Post-disaster reproductive health outcomes

Climate change, air pollution and maternal and newborn health: An overview of reviews of health outcomes

Background

Climate change represents a fundamental threat to human health, with pregnant women and newborns being more susceptible than other populations. In this review, we aimed to describe the current landscape of available epidemiological evidence on key climate risks on maternal and newborn health (MNH).

Methods

We sought to identify published systematic and scoping reviews investigating the impact of different climate hazards and air pollution on MNH outcomes. With this in mind, we developed a systematic search strategy based on the concepts of 'climate/air pollution hazards, 'maternal health,' and 'newborn health,' with restrictions to reviews published between 1 January 2010 and 6 February 2023, but without geographical or language restriction. Following full text screening and data extraction, we synthesised the results using narrative synthesis.

Results

We found 79 reviews investigating the effects of climate hazards on MNH, mainly focussing on outdoor air pollution (n = 47, 59%), heat (n = 24, 30%), and flood/storm disasters (n = 7, 9%). Most were published after 2015 (n = 60, 76%). These reviews had consistent findings regarding the positive association of exposure to heat and to air pollution with adverse birth outcomes, particularly preterm birth. We found limited evidence for impacts of climate-related food and water security on MNH and did not identify any reviews on climate-sensitive infectious diseases and MNH.

Conclusions

Climate change could undermine recent improvements in maternal and newborn health. Our review provides an overview of key climate risks to MNH. It could therefore be useful to the MNH community to better understand the MNH needs for each climate hazard and to strengthen discussions on evidence and research gaps and potential actions. Despite the lack of comprehensive evidence for some climate hazards and for many maternal, perinatal, and newborn outcomes, we observed repeated findings of the impact of heat and air pollutants on birth outcomes, particularly preterm birth. It is time for policy dialogue to follow to specifically design climate policy and actions to protect the needs of MNH.

Fifty years of evidence on perinatal experience among refugee and asylum-seeking women in Organization for Economic Co-operation and Development (OECD) countries: A scoping review

BACKGROUND

Members of the Organization for Economic Co-operation and Development (OECD) play a significant role in hosting and supporting refugees. Refugees and asylum seekers in OECD countries may face unique challenges in accessing perinatal healthcare. These challenges can impact their use of and experience with perinatal health services leading to poor maternal and infant outcomes. This scoping review describes the general trends in perinatal health research among refugees/asylum seekers in OECD countries over the past fifty years (1970 to 2021) as well as summarizes their perinatal experience.

METHODS

Databases including Embase and Medline were searched using relevant key words for "refugee/ asylum seeker", "perinatal ", and " OECD countries.". Articles were excluded if they only involved economic migrants or internally displaced persons, conducted in non-OECD countries, only assessed health behaviors and practices during pregnancy (e.g., smoking), or were published in a language other than English. The final list of articles included 82 unique studies.

RESULTS

In the 40 years between 1970 and 2009, very few studies (n = 9) examined perinatal health among refugees/ asylum seekers in OECD countries. However, an increasing trend was observed over the past decade. Early studies (1980 to 2009) focused more on traditional perinatal outcomes; however, from 2010 onwards, studies related to perinatal experience were more likely to emerge in the global health literature. Access to timely prenatal care remains a challenge with failure to address the root causes of the problem in several OECD countries including those with a long history of hosting refugees. The limited availability of interpretation services and the lack of a patient-centered approach to care have also interfered with the perceived quality of care. In addition, perceived isolation and the limited social support experienced by this vulnerable population have negatively impacted their perinatal experiences in several OECD countries.

CONCLUSION

Refugee/asylum seekers in OECD countries face a number of challenges during the perinatal period. Policy changes and further research are needed to address access barriers and identify specific interventions that can improve their well-being during this critical period.

Human fertility after a disaster: a systematic literature review

Fertility is a key demographic parameter influenced by disaster. With the growing risk of disasters, interest in the fertility response to a disaster is increasing among the public, policy makers and researchers alike. However, a systematic literature review on how disaster affects live birth counts does not yet exist. We reviewed 50 studies retrieved from a systematic search based on a pre-registered protocol. We found an overall negative impact of disasters on fertility. If any, increases in fertility were mostly linked with weather-related physical disasters. We also identified 13 distinct mechanisms which researchers have considered as underlying the fertility effects of disaster. By contrast to the common belief that disasters are more likely to increase fertility in contexts with already high fertility, we found little evidence to suggest that the total fertility rate of the studied populations was an important predictor of the direction, timing or size of fertility impacts. While this may be because no relationship exists, it may also be due to biases we observed in the literature towards studying high-income countries or high-cost disasters. We summarize the methodological limitations identified from the reviewed studies into six practical recommendations for future research. Our findings inform both the theories behind the fertility effects of disasters and the methods for studying them.

