Predicting low birthweight and complicated labor in urban black women: a biopsychosocial perspective

Paternal exposure to medical-related radiation associated with low birthweight infants: A large population-based, retrospective cohort study in rural China

Low birthweight (LBW) is closely associated with fetal and perinatal mortality and morbidity. We identified the risk factors of LBW and geographical differences in LBW incidence in 30 Chinese provinces in the present study.This study was a population-based, retrospective cohort study performed in 30 Chinese provinces. We used data from the free National Pre-pregnancy Checkups Project, which is a countrywide population-based retrospective cohort study. To identify regional differences in LBW incidence, we used the Qinling-Huaihe climate line to divide China into northern and southern sections and the Heihe-Tengchong economic line to divide it into eastern and western sections. Multivariate unconditional logistic regression analysis with SAS 9.4 was used for data analysis. P < .05 was considered statistically significant.LBW incidence was 4.54% in rural China. Southern China had a significantly higher incidence (4.65%) than northern China (4.28%). Our main risk factor for LBW is paternal exposure to radiation (odds ratio = 1.537), which has never been studied before.This study identifies multiple risk factors of couples giving birth to LBW babies including paternal risk factors.

Prediction of Low Birth Weight Delivery by Maternal Status and Its Validation: Decision Curve Analysis

Background:

In this study, we evaluated assessed elements connected with low birth weight (LBW) and used decision curve analysis (DCA) to define a scale to anticipate the probability of having a LBW newborn child.

Methods:

This hospital-based case–control study was led in Arak Hospital in Iran. The study included 470 mothers with LBW neonate and 470 mothers with natural neonates. Information were gathered by meeting moms utilizing preplanned organized questionnaire and from hospital records. The estimated probabilities of detecting LBW were calculated using the logistic regression and DCA to quantify the clinical consequences and its validation.

Results:

Factors significantly associated with LBW were premature membrane rupture (odds ratio [OR] = 3.18 [1.882–5.384]), former LBW infants (OR = 2.99 [1.510–5.932]), premature pain (OR = 2.70 [1.659–4.415]), hypertension in pregnancy (OR = 2.39 [1.429–4.019]), last trimester of pregnancy bleeding (OR = 2.58 [1.018–6.583]), mother age >30 (OR = 2.17 [1.350–3.498]). However, with DCA, the prediction model made on these 15 variables has a net benefit (NB) of 0.3110 is best predictive with the highest NB. NB has simple clinical interpretation and utilizing the model is what might as well be called a procedure that distinguished what might as well be called 31.1 LBW per 100 cases with no superfluous recognize.

Conclusions:

It is conceivable to foresee LBW utilizing a prediction model show in light of noteworthy hazard components connected with LBW. The majority of the hazard elements for LBW are preventable, and moms can be alluded amid early pregnancy to a middle which is furnished with facilities for administration of high hazard pregnancy and LBW infant.

Stress, Social Support and Coping in Pregnancy

The social support literature, despite its focus on women's strengths in relationships, has not fully addressed the social realities of women of diverse ethnic backgrounds and socio economic conditions. Specifically, the emphasis on marital relationships as primary sources of support during pregnancy marginalizes those women for whom these partnerships are unhelpful or unavailable. In addition, women's greater use of social support as a coping strategy is often portrayed in the coping literature as an ineffective approach to stress. Data from two studies of pregnant women are presented to illustrate these points and to present a new model of coping that reframes women's coping as prosocial, active and effective. Our article is designed to challenge researchers to examine the relevance of work on social support and coping to women of varying ethnicities and economic circumstances.

