial and biomedical risks. Subjects were low income AA women ≥18 years living in the Washington, DC, metropolitan area and seeking prenatal care. Subjects (n = 1,044) were screened for active smoking, environmental tobacco smoke exposure (ETSE), depression, or intimate partner violence (IPV) and then randomized to intervention (IG) or usual care (UCG) groups. Data were collected prenatally, at delivery, and postpartum by maternal report and medical record abstraction. Multiple imputation methodology was used to estimate missing variables. Rates of pregnancy outcomes (miscarriage, live birth, perinatal death), preterm labor, Caesarean section, sexually transmitted infection (STI) during pregnancy, preterm birth (<37 weeks), low birth weight (<2,500 g), very low birth weight (<1,500 g), small for gestational age, neonatal intensive care unit (NICU) admission, and >2 days of hospitalization were compared between IG and UCG. Logistic regression models were created to predict outcomes based on biomedical risk factors and the four psychosocial risks (smoking, ETSE, depression, and IPV) targeted by the intervention. Rates of adverse pregnancy and neonatal outcomes were high and did not differ significantly between IG and UCG. In adjusted analysis, STI during the current pregnancy was associated with IPV (OR = 1.41, 95% CI 1.04–1.91). Outcomes such as preterm labor, caesarian section in pregnancy and preterm birth, low birth weight, small for gestational age, NICU admissions and >2 day hospitalization of the infants were associated with biomedical risk factors including preexisting hypertension and diabetes, previous preterm birth (PTB), and late initiation of prenatal care, but they were not significantly associated with active smoking, ETSE, depression, or IPV. Neither the intervention to reduce BPSR nor the psychosocial factors significantly contributed to the pregnancy and neonatal outcomes. This study confirms that biomedical factors significantly contribute to adverse outcomes in low income AA women. Biomedical factors outweighed psychosocial factors in contributing to adverse pregnancy and neonatal outcomes in this high-risk population. Early identification and management of hypertension, diabetes and previous PTB in low income AA women may reduce health disparities in birth outcomes.     

Relationships Between Self-Reported Smoking,Household Environmental Tobacco Smoke Exposure and Depressive Symptoms in a Pregnant Minority Population

This study sought to examine relationships between depressive symptoms and prenatal smoking and/or household environmental tobacco smoke exposure (HH-ETSE) among urban minority women. We analyzed private, audio computer-assisted self interview data from a clinic-based sample of 929 minority pregnant women in Washington, DC. Depressive symptoms were assessed via the Beck Depression Inventory Fast Screen. HH-ETSE, current smoking, and former smoking were assessed via self-report. Depression levels and demographic characteristics were compared: (1) among nonsmokers, for those reporting HH-ETSE versus no HH-ETSE; and (2) among smokers, for those reporting current smoking (in last 7 days) versus former smokers. Measures associated with HH-ETSE/current smoking in bivariate analysis at P < 0.20 were included in adjusted logistic regression models. HH-ETSE, as a possible indicator of a social smoking network, was assessed as a mediator for the relationship between depression and current smoking. Results: Non-smokers reporting moderate-to-severe depressive symptoms showed significantly higher adjusted odds of prenatal HH-ETSE (AOR 2.5, 95% CI [1.2, 5.2]). Smokers reporting moderate-to-severe or mild depressive symptoms showed significantly higher adjusted odds of current smoking (AOR 1.9, 95% CI [1.1, 3.5] and AOR 1.8, 95% CI [1.1, 3.1], respectively). Among smokers, HH-ETSE was a significant mediator for the association between moderate-to-severe symptoms and current smoking. In conclusion, health care providers should be aware that depressed urban minority women are at risk of continued smoking/HH-ETSE during pregnancy. Interventions designed to encourage behavior change should include screening for depression, and build skills so that women are better able to address the social environment.     

Attitudes,Experience, and Anticipation of Sex Among 5th Graders in an Urban Setting: Does Gender Matter?

To identify gender differences in correlates of anticipation and initiation of sexual activity in the baseline survey of 562 African-American 5th grade students prior to initiation of a school-based pregnancy prevention intervention curriculum. Students from 16 elementary schools were administered the baseline questionnaire during classroom periods. Using these data, binary and ordered logistic regression models were used to analyze the factors affecting virginity and anticipation of sexual activity separately by gender, and tests of interaction between each factor and gender were conducted on the combined sample. More boys than girls had already had sex (18% vs. 5%) and anticipated having sexual intercourse in the next 12 months (56% vs. 22%). Boys and girls also differed in the factors that affected these outcomes. The perception that their neighborhood was safe reduced the odds that boys anticipated sexual activity but was not associated with this outcome among girls. Pubertal knowledge increased the odds of anticipation, but only among boys. Attitudes favoring abstinence decreased anticipation of sex among both genders, but slightly more among girls than boys. Having more frequent parent–child communication about sex was associated with increased anticipation among girls but decreased anticipation among boys. Curriculum based approaches to adolescent pregnancy prevention are appropriate for 5th grade elementary students who may already be anticipating sexual activity in communities with disproportionate rates of teen pregnancy. The design of the interventions should consider the differences in motivating factors by gender.     