Counseling women of reproductive age about emergency preparedness - Provider attitudes and practices

We report healthcare provider attitudes and practices on emergency preparedness counseling for women of reproductive age (WRA), including pregnant, postpartum, and lactating women (PPLW), for disasters and weather emergencies. DocStyles is a web-based panel survey of primary healthcare providers in the United States. During March 17-May 17, 2021, obstetricians-gynecologists, family practitioners, internists, nurse practitioners, and physician assistants were asked about the importance of emergency preparedness counseling, level of confidence, frequency, barriers to providing counseling, and preferred resources to support counseling among WRA and PPLW. We calculated frequencies of provider attitudes and practices, and prevalence ratios with 95% CIs for questions with binary responses. Among 1503 respondents (family practitioners (33%), internists (34%), obstetrician-gynecologists (17%), nurse practitioners (8%), and physician assistants (8%)), 77% thought emergency preparedness was important, and 88% thought counseling was necessary for patient health and safety. However, 45% of respondents did not feel confident providing emergency preparedness counseling, and most (70%) had never talked to PPLW about this topic. Respondents cited not having time during clinical visits (48%) and lack of knowledge (34%) as barriers to providing counseling. Most respondents (79%) stated they would use emergency preparedness educational materials for WRA, and 60% said they were willing to take an emergency preparedness training. Healthcare providers have opportunities to provide emergency preparedness counseling; however, many have not, noting lack of time and knowledge as barriers. Emergency preparedness resources combined with training may improve healthcare provider confidence and increase delivery of emergency preparedness counseling.

Pregnant women's migration patterns before childbirth after large-scale earthquakes and the added impact of concerns regarding radiation exposure in Fukushima and five prefectures

The 2011 Great East Japan Earthquake (within Fukushima, Iwate, and Miyagi prefectures) was a complex disaster; it caused a tsunami and the Fukushima Daiichi Nuclear Power Plant accident, resulting in radiation exposure. This study investigated the earthquake's effects on the migration patterns of pregnant women and their concerns regarding radiation exposure. We also considered the following large-scale earthquakes without radiation exposure: Great Hanshin-Awaji (Hyogo prefecture), Niigata-Chuetsu, and Kumamoto. Pregnant women were categorized as outflow and inflow pregnant women. Data on the annual number of births three years before and after the earthquake were used as a denominator to calculate the outflow and inflow rates per 100 births. The odds ratios of annual outflow and inflow rates after the earthquake, using three years before the earthquake as the baseline, were calculated. The odds-ratio for outflow significantly increased for Hyogo, Fukushima, Miyagi, and Kumamoto prefectures after the earthquake, particularly for Fukushima, showing a significant increase until three years post the Great East Japan Earthquake (disaster year: odds-ratio: 2.66 [95% confidence interval: 2.44-2.90], 1 year post: 1.37 [1.23-1.52], 2 years post: 1.13 [1.00-1.26], 3 years post: 1.18 [1.05-1.31]), while the remaining three prefectures reported limited increases post one year. The inflow decreased after the earthquake, particularly in Fukushima, showing a significant decrease until 2 years post the Great East Japan Earthquake (disaster year: 0.58 [0.53-0.63], 1 year post: 0.76 [0.71-0.82], 2 years post: 0.83 [0.77-0.89]). Thus, pregnant women's migration patterns changed after large-scale earthquakes, suggesting radiation exposure concerns possibly have a significant effects. These results suggested that plans for receiving assistance and support that considers the peculiarities of disaster related damage and pregnant women's migration patterns are needed in both the affected and non-affected areas.

Fertility and contraception among women of reproductive age following a disaster: a scoping review

Background

The prevalence and severity of disasters triggered by natural hazards has increased over the last 20 years. Women of reproductive age may encounter unique reproductive health challenges following a disaster. In this scoping review we identify gaps in literature to inform future research and search for potential associations between disasters by natural hazards and post-disaster fertility and contraception among women of reproductive age.

Methods

Medline (OVID), Embase (OVID), PsycInfo (OVID), CINAHL (Ebsco), Scopus, Environmental Science Collection (ProQuest Central), and Sociological Abstracts (ProQuest Central) were searched for articles published from 1980 through March 3, 2022 in English or Spanish language. Search terms were related to fertility, contraception, and disasters. We included original research that described a discrete natural hazard exposure, a population of women of reproductive age (15–49 years), and outcomes of fertility or contraception use or access, with pre- and post-disaster measures.

Results

Among 9788 citations, after initial exclusion 5121 remained for title and abstract review. One hundred and eighteen citations underwent full-text review and 26 articles met the inclusion criteria. Following critical appraisal, 20 articles were included in this review. Eighteen articles described outcomes related to fertility, five articles described contraception access, and three articles described contraception use.

Conclusions

Clearly defined exposure measures, robust analyses, and methodical post-disaster assessment periods, may address the current gaps within disaster research on fertility and contraception among women of reproductive age. Consistent patterns in fertility following a disaster triggered by natural hazards were not identified between or within disaster types. Studies that assessed contraception found no change in use, while some studies found a decrease in contraceptive access overall.

Supplementary information

The online version contains supplementary material available at 10.1186/s12978-022-01436-4.

Natural disasters are becoming more frequent and severe. In this scoping review, we explore published literature from 1980 to March 3, 2022 on the impacts of natural disasters for women of reproductive age, 15–49 years. We assess gaps in the literature and search for possible trends in fertility and contraception use and access after a disaster. A targeted literature search in multiple databases resulted in 9,788 citations. Systematic methods were used to identify relevant articles for this scoping review. Of the 20 articles included, we identify several gaps. Future research may benefit from improved disaster exposure measurements, comparing exposed samples to a similar unexposed sample, and measuring outcomes at purposeful post-disaster time points. No consistent patterns were identified among studies assessing post-disaster fertility. Contraception use did not appear to change following disasters, while contraception access generally decreased.