The post-disaster negative health legacy: pregnancy outcomes in Louisiana after Hurricane Andrew

Disasters and displacement increasingly affect and challenge urban settings. How do pregnant women fare in the aftermath of a major disaster? This paper investigates the effect of pregnancies in disaster situations. The study tests a hypothesis that pregnant women residing in hurricane-prone areas suffer higher health risks. The setting is Louisiana in the Gulf Coast, United States, a state that continually experiences hurricane impacts. The time period for the analysis is three years following the landfall of Hurricane Andrew in 1992. We analysed low birth weight and preterm deliveries before and after landfall, as a whole and by race. Findings support an association between hazards and health of a community and indicate that pregnant women in the affected area, irrespective of race, are more likely to experience preterm deliveries compared to pre-event births. Results suggest there is a negative health legacy impact in Louisiana as a result of hurricane landfall.

Role of stress in low birthweight disparities between black and white women: a population-based study

AIM

This study examines the role of stress in low birthweight (LBW) risk in Black and White women in the United States.

METHODS

Data from the 1998-2000 Fragile Family and Child Wellbeing Study were used (n = 3869). We included several self-reported conditions which we categorised as stressors (i.e. socio-economic conditions, health behaviours, access to quality care and cultural factors), then we used logistic regression models to analyse the role of stressors in explaining the health disparities in LBW.

RESULTS

Most women were unmarried (59% for White women and 87% for Black women). Among unmarried White women, the only stressor associated with a higher likelihood of LBW was smoking (odds ratio (OR) = 2.0, 95% confidence interval (CI) (1.2, 3.3)). Among unmarried Black women, smoking (OR = 1.7, 95% CI (1.2, 2.3)), drug use (OR = 1.7, 95% CI (1.0, 2.6)), paying for the baby's birth with government resources (OR = 1.6, 95% CI (1.1, 2.4)) and religious affiliation (OR = 1.6, 95% CI (1.0, 2.5)) were associated with higher likelihood of LBW. Among married White women, older age (OR = 1.1, 95% CI (1.0, 1.2)), smoking (OR = 5.2, 95% CI (1.7, 15.5)), using governmental resources to pay for birth (OR = 3.6, 95% CI (1.0, 12.4)) and living in governmental housing (OR = 9.1, 95% CI (2.0, 41.1)) were associated with higher likelihood of LBW. No stressors were statistically significant for married Black women.

CONCLUSION

We analysed a large number of stressors at the individual, household and societal levels and found differences on the stressors among Black and White women. However, the stressors included in the analyses did not fully explain the racial disparities in LBW.

Prediction model for low birth weight and its validation

OBJECTIVE

To evaluate the factors associated with low birth weight (LBW) and to formulate a scale to predict the probability of having a LBW infant.

METHODS

This hospital based case-control study was conducted in a tertiary care university hospital in North India. The study included 250 LBW neonates and 250 neonates with birth weight ≥2,500 g. Data were collected by interviewing mothers using pre-designed structured questionnaire and from hospital records.

RESULTS

Factors significantly associated with LBW were inadequate weight gain by the mother during pregnancy (<8.9 kg), inadequate proteins in diet (<47 g/d), previous preterm baby, previous LBW baby, anemic mother and passive smoking. The prediction model made on these six variables has a sensitivity of 71.6 %, specificity 67.0 %, positive LR 2.17 and negative LR of 0.42 for a cut-off score of ≥29.25. On validation, it has a sensitivity of 72 % and specificity of 64 %.

CONCLUSIONS

It is possible to predict LBW using a prediction model based on significant risk factors associated with LBW.

Prediction of low birth weight using modified Indian council of medical research antenatal scoring method

OBJECTIVE

To study the prediction of low birth weight (LBW) using modified Indian Council of Medical Research (ICMR) antenatal scoring method.

METHOD

The present longitudinal study was carried out amongst 1138 pregnant women residing in area covered by Kinaye primary health centre (PHC) in rural Karnataka, India.

RESULTS

Modified ICMR risk scoring revealed that 597 (52.5%) women had a risk score 6-10 (mild risk), 142 (12.5%) women had risk score 11-15 (moderate risk) and 29 (2.5%) had risk score ≥16 (severe risk), whereas, remaining 370 (32.5%) had a score of 0-5 considered as "no risk group". The incidence of LBW had direct relationship with the risk score. The sensitivity was high (80.6%), whereas, specificity was slightly low (70.4%), positive predictive value was low (43.8%) and negative predictive value high (92.7%) for LBW when the risk score cut-off point was >7.