African American and Latino patient versus provider perceptions of determinants of prenatal care initiation

Few studies have compared provider and patient perceptions of barriers, motivators and facilitators of prenatal care (PNC) initiation. The current study compared these perceptions in providers and patients in Washington, DC, a city characterized by infant mortality and low birth weight rates that are among the highest in the nation, and poor utilization of PNC, particularly among minority groups. The results reported here were part of a larger study of barriers, motivators and facilitators influencing PNC utilization in Washington, DC. A convenience sample of 331 African American and Latino patients and 61 providers were interviewed to identify which of 63 motivators, facilitators, and barriers significantly influenced PNC initiation. Both sample groups were recruited at 14 PNC facilities, selected to represent all sites in DC known to serve high-risk, low-income minority women, including hospital-based clinics, community-based clinics, and private practices. Data were analyzed using Fisher exact tests and Kendall's concordance tests. Results indicated that there was good agreement between patients and providers about the relative importance of the various barriers (especially psychosocial), motivators, and facilitators. However, differences were found between patients and providers in the response frequencies. Providers were more likely to report barriers while patients were more likely to report certain motivators (especially learning better health habits and how to protect health). These results indicate that despite widespread agreement on most issues, especially psychosocial barriers, patients rated health education higher than providers.     

Understanding the association of biomedical, psychosocial and behavioral risks with adverse pregnancy outcomes among African-Americans in Washington, DC

This study investigates the relationship between adverse pregnancy outcomes in high-risk African American women in Washington, DC and sociodemographic risk factors, behavioral risk factors, and the most common and interrelated medical conditions occurring during pregnancy: diabetes, hypertension, preeclampsia, and Body Mass Index (BMI). Data are from a randomized controlled trial conducted in 6 prenatal clinics. Women in their 1st or 2nd trimester were screened for behavioral risks (smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) and demographic eligibility. 1,044 were eligible, interviewed and followed through their pregnancies. Classification and Regression Trees (CART) methodology was used to: (1) explore the relationship between medical and behavioral risks (reported at enrollment), sociodemographic factors and pregnancy outcomes; (2) identify the relative importance of various predictors of adverse pregnancy outcomes; and (3) characterize women at the highest risk of poor pregnancy outcomes. The strongest predictors of poor outcomes were prepregnancy BMI, preconceptional diabetes, employment status, intimate partner violence, and depression. In CART analysis, preeclampsia was the first splitter for low birthweight; preconceptional diabetes was the first splitter for preterm birth (PTB) and neonatal intensive care admission; BMI was the first splitter for very PTB, large for gestational age, Cesarean section and perinatal death; employment was the first splitter for miscarriage. Preconceptional factors strongly influence pregnancy outcomes. For many of these women, the high risks they brought into pregnancy were more likely to impact their pregnancy outcomes than events during pregnancy.     

Prenatal care reduces the impact of illicit drug use on perinatal outcomes.

OBJECTIVE: To estimate the extent that prenatal care (PNC) retains its protective influence against prematurity, low birth weight (LBW), and small for gestational age (SGA) status in infants exposed to illicit drug use (IDU) in pregnancy. STUDY DESIGN: This was a prospective cohort analysis including 6673 women residents of the District of Columbia (Washington, DC, USA) delivering at four city hospitals. Women were screened in the immediate postpartum period. Levels of PNC were established according to American College of Obstetrics and Gynecology guidelines and the Kotelchuck index. PNC and IDU were compared between subgroups. Adjusted relative risks for prematurity, LBW and SGA, controlling for maternal and gestational ages, were calculated in different groups according to IDU and level of PNC. RESULTS: IDU was identified in 13% of mothers screened. PNC was classified as none (6%), inadequate (10%), intermediate (20%), and adequate (64%). The highest risk for prematurity, LBW, or SGA occurred in infants born to mothers with no PNC and positive IDU in pregnancy (prematurity OR=12.05, 95% CI: 8.99 to 16.16; LBW OR=14.76, 95% CI: 11.03 to 19.75; SGA OR=9.20, 95% CI: 5.32 to 15.92). As PNC levels increased, significant reductions in risk for prematurity and LBW (not for SGA) in IDU-exposed infants were observed. Risk for SGA in IDU-exposed infants reduced significantly when PNC was introduced. CONCLUSIONS: In infants exposed to IDU, a reduction in risk for prematurity, LBW, and SGA, was consistently demonstrated with improved levels of PNC. In high-risk populations, health care should seek to reach mothers early, especially those identified at risk for IDU, and deliver PNC to them effectively.     

Smoking Cessation and Relapse Among Pregnant African-American Smokers in Washington,DC

Smoking is the single most preventable cause of perinatal morbidity. This study examines smoking behaviors during pregnancy in a high risk population of African Americans. The study also examines risk factors associated with smoking behaviors and cessation in response to a cognitive behavioral therapy (CBT) intervention. This study is a secondary analysis of data from a randomized controlled trial addressing multiple risks during pregnancy. Five hundred African-American Washington, DC residents who reported smoking in the 6 months preceding pregnancy were randomized to a CBT intervention. Psycho-social and behavioral data were collected. Self-reported smoking and salivary cotinine levels were measured prenatally and postpartum to assess changes in smoking behavior. Comparisons were made between active smokers and those abstaining at baseline and follow-up in pregnancy and postpartum. Sixty percent of participants reported quitting spontaneously during pregnancy. In regression models, smoking at baseline was associated with older age, <a high school education and illicit drug use. At follow-up closest to delivery, smoking was associated with lower education, smoking and cotinine level at baseline and depression. At postpartum, there was a relapse of 34%. Smokers postpartum were significantly more likely to smoke at baseline and use illicit drugs in pregnancy. Mothers in the CBT intervention were less likely to relapse. African-American women had a high spontaneous quit rate and no response to a CBT intervention during pregnancy. Postpartum mothers’ resolve to maintain a quit status seems to wane despite their prolonged period of cessation. CBT reduced postpartum relapse rates.