Exposure to oil pollution and maternal outcomes: The Niger Delta prospective cohort study

Background

Maternal exposure to oil pollution is an important public health concern. However, there is a dearth of literature on the effects of maternal exposure to oil pollution on maternal outcomes in the Niger Delta region of Nigeria. This study was therefore designed to determine the effect of maternal exposure to oil pollution on maternal outcomes in the Niger Delta region of Nigeria.

Methods

Prospective cohort study design involving 1720 pregnant women followed from pregnancy to delivery was conducted. The participants were 18–45 years old at a gestational age of less than 17 weeks, who attended randomly selected health facilities in the areas with high exposure and low exposure to oil pollution in the Niger Delta, Nigeria. Data were collected using an interviewer-administered questionnaire and review of medical records from April 2018 to April 2019. Multivariate log-binomial model was used to examine the effect of maternal exposure to oil pollution on the risk of adverse maternal outcomes adjusting for sociodemographic, maternal and lifestyle characteristics.

Results

A total of 1418 women completed the follow-up and were included in the analysis. Women in high exposure areas had a higher incidence of premature rupture of membrane (PROM), caesarean section (CS) and postpartum haemorrhage (PPH) compared to women in areas with low exposure to oil pollution. After adjusting for cofounders, women in high exposure areas also had a higher risk of PROM (ARR = 1.96; 95% CI: 1.24–3.10) and PPH (ARR = 2.12; 95% CI: 1.28–3.36) in Model I–III when compared to women in areas with low exposure to oil pollution. However, pregnancy-induced hypertension and CS had no association with maternal exposure area status to oil pollution.

Conclusion

Women in high exposure areas are at a higher risk of PROM and PPH. This calls for policies and intervention toward reducing maternal exposure to oil pollution in the Niger Delta region of Nigeria.

Emergency Preparedness and Response: Highlights from the Division of Reproductive Health, 2011-2021

This report provides historical context and rationale for coordinated, systematic, and evidence-based public health emergency preparedness and response (EPR) activities to address the needs of women of reproductive age. Needs of pregnant and postpartum women, and infants-before, during, and after public health emergencies-are highlighted. Four focus areas and related activities are described: (1) public health science; (2) clinical guidance; (3) partnerships, communication, and outreach; and (4) workforce development. Finally, the report summarizes major activities of the Division of Reproductive Health's EPR Team at the Centers for Disease Control and Prevention.

Pregnancy outcomes among evacuees of the Sinabung volcano, 2010-2018 (North Sumatra, Indonesia): A matched cohort study

OBJECTIVES

Exposure to natural disasters during pregnancy is associated with adverse birth outcomes and increased probability of female births. Nonetheless, relatively little work has been done on evacuations of women living in close vicinity to volcanic eruptions. We conducted a retrospective cohort study among women from villages near the Sinabung volcano in North Sumatra, Indonesia, which has been active since 2010.

METHODS

We compared an "exposed" sample of women (n = 97) who were pregnant when forced to evacuate their villages due to the volcanic eruptions and an "unexposed" sample of non-evacuees (n = 97) matched for age and year of child's birth. We collected anthropometric data (height and weight of each woman) and conducted structured interviews about pregnancy outcomes and evacuation-related stress.

RESULTS

Evacuation led to an almost five-fold increase in the adjusted odds of having an early or preterm birth in non-imputed (OR = 4.84, 95% CI: 1.31-17.92) and multiply imputed (OR = 4.84, 95% CI: 1.29-19.19) analyses. It also led to approximately a 1 cm decrease in birth length in the non-imputed (β = -1.10, 95% CI: -1.96-0.24) and multiply imputed (β = -1.17, 95% CI: -1.20-0.36) analyses, both including controls for confounders. We found decreasing birth length with increasing stress among evacuees. There was no discernible effect of evacuation or stress on the other outcomes.

CONCLUSIONS

Both adverse effects we documented can exert negative influences on later-in-life outcomes for children of women pregnant during evacuation. This should be considered when developing protocols for supporting women and connecting them with clinical resources when evacuated from natural disasters.

Tropical cyclones and risk of preterm birth: A retrospective analysis of 20 million births across 378 US counties

BACKGROUND

The public health impacts of tropical cyclones (TCs) are expected to increase due to the continued growth of coastal populations and the increasing severity of these events. However, the impact of TCs on pregnant women, a vulnerable population, remains largely unknown. We aimed to estimate the association between prenatal exposure to TCs and risk of preterm birth in the eastern United States (US) and to assess whether the association varies by individual- and area-level characteristics.

METHODS

We included data on 19,529,748 spontaneous singleton births from 1989 to 2002 across 378 US counties. In each county, we classified days as exposed to a TC when TC-associated peak sustained winds at the county's population-weighted center were >17.2 m/s (gale-force winds or greater). We defined preterm birth as births delivered prior to 37 completed weeks of gestation. We used distributed lag log-linear mixed-effects models to estimate the relative risk (RR) and absolute risk difference (ARD) for TC exposure by comparing preterm births occurring in TC-periods (from 2 days before to 30 days after the TC's closest approach to the county's population center) to matched non-TC periods. We conducted secondary analyses using other wind thresholds (12 m/s and 22 m/s) and other exposure metrics: county distance to storm track (30 km, 60 km, and 100 km) and cumulative rainfall within the county (75 mm, 100 mm, and 125 mm).