CONCLUSION

The modified ICMR antenatal scoring method can be used at all levels of health care and is an ideal instrument for prediction of LBW at the community level. It can be easily applied by even a health worker, not time consuming and at the same time does not lose its predictability.

The social determinants of infant mortality and birth outcomes in Western developed nations: a cross-country systematic review

Infant mortality (IM) and birth outcomes, key population health indicators, have lifelong implications for individuals, and are unequally distributed globally. Even among western industrialized nations, striking cross-country and within-country patterns are evident. We sought to better understand these variations across and within the United States of America (USA) and Western Europe (WE), by conceptualizing a social determinants of IM/birth outcomes framework, and systematically reviewing the empirical literature on hypothesized social determinants (e.g., social policies, neighbourhood deprivation, individual socioeconomic status (SES)) and intermediary determinants (e.g., health behaviours). To date, the evidence suggests that income inequality and social policies (e.g., maternal leave policies) may help to explain cross-country variations in IM/birth outcomes. Within countries, the evidence also supports neighbourhood SES (USA, WE) and income inequality (USA) as social determinants. By contrast, within-country social cohesion/social capital has been underexplored. At the individual level, mixed associations have been found between individual SES, race/ethnicity, and selected intermediary factors (e.g., psychosocial factors) with IM/birth outcomes. Meanwhile, this review identifies several methodological gaps, including the underuse of prospective designs and the presence of residual confounding in a number of studies. Ultimately, addressing such gaps including through novel approaches to strengthen causal inference and implementing both health and non-health policies may reduce inequities in IM/birth outcomes across the western developed world.

The use of psychosocial stress scales in preterm birth research

Psychosocial stress has been identified as a potential risk factor for preterm birth. However, an association has not been found consistently, and a consensus on the extent to which stress and preterm birth are linked is still lacking. A literature search was performed with a combination of keywords and MeSH terms to detect studies of psychosocial stress and preterm birth. Studies were included in the review if psychosocial stress was measured with a standardized, validated instrument and if the outcomes included either preterm birth or low birthweight. Within the 138 studies that met inclusion criteria, 85 different instruments were used. Measures that had been designed specifically for pregnancy were used infrequently, although scales were sometimes modified for the pregnant population. The many different measures that have been used may be a factor that accounts for the inconsistent associations that have been observed.

Psychosocial stress during pregnancy and perinatal outcomes: a meta-analytic review

The objective of this study was to evaluate the relationship between psychosocial stress in pregnancy and negative perinatal outcomes and to identify key moderators of this relationship. To evaluate this relationship, a meta-analytic review was conducted of studies that prospectively assessed the relationship between psychosocial stress in pregnancy and perinatal outcomes. A total of 35 studies, written or published between 1991 and 2009, involving 31,323 women were located. The overall association between psychosocial stress and negative perinatal outcomes was significant, but negligibly small in size (r (35) = -0.04, CI = -0.08, -0.01). Examining specific perinatal outcomes, only the associations with neonatal weight (r (14) = -0.07, CI = -0.03, -0.01) and risk for low birth weight (r (5) = 0.07, CI = 0.03, 0.10) were statistically significant, but again, very small. Results support that psychosocial stress explains a negligible to very small amount of the variability in perinatal outcomes. Future research should focus on identifying other psychosocial and lifestyle variables that alone or in interaction with other factors explain larger amounts of the variability in perinatal outcomes. Future research should also examine whether psychosocial stress increases risk for negative outcomes in combination with other biomedical and psychosocial risk factors.

Life course perspectives on the epidemiology of depression

Life course epidemiology seeks to understand how determinants of health and disease interact across the span of a human life, and has made significant contributions to understanding etiological mechanisms in many chronic diseases, including schizophrenia. The life course approach is ideal for understanding depression: causation in depression appears to be multifactorial, including interactions between genes and stressful events, or between early life trauma and later stress in life; timing of onset and remission of depression varies widely, indicating differing trajectories of symptoms over long periods of time, with possible differing causes and differing outcomes; and early life events and development appear to be important risk factors for depression, including exposure to acute and chronic stress in the first years of life. To better understand etiology and outcome of depression, future research must move beyond basic epidemiologic techniques that link specific exposures to specific outcomes and embrace life course principles and methods. Time-sensitive modelling techniques that are able to incorporate multiple interacting factors across long periods of time, such as structural equation models, will be critical in understanding the complexity of causal and influencing factors from early development to the end stages of life. Using these models to identify key pathways that influence trajectories of depression across the life course will help guide prevention and intervention.

Stress, bacterial vaginosis, and the role of immune processes

Bacterial vaginosis (BV), the most common lower genital tract infection in women of reproductive age, is associated with adverse gynecologic and reproductive health outcomes. Women at highest risk for BV are young, unmarried, low income, undereducated, and African American. Behaviors such as vaginal douching, numerous sexual partners, frequent sexual intercourse, receptive oral sex, and substance use may contribute to risk, but they account for only a modest proportion of the observed race/ethnicity variance in BV. These subpopulations are also exposed to more social disadvantages or "stressors" such as poverty, poor housing, crime-infested neighborhoods, and discrimination than other groups. Growing physiologic evidence links psychosocial stress to the development of disease. Evidence supports a statistically significant, independent effect of stress on the risk and observed racial/ethnic disparity in the rate of BV. This paper reviews such evidence.

Evaluation of a social support measure that may indicate risk of depression during pregnancy

BACKGROUND

Strong social support has been linked with positive mental health and better birth outcomes for pregnant women. Our aim was to replicate the psychometric properties of the Kendler Social Support Interview modified for use in pregnant women and to establish the inventory's relationship to depression in pregnancy.

METHODS

The modified Kendler Social Support Interview (MKSSI) was evaluated using principal components analysis. The association with depression was used as an indicator of external validity and was assessed by logistic regression.

RESULTS

Data from 783 subjects were analyzed. One large principal component, termed "global support," (eigenvalue=6.086) represented 22.5% of the total variance. However, 6 of the 27 items (frequency of contact with spouse, siblings, other relatives, and friends, and attendance at church and clubs) had low levels of association (<0.4) and thus were excluded from suggested items for a total score. Varimax rotation of the remaining 21 items resulted in subscales that fell into expected groupings: mother, father, siblings, friends, etc. One unit and two unit increases in the global support score were associated with 58.3% (OR=0.417, 95% CI=0.284-0.612) and 82.6% (OR=0.174, 95% CI=0.081-0.374) reductions in odds for depression, respectively.

LIMITATIONS

The ability of this social support scale to predict future depression in pregnancy has not yet been established due to cross-sectional design.

CONCLUSION

The MKSSI is reliable and valid for use in evaluating social support and its relationship to depression in pregnant women.

Effects of posttraumatic stress disorder on pregnancy outcomes

BACKGROUND

The purpose of this study was to determine the association between posttraumatic stress disorder (PTSD), diagnosed prospectively during pregnancy, and the risk of delivering a low birth weight (<2500 g) or preterm (<37 weeks gestational age) infant.

METHODS

Pregnant women were recruited from obstetrics clinics and screened for major and minor depressive disorder, panic disorder, PTSD, and substance use. Current episodes of PTSD were diagnosed according to the MINI International Neuropsychiatric Interview, and pregnancy outcomes were abstracted from hospital records.

RESULTS

Among the 1100 women included in analysis, 31 (3%) were in episode for PTSD during pregnancy. Substance use in pregnancy, panic disorder, major and minor depressive disorder, and prior preterm delivery were significantly associated with a diagnosis of PTSD. Preterm delivery was non-significantly higher in pregnant women with (16.1%) compared to those without (7.0%) PTSD (OR=2.82, 95% C.I. 0.95, 8.38). Low birth weight (LBW) was present in 6.5% of women and was not significantly associated with a diagnosis of PTSD in pregnancy after adjusting for potential confounders. However, LBW was significantly associated with minor depressive disorder (OR=1.82, 95% C.I. 1.01, 3.29).