RESULTS

During the study period, there were 1,981,797 (10.1%) preterm births and 58 TCs that affected at least one US county on which we had birth data. The risk of preterm birth was positively associated with TC exposure defined as peak sustained wind speed >17.2 m/s (gale-force winds or greater) [RR: 1.01 (95% CI: 0.99, 1.03); ARD: 9 (95% CI: -7, 25) per 10,000 pregnancies], distance to storm track <60 km [RR: 1.02 (95% CI: 1.01, 1.04); ARD: 23 (95% CI: 9, 38) per 10,000 pregnancies], and cumulative rainfall >100 mm [RR: 1.04 (95% CI: 1.02, 1.06); ARD: 36 (95% CI: 16, 56) per 10,000 pregnancies]. Results were comparable when considering other wind, distance, or rain thresholds. The association was more pronounced among early preterm births and mothers living in more socially vulnerable counties but did not vary across strata of other hypothesized risk factors.

CONCLUSIONS

Maternal exposure to TC was associated with a higher risk of preterm birth. Our findings provide initial evidence that severe storms may trigger preterm birth.

Integrative Review of Pregnancy and Birth Outcomes After Exposure to a Hurricane

OBJECTIVE

To appraise and analyze published research on the relationships among hurricane exposure and adverse pregnancy and birth outcomes.

DATA SOURCES

A literature search was conducted in four electronic databases: CINAHL Plus, Embase, PubMed, and Web of Science. The following search terms were used: "cyclonic storms," "cesarean section," "premature birth," "fetal mortality," "low birth weight," "infant mortality," "pregnancy complications," and "pregnancy outcome."

STUDY SELECTION

Documents were included if they were peer-reviewed, full-text articles or government documents published in English through February 2020 that focused on the associations among exposure to hurricanes and adverse pregnancy and birth outcomes. The initial search yielded 211 articles, and one article was identified through a hand search. After 48 duplicates were removed, we screened the titles and abstracts of 164 articles. We conducted a full-text review of 57 articles, and 19 articles were included in the integrative review.

DATA EXTRACTION

We extracted data from the full text of each article into a standardized table with the following headings: author, year of publication, location, hurricane and year, population studied, study design, outcomes, data source, and results.

DATA SYNTHESIS

We analyzed study findings based on the outcomes of pregnancy complications, preterm birth, cesarean birth, labor and birth complications, low birth weight, abnormal newborn conditions, and fetal mortality. We synthesized data in a narrative format, and the synthesis indicated that hurricane exposure was frequently associated with pregnancy complications, preterm birth, low birth weight, cesarean birth, and abnormal newborn conditions. However, these associations were not always consistent. Extant research is limited by inconsistency among study designs and the type of hurricane exposure.

CONCLUSION

Interdisciplinary teams that include nurses, midwives, obstetricians and gynecologists, and other health care professionals should ensure that hurricane preparedness and response efforts specifically address the needs of pregnant women to mitigate adverse outcomes.

Post-traumatic stress disorder and hypertensive disorders of pregnancy among military women

BACKGROUND

Women are more likely to develop post-traumatic stress disorder (PTSD) than men. Limited research exists evaluating the risk of hypertensive disorders of pregnancy (HDP) among military women with PTSD.

METHODS

We conducted a retrospective cohort study using US Department of Defense (DoD) data comprised of all active-duty women giving birth to their first, liveborn singleton infant using DoD-sponsored health insurance from 1 January 2004 to 31 December 2008 (n = 34 176). Birth hospitalisation records, maternal mental health visits, and Post-Deployment Health Assessment (PDHA) and Reassessment (PDHRA) screenings were included. The HDP outcome (yes vs no) was defined using ICD-9-CM codes in the maternal birth hospitalisation record. Women fit into one of four PTSD exposure categories (confirmed, probable, possible, none). Confirmed cases had a PTSD ICD-9-CM diagnosis code. Probable/possible cases were classified using PDHA screening items. We used multiple log-linear regression to assess PTSD (confirmed, any vs none) and the risk of HDP overall, and then explored effect modification by military service and demographic variables. We assessed the risk of HDP among deployed mothers with PTSD (confirmed, probable/possible vs none) who completed a PDHA, and explored effect modification by race/ethnicity. We also assessed risk of HDP with differing PTSD lead times.

RESULTS

Overall, PTSD was not associated with HDP except among mothers whose PTSD was diagnosed ≥1 year prior to conception (RR 1.42, 95% CI 1.06, 1.90).

CONCLUSIONS

Post-traumatic stress disorder preceding conception by at least a year appeared to confer an increased risk of HDP, but further research is needed using more thorough PTSD assessment.

Mental health and worries of pregnant women living through disaster recovery

The health and well-being of pregnant women during and after natural disasters remains an international concern. In this mixed methods study we described pregnant women's mental health, psychosocial concerns and sources of stress living in New Orleans during long term recovery from Hurricane Katrina. Our survey of 402 pregnant women indicated poor social support was associated with higher levels of depression symptomology, post-traumatic stress disorder, anxiety, and stress. Women were interviewed and described seven common areas of worry. We concluded that pregnant women living in post-disaster communities have stressful lives years after the event, needing innovative models of care to build resilience.

When Disaster Strikes in Rural America-Call the Midwife!

Midwives can play a critical role in emergency preparedness and response. Rural areas have unique disaster preparedness needs but receive less attention than urban centers. Childbearing women and infants are particularly affected during disasters. Midwives are well positioned to coordinate disaster preparedness training and response to optimize the health of women and infants in rural areas.

Flooding: what is the impact on pregnancy and child health?

Floods are the most common type of natural disaster in both developed and developing countries and have led to extensive morbidity and mortality throughout the world. Worldwide, over the past 30 years, flooding has claimed the lives of more than 200,000 people and affected more than 2.8 billion others. The impact of flooding on health varies among populations and depends primarily on vulnerability and the kind of event experienced. It severely disrupts livelihoods and has a significant impact on the health of pregnant women and children. In addition, it may exacerbate a range of negative psychological and physiological child and reproductive health outcomes. Awareness-raising, education, and the issuing of warnings appear to be key initiatives to mitigate or prevent flood morbidity and mortality, especially among people living in low- and middle-income countries. Agencies responding to emergencies also need to be more cognisant of the dangers, specifically those engaged in healthcare, nutrition, and water safety programmes.

Addressing Maternal Health During CDC's Ebola Response in the United States

Previous outbreaks suggest that pregnant women with Ebola virus disease (EVD) are at increased risk for severe disease and death. Healthcare workers who treat pregnant women with EVD are at increased risk of body fluid exposure. Despite the absence of pregnant women with EVD in the United States, CDC activated the Maternal Health Team (MHT), a functional unit dedicated to emergency preparedness and response issues, on October 18, 2014. We describe major activities of the MHT. A high-priority MHT activity was to publish guiding principles early in the response. The MHT also prepared guidance documents, provided guidance and technical support for hospital preparedness, and addressed inquiries. We analyzed maternal health inquiries received through CDC-INFO, MHT, and CDC's Medical Investigations Team from August 2014 to December 2015. Internal call logs used to capture, monitor, and track inquiries for the three data sources were merged. Inquiries not related to maternal health issues and duplicates were removed. Each inquiry was categorized by route (email/phone), inquirer type, and topic. In total, 201 inquiries were received from clinicians, public health professionals, and the public. The predominant topic was related to infection control for high-risk situations such as labor and delivery. During the Ebola response, most inquiries were received via email rather than telephone, a notable shift compared to the H1N1 emergency response. Lessons learned during the H1N1 and Ebola responses are currently informing CDC's Zika Response, an unprecedented emergency response primarily focused on reproductive health issues.

History of Disaster Epidemiology

Disaster epidemiology is not a new field, and the methods utilized to conduct disaster epidemiology studies are no different than the methods used in everyday applied public health research and investigations. The only difference is the circumstances under which the methods are employed. The challenges of conducting epidemiologic studies during a disaster are many—limited access to study sites and populations; access to reliable electricity, connectivity, and communication systems; and typically a short time frame in which to gather, analyze, and report data to decision-makers so that it can be utilized to prevent morbidity and mortality. However, many innovations have been developed by disaster epidemiologists to meet these challenges. Rapid needs assessments, innovative surveillance and tracking systems, and adapted epidemiologic study designs are some of the innovations that will be discussed in this chapter.

Midwives' Professional Competencies for Preventing Maternal Mortality in Disasters: A Cross-Sectional Study in Iran

OBJECTIVE

Maternal mortality may increase after a disaster. Because midwives are at the frontline of offering reproductive health care services in disasters, they should be competent.

METHODS

This was a cross-sectional, descriptive study carried out in 2015 in Tehran. The sample consisted of 361 midwives selected by use of a cluster random sampling method. Data were collected by using a questionnaire on professional competency for preventing maternal mortality in disasters.

RESULTS

The midwives' mean professional competency score was 177.74±31, which was an average level of professional competency. The level of knowledge and skills of the midwives was reported as inadequate for most items, particularly for the items of "managing mothers affected by chronic diseases," "physical trauma," "recognizing patients who needed to be referred," and "stabilizing mothers when referring them." Statistically significant relationships were observed between the midwives' competencies and age (P=0.001), work experience (P=0.054), educational level (P= 0.043), previous experience in a disaster (P=0.014), and workplace (P=0.006). These data were drawn by using Spearman's correlation, t-test, and ANOVA, respectively.

CONCLUSIONS

Given the average scores for midwives' professional competency in disasters and the inadequacy of prior training courses, extra educational programs for midwives are recommended. (Disaster Med Public Health Preparedness. 2018; 12: 305-311).

Self-Reported Oil Spill Exposure and Pregnancy Complications: The GROWH Study

Adverse infant outcomes often rise in the aftermath of disaster, but few studies have assessed the effects of disaster on maternal health. 1091 southern Louisiana women were interviewed about their pregnancy history, including pregnancy complications. Associations between oil spill exposures and gestational diabetes, hypertensive disorders, and nausea/vomiting were assessed for all reported pregnancies. 631 women had a pregnancy both before and after the oil spill. Generalized estimating equations (logistic regression) with adjustment for confounders were used. To assess possible unmeasured confounding, instead of considering oil spill exposure as a time-varying exposure, women were defined as oil spill-exposed or not. If oil spill-exposed women were equally prone to complications in pregnancies that occurred prior to the oil spill as after it, it was considered that any associations were likely due to selection or reporting issues. Women who reported oil spill exposure, particularly loss of use of the coast, were more likely to report gestational diabetes; however, the level of association was similar for pregnancies before and after the spill (p for interaction >0.10 and odds ratios (ORs) for pregnancies prior to the spill > than those after the spill). No associations were found between oil spill exposure and hypertensive disorders. This analysis does not suggest an increased risk of pregnancy complications associated with exposure to the oil spill; however, future studies should assess exposure and outcomes prospectively and clinically instead of relying on self-report.