LIMITATIONS

There was a low prevalence of PTSD in this cohort, resulting in limited power.

CONCLUSIONS

These data suggest a possible association between PTSD and preterm delivery. Coupled with the association found between LBW and a depressive disorder, these results support the utility of screening for mental health disorders in pregnancy.

Treating mood disorders during pregnancy: safety considerations

Mood disorders in pregnancy may have a negative effect on self care and pregnancy outcome that affects the mother directly and the child indirectly. Thus, some women may require pharmacological treatment. Pharmacotherapy of mood disorders during pregnancy implies specific considerations. This paper presents an updated review of available studies on the treatment of mood disorders and present knowledge on teratogenicity, neonatal effects and long-term neurobehavioural effects for the different psychotropic drugs, including treatment with selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), other antidepressants, benzodiazepines, lithium, carbamazepine/valproic acid, lamotrigine and novel antipsychotics. However, the existing knowledge on the use of antidepressants and mood stabilising agents during pregnancy is hampered by a lack of results from randomised controlled trials.SSRIs and TCAs have not been associated with an increased risk of major malformations, but poor neonatal adaptation has been described. Benzodiazepines used in the first trimester have been associated with orofacial clefts. Mood stabilisers such as lithium, carbamazepine and valproic acid (sodium valproate) are associated with an increased risk of fetal malformations. Both benzodiazepines and lithium may cause adaptation problems in the newborn. In utero exposure to novel antipsychotics has not been associated with congenital malformations; however, the data are still limited. The knowledge about long-term neurobehavioural effects in the offspring is still limited for all agents and requires further investigation. Possible adverse effects of fetal exposure must be balanced against the adverse effects of an untreated maternal mood disorder.

Depressive Symptoms in Adolescents Living in Rural America

PURPOSE

The purposes of this pilot study were to examine prevalence of depressive symptoms among rural adolescents and identify related social and environmental variables.

METHODS

A convenience sample of 299 14- to 18-year-old agriculture class students at 5 rural high schools in Kentucky and Iowa completed a survey that included demographic information, family farm history, experience with suicide, perception of school environment, and indicators of farm injuries and risky behaviors. Participants also completed the Center for Epidemiologic Studies Depression Scale (CES-D) as well as scales to assess the number of major life events in the last year, active coping use, and family closeness.

FINDINGS

The prevalence of a high level of depressive symptoms (CES-D > or = 16) in this sample was 34%. Nine percent had seriously considered suicide in the last year. Unlike previous reports, boys reported as many depressive symptoms as girls. Although the literature reports that engaging in risky behavior is associated with depressive symptoms, the only risky behavior linked with depressive symptoms in this sample was operating a 4-wheel all-terrain vehicle. Other predictors of depressive symptoms included poor family relationships and poor active coping.

CONCLUSIONS

Interventions to identify and prevent depressive symptoms in rural adolescents are needed. Boosting active coping and improving family function may also prevent the development of clinical depression in rural adolescents.

The association between pregnancy processes, preterm delivery, low birth weight, and postpartum depressions--the need for interdisciplinary integration

Pregnancy and peripartum/perinatal periods are characterized by significant biologic as well as psychosocial processes and changes that influence the 2 individuals at focus (mother and fetus), as well as their interactions with the immediate environment. Multiple intertwined pathologic pregnancy processes (hormonal, biologic, stress and other mental occurrences) may lead to fetal distress, preterm delivery (PTD), low birth weight (LBW), and other delivery complications as well as to postpartum disorders. PTD and LBW in particular have been demonstrated to be associated with significant mortality as well as short- and long-term morbidity. Underlying processes and risk factors for PTD, LBW and postpartum disorders may overlap. Their impact on the offspring is compounded. Currently, the multiple clinical and research disciplines that are concerned with the various aspects of pregnancy, delivery, and postpartum period are not conceptually and practically integrated. Specifically, obstetricians are more concerned with delivery complications, whereas mental health professionals are concerned with postpartum depression. An interdisciplinary approach is needed for better understanding of developmental processes and the development of measurements and interventions to prevent long-term impact on the offspring.