Birth Outcomes after the Fukushima Daiichi Nuclear Power Plant Disaster: A Long-Term Retrospective Study

Changes in population birth outcomes, including increases in low birthweight or preterm births, have been documented after natural and manmade disasters. However, information is limited following the 2011 Fukushima Daiichi Nuclear Power Plant Disaster. In this study, we assessed whether there were long-term changes in birth outcomes post-disaster, compared to pre-disaster data, and whether residential area and food purchasing patterns, as proxy measurements of evacuation and radiation-related anxiety, were associated with post-disaster birth outcomes. Maternal and perinatal data were retrospectively collected for all live singleton births at a public hospital, located 23 km from the power plant, from 2008 to 2015. Proportions of low birthweight (<2500 g at birth) and preterm births (<37 weeks gestation at birth) were compared pre- and post-disaster, and regression models were conducted to assess for associations between these outcomes and evacuation and food avoidance. A total of 1101 live singleton births were included. There were no increased proportions of low birthweight or preterm births in any year after the disaster (merged post-disaster risk ratio of low birthweight birth: 0.98, 95% confidence interval (CI): 0.64–1.51; and preterm birth: 0.68, 95% CI: 0.38–1.21). No significant associations between birth outcomes and residential area or food purchasing patterns were identified, after adjustment for covariates. In conclusion, no changes in birth outcomes were found in this institution-based investigation after the Fukushima disaster. Further research is needed on the pathways that may exacerbate or reduce disaster effects on maternal and perinatal health.

From Devastation to Recovery and Revival in the Aftermath of Fukushima’s Nuclear Power Plants Accident

Japan’s earthquake, tsunami, and subsequent Fukushima nuclear power plant accident in March 2011 forced the evacuation of 185 000 residents. Psychological and social impacts exacerbated by long-term evacuation and widespread rumors have influenced residents’ physical and mental health, despite the fact that no direct fatalities occurred from radiation exposure. However, during the 5 years following the accident, steady recovery in industrial and economic activity has lessened previously widespread, deeply rooted stigma and self-stigma among a significant number of affected victims. More than 21 000 of 62 800 people who evacuated from Fukushima are gradually returning, and concurrently, Fukushima’s economic and social recovery are progressing, as can be seen from remarkable increases in residential construction, recovering agricultural production, job growth, and industrial output. Although post-disaster interventions such as seminars and dialogues with residents are credited with building resilience, a significant proportion of people in the area have depressive tendencies and loss of purpose.

Management of Infection for the Obstetrician/Gynecologist

Pregnant women have an increased morbidity and mortality for certain illnesses owing to the physiologic and immunologic changes in pregnancy. Certain infections are common during pregnancy, including urinary tract infections and pneumonia. Others are uncommon, but yield increased severity, including influenza. Human immunodeficiency virus, although it does not increase in pathogenesis during pregnancy, requires specific attention and management in the context of pregnancy.

Impact of Hurricane Exposure on Reproductive Health Outcomes, Florida, 2004

OBJECTIVE

Prenatal hurricane exposure may be an increasingly important contributor to poor reproductive health outcomes. In the current literature, mixed associations have been suggested between hurricane exposure and reproductive health outcomes. This may be due, in part, to residual confounding. We assessed the association between hurricane exposure and reproductive health outcomes by using a difference-in-difference analysis technique to control for confounding in a cohort of Florida pregnancies.

METHODS

We implemented a difference-in-difference analysis to evaluate hurricane weather and reproductive health outcomes including low birth weight, fetal death, and birth rate. The study population for analysis included all Florida pregnancies conceived before or during the 2003 and 2004 hurricane season. Reproductive health data were extracted from vital statistics records from the Florida Department of Health. In 2004, 4 hurricanes (Charley, Frances, Ivan, and Jeanne) made landfall in rapid succession; whereas in 2003, no hurricanes made landfall in Florida.

RESULTS

Overall models using the difference-in-difference analysis showed no association between exposure to hurricane weather and reproductive health.

CONCLUSIONS

The inconsistency of the literature on hurricane exposure and reproductive health may be in part due to biases inherent in pre-post or regression-based county-level comparisons. We found no associations between hurricane exposure and reproductive health. (Disaster Med Public Health Preparedness. 2017;11:407-411).

CDC Online Course: Reproductive Health in Emergency Preparedness and Response

In an emergency, the needs of women of reproductive age, particularly pregnant and postpartum women, introduce unique challenges for public health and clinical care. Incorporating reproductive health issues and considerations into emergency preparedness and response is a relatively new field. In recent years, several resources and tools specific to reproductive health have been developed. However, there is still a need for training about the effects of emergencies on women of reproductive age. In an effort to train medical and public health professionals about these topics, the CDC Division of Reproductive Health developed Reproductive Health in Emergency Preparedness and Response, an online course that is available across the United States.

Evaluation of reproductive health indicators in women affected by East Azarbaijan earthquake on August 2012

Background:

Ignoring reproductive health services during natural disasters leads to some negative consequences such as reduced access to contraceptive methods, sexual disorders, and pregnancy complications. Despite previous researches, there is still more need for research on this area of health. This study attempts to identify the indicators of reproductive health in the women affected by the East Azarbaijan earthquake on August 2012.

Materials and Methods:

In this descriptive study, reproductive health information pertaining to the years before, during, and after the earthquake were collected and compared in the health centers of the three affected cities including Ahar, Heriss, and Varzaghan as well as the health and forensics centers of the East Azarbaijan province in Iran by census method.