The health of immigrants and refugees in Canada

Canada admits between more than 200,000 immigrants every year. National policy emphasizes rigorous selection to ensure that Canada admits healthy immigrants. However, remarkably little policy is directed to ensuring that they stay healthy. This neglect is wrong-headed: keeping new settlers healthy is just, humane, and consistent with national self-interest. By identifying personal vulnerabilities, salient resettlement stressors that act alone or interact with predisposition in order to create health risk, and the personal and social resources that reduce risk and promote well-being, health research can enlighten policy and practice. However, the paradigms that have dominated immigrant health research over the past 100 years--the "sick" and "healthy immigrant," respectively--have been inadequate. Part of the problem is that socio-political controversy has influenced the questions asked about immigrant health, and the manner of their investigation. Beginning with a review of studies that point out the shortcomings of the sick immigrant and healthy immigrant paradigms, this article argues that an interaction model that takes into account both predisposition and socio-environmental factors, provides the best explanatory framework for extant findings, and the best guide for future research. Finally, the article argues that forging stronger links between research, policy and the delivery of services will not only help make resettlement a more humane process, it will help ensure that Canada benefits from the human capital that its newest settlers bring with them.

Stress in african american pregnancies: testing the roles of various stress concepts in prediction of birth outcomes

BACKGROUND

The persistently higher rates of adverse birth outcomes among African American women are a major public health concern.

PURPOSE

The purpose of this study was to explore the relations among psychosocial stress, socioeconomic status, and birth outcomes in African American women.

METHODS

A prospective survey research design was used to measure stress exposure, subjective responses to stressors, including intrusive effects of life events, and medical and sociodemographic variables in a sample of 178 pregnant African American women. Birth outcomes were obtained from medical charts.

RESULTS

Life event exposure was high, but levels of perceived stress and negative emotional responses were low to moderate. Lower income African American women reported significantly greater pregnancy undesirability than higher income African American women. Educational attainment was not related to any of the stress variables, and neither income nor educational attainment was significantly related to birth outcomes. Number of stressful life events significantly predicted 3% additional variance in gestational age after controlling for potential confounders. Psychosocial stress variables altogether accounted for 7% additional variance in gestational age-adjusted birth weight, with event distress and intrusive thoughts concerning severe life events emerging as the significant independent stress predictors.

CONCLUSIONS

These results contribute to our understanding of the complex etiological processes involved in African American birth outcomes and set the stage for further research into their reproductive health status.

The interrelationship of maternal stress, endocrine factors and inflammation on gestational length

Preterm birth rates continue to rise in the United States despite the advent of tocolytic agents and the identification of risk factors for preterm birth, such as vaginal infection and a shortened cervix. Although improvement in gestational-age-related survival of preterm infants has occurred as a result of the use of antenatal corticosteroids, neonatal surfactant therapy, and regionalization of perinatal care, there has been no reduction in the incidence of preterm birth. Recently, investigators have appreciated that the etiology of preterm birth is heterogeneous, perhaps accounting for one reason for the failure of current interventions to improve pregnancy outcome. Both abnormal maternal hormonal homeostasis and intrauterine inflammatory responses appear to contribute to a significant proportion of the cases of preterm birth, and the interaction of the maternal endocrine and immunologic systems may contribute to the pathophysiology of this condition. An important modulator of endocrine and immune function is perceived emotional and social stress. Maternal stress has been strongly associated with preterm birth, but the links between maternal stress and resultant aberrations of maternal endocrine and immune function remain difficult to quantify and investigate. However, new insights into the role of perceived maternal stress on gestational length suggest that specific interventions to alleviate stress could contribute to an increase in gestational length and a decrease in the risk for preterm birth. This review addresses the role of maternal stress on the regulation of maternal hormone and inflammatory responses and how aberrations in these systems may lead to preterm birth.