Results:

Findings indicated a decrease in live birth rate, general marriage fertility rate, stillbirth rate, contraceptive methods coverage, and prevalence of sexually transmitted diseases during and after the earthquake. Moreover, important indicators such as neonatal mortality rate and percentage of infants screened for breast milk, decreased during the disaster year in comparison with the years before and after. Other indicators such as preconception care, pregnancy first visit, rate of caesarian delivery, and under 1-year formula milk-fed infants’ percentages increased during the year of disaster in comparison with the years before and after.

Conclusions:

During the earthquake, some indicators of reproductive health have been reported to decrease whereas some others have gone through negative changes. Despite the partly favorable status of services, decision-makers and health service providers should pay more attention to the needs of women during disasters.

County-level hurricane exposure and birth rates: application of difference-in-differences analysis for confounding control

Background

Epidemiological analyses of aggregated data are often used to evaluate theoretical health effects of natural disasters. Such analyses are susceptible to confounding by unmeasured differences between the exposed and unexposed populations. To demonstrate the difference-in-difference method our population included all recorded Florida live births that reached 20 weeks gestation and conceived after the first hurricane of 2004 or in 2003 (when no hurricanes made landfall). Hurricane exposure was categorized using ≥74 mile per hour hurricane wind speed as well as a 60 km spatial buffer based on weather data from the National Oceanic and Atmospheric Administration. The effect of exposure was quantified as live birth rate differences and 95 % confidence intervals [RD (95 % CI)]. To illustrate sensitivity of the results, the difference-in-differences estimates were compared to general linear models adjusted for census-level covariates. This analysis demonstrates difference-in-differences as a method to control for time-invariant confounders investigating hurricane exposure on live birth rates.

Results

Difference-in-differences analysis yielded consistently null associations across exposure metrics and hurricanes for the post hurricane rate difference between exposed and unexposed areas (e.g., Hurricane Ivan for 60 km spatial buffer [−0.02 births/1000 individuals (−0.51, 0.47)]. In contrast, general linear models suggested a positive association between hurricane exposure and birth rate [Hurricane Ivan for 60 km spatial buffer (2.80 births/1000 individuals (1.94, 3.67)] but not all models.

Conclusions

Ecological studies of associations between environmental exposures and health are susceptible to confounding due to unmeasured population attributes. Here we demonstrate an accessible method of control for time-invariant confounders for future research.

Electronic supplementary material

The online version of this article (doi:10.1186/s12982-015-0042-7) contains supplementary material, which is available to authorized users.

Barriers in the Delivery of Emergency Obstetric and Neonatal Care in Post-Conflict Africa: Qualitative Case Studies of Burundi and Northern Uganda

Objectives

Maternal and neonatal mortality and morbidity rates are particularly grim in conflict, post-conflict and other crisis settings, a situation partly blamed on non-availability and/or poor quality of emergency obstetric and neonatal care (EmONC) services. The aim of this study was to explore the barriers to effective delivery of EmONC services in post-conflict Burundi and Northern Uganda, in order to provide policy makers and other relevant stakeholders context-relevant data on improving the delivery of these lifesaving services.

Methods

This was a qualitative comparative case study that used 42 face-to-face semi-structured in-depth interviews and 4 focus group discussions for data collection. Participants were 32 local health providers and 37 staff of NGOs working in the area of maternal health. Data was analysed using the framework approach.

Results

The availability, quality and distribution of EmONC services were major challenges across the sites. The barriers in the delivery of quality EmONC services were categorised into two major themes; human resources-related challenges, and systemic and institutional failures. While some of the barriers were similar, others were unique to specific sites. The common barriers included shortage of qualified staff; lack of essential installations, supplies and medications; increasing workload, burn-out and turnover; and poor data collection and monitoring systems. Barriers unique to Northern Uganda were demoralised personnel and lack of recognition; poor referral system; inefficient drug supply system; staff absenteeism in rural areas; and poor coordination among key personnel. In Burundi, weak curriculum; poor harmonisation and coordination of training; and inefficient allocation of resources were the unique challenges. To improve the situation across the sites, efforts are ongoing to improve the training and recruitment of more staff; harmonise and strengthen the curriculum and training; increase the number of EmONC facilities; and improve staff supervision, monitoring and support.

Conclusions

Post-conflict health systems face different challenges in the delivery of EmONC services and as such require context-specific interventions to improve the delivery of these services.

Post-disaster health indicators for pregnant and postpartum women and infants

United States (U.S.) pregnant and postpartum (P/PP) women and their infants may be particularly vulnerable to effects from disasters. In an effort to guide post-disaster assessment and surveillance, we initiated a collaborative process with nationwide expert partners to identify post-disaster epidemiologic indicators for these at-risk groups. This 12 month process began with conversations with partners at two national conferences to identify critical topics for P/PP women and infants affected by disaster. Next we hosted teleconferences with a 23 member Indicator Development Working Group (IDWG) to review and prioritize the topics. We then divided the IDWG into three population subgroups (pregnant women, postpartum women, and infants) that conducted at least three teleconferences to discuss the proposed topics and identify/develop critical indicators, measures for each indicator, and relevant questions for each measure for their respective population subgroup. Lastly, we hosted a full IDWG teleconference to review and approve the indicators, measures, and questions. The final 25 indicators and measures with questions (available online) are organized by population subgroup: pregnant women (indicators = 9; measures = 24); postpartum women (indicators = 10; measures = 36); and infants (indicators = 6; measures = 30). We encourage our partners in disaster-affected areas to test these indicators and measures for relevancy and completeness. In post-disaster surveillance, we envision that users will not use all indicators and measures but will select ones appropriate for their setting. These proposed indicators and measures promote uniformity of measurement of disaster effects among U.S. P/PP women and their infants and assist public health practitioners to identify their post-disaster needs.

Perceptions of the effects of armed conflict on maternal and reproductive health services and outcomes in Burundi and Northern Uganda: a qualitative study

Background

Armed conflict potentially poses serious challenges to access and quality of maternal and reproductive health (MRH) services, resulting in increased maternal morbidity and mortality. The effects of armed conflict may vary from one setting to another, including the mechanisms/channels through which the conflict may lead to poor access to and quality of health services. This study aims to explore the effects of armed conflict on MRH in Burundi and Northern Uganda.

Methods

This is a descriptive qualitative study that used in-depth interviews (IDIs) and focus group discussions (FGDs) with women, health providers and staff of NGOs for data collection. Issues discussed include the effects of armed conflict on access and quality of MRH services and outcomes, and the mechanisms through which armed conflict leads to poor access and quality of MRH services. A total of 63 IDIs and 8 FGDs were conducted involving 115 participants.

Results

The main themes that emerged from the study were: armed conflict as a cause of limited access to and poor quality of MRH services; armed conflict as a cause of poor MRH outcomes; and armed conflict as a route to improved access to health care. The main mechanisms through which the conflict led to poor access and quality of MRH services varied across the sites: attacks on health facilities and looting of medical supplies in both sites; targeted killing of health personnel and favouritism in the provision of healthcare in Burundi; and abduction of health providers in Northern Uganda. The perceived effects of the conflict on MRH outcomes included: increased maternal and newborn morbidity and mortality; high prevalence of HIV/AIDS and SGBV; increased levels of prostitution, teenage pregnancy and clandestine abortion; and high fertility levels. Relocation to government recognised IDP camps was perceived to improve access to health services.

Conclusions

The effects of armed conflict on MRH services and outcomes are substantial. The mechanisms through which armed conflict leads to poor access and quality of MRH services vary from one setting to another. All these issues need to be considered in the design and implementation of interventions to improve MRH in these settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12914-015-0045-z) contains supplementary material, which is available to authorized users.

Maternal exposure to hurricane destruction and fetal mortality

BACKGROUND

The majority of research documenting the public health impacts of natural disasters focuses on the well-being of adults and their living children. Negative effects may also occur in the unborn, exposed to disaster stressors when critical organ systems are developing and when the consequences of exposure are large.

METHODS

We exploit spatial and temporal variation in hurricane behaviour as a quasi-experimental design to assess whether fetal death is dose-responsive in the extent of hurricane damage. Data on births and fetal deaths are merged with Parish-level housing wreckage data. Fetal outcomes are regressed on housing wreckage adjusting for the maternal, fetal, placental and other risk factors. The average causal effect of maternal exposure to hurricane destruction is captured by difference-in-differences analyses.

RESULTS

The adjusted odds of fetal death are 1.40 (1.07-1.83) and 2.37 (1.684-3.327) times higher in parishes suffering 10-50% and >50% wreckage to housing stock, respectively. For every 1% increase in the destruction of housing stock, we observe a 1.7% (1.1-2.4%) increase in fetal death. Of the 410 officially recorded fetal deaths in these parishes, between 117 and 205 may be attributable to hurricane destruction and postdisaster disorder. The estimated fetal death toll is 17.4-30.6% of the human death toll.

CONCLUSIONS

The destruction caused by Hurricanes Katrina and Rita imposed significant measurable losses in terms of fetal death. Postdisaster migratory dynamics suggest that the reported effects of maternal exposure to hurricane destruction on fetal death may be conservative.

Preparedness planning for emergencies among postpartum women in arkansas during 2009

PURPOSE

Having an emergency plan may reduce negative effects of disaster on the health of postpartum women and their infants. However, little is known about the prevalence of emergency plans among postpartum women. In 2009, Arkansas added a question to the Pregnancy Risk Assessment Monitoring System surveillance system about whether women who gave birth that year had an emergency plan. In this study, we first describe the sociodemographic characteristics, disaster experience, and region of residence of postpartum women in Arkansas who indicated that they had an emergency plan for their families in 2009, and second, examine associations between sociodemographic characteristics and disaster experience and the presence of an emergency plan.

METHODS

Multivariable logistic regression (n = 1,173) was conducted to examine associations between maternal race/ethnicity, sociodemographic characteristics, region of residence, disaster experience, and having a disaster plan. We adjusted for maternal education, federal poverty level, and family size in our final model.

FINDINGS

Forty-eight percent (n = 559) of women reported having an emergency plan. Hispanic women were less likely to report having a plan compared with non-Hispanic White women (n = 102 [10%]; adjusted prevalence ratio [aPR], 0.6; 95% confidence interval [CI], 0.4-0.9). Families with five or more members were more likely to have a plan compared with smaller families (n = 123 [11%]; aPR, 1.3; 95% CI, 1.1-1.6).

CONCLUSIONS

Policymakers and public health practitioners can use these results to promote emergency planning among postpartum women in Arkansas, with special outreach to postpartum women who are Hispanic or have smaller families.