Obstetric complications and anxiety during pregnancy: is there a relationship?

This review examines the contribution of recent research into the effects of anxiety during pregnancy. The focus of interest is upon the process of labor and delivery rather than its timing or the size of the baby. Therefore studies directed at areas of prematurity or low birthweight are specifically excluded as these have already been well evaluated in the literature. It is known that one proximal cause of obstetric complications is increased hormone levels in the uterus. It seems likely therefore that anxiety, a form of arousal, known to influence hormone levels, may be implicated as a distal determinant of obstetric complications. Attempts to evaluate this hypothesis have been hampered by methodological issues such as: poor definition and measurement of obstetric outcomes, in particular utilizing composite measures of diverse components; inappropriate measurements or over broad conceptualizations of anxiety; failure to account for confounding variables and inadequate sample sizes. On balance the evidence reviewed suggests that a general association between anxiety and obstetric complications per se does not exist, but specific types of anxiety, such as psychosocial stress, family functioning, or fear of childbirth may have associations with specific complications, such as prolonged labor or Cesarean section. Recent studies considering the effect of fear of childbirth, for example, on specific obstetric outcomes, such as type of delivery, have produced more clear-cut relationships. Recommendations for future research into the relationships between specific combinations of types of anxiety and individual obstetric complications are discussed.

Negative consequences of acculturation on health behaviour, social support and stress among pregnant Southeast Asian immigrant women in Montreal: an exploratory study

It is frequently assumed that migrant status constitutes a health risk because migration is inevitably associated with a period of significant adjustment and stress. This paper describes the role of acculturation in understanding the relationship between migration and low birthweight (LBW). Psychosocial and behavioural risk factors for LBW were explored using semi-structured interviews with 17 pregnant Southeast Asian women who represented different levels of acculturation. Findings suggested that acculturation had negative consequences for immigrant women. Higher levels of acculturation were associated with dieting during pregnancy, inadequate social support and stressful life experiences.

Does smoking by pregnant women influence IQ, birth weight, and developmental disabilities in their infants? A methodological review and multivariate analysis

Neuropsychologists are asked frequently to address the issue of the cause of a variety of central nervous system problems that may affect higher cortical function. One such issue is the relationship of maternal smoking to adverse reproductive outcomes involving neocortical insult including mental retardation, learning disabilities, attention-deficit hyperactivity disorder, and other insults that may be related to prolonged hypoxic states in utero. The instant paper develops the issue of causation as a scientific inquiry, reviews several traditional, applicable models, and critiques these models. An additional model of motility is proposed and discussed. The issue of the relationship of maternal smoking to adverse reproductive outcomes is then addressed from a review perspective along with new empirical analyses, the latter demonstrating that researchers tend to draw causal conclusions independent of whether the respective design of their studies would support conclusions about the causation of an event. Causal conclusions in the absence of causal designs have often lead to incomplete and incorrect conclusions. It is necessary to match conclusions not only to the outcomes of a research project but also to its design and accompanying limitations.

The relationship of maternal personality characteristics to birth outcomes and infant development

BACKGROUND

Previous studies reported an association between maternal psychological factors and adverse pregnancy outcomes. The objective of this study was to evaluate the relationships between maternal personality characteristics, as determined by the Minnesota Multiphasic Personality Inventory (MMPI), and infant birth outcomes and development.

METHOD

The inventory was administered during pregnancy to 638 pregnant women enrolled in a staff model health maintenance organization. MMPI validity as well as clinical and research scales were evaluated in relationship to infant birth outcomes (low birthweight, preterm birth) and 15-month-old infant development as assessed by the Bayley Scales of Infant Development.

RESULTS

Mothers of low birthweight infants scored significantly lower on the hypochondriasis scale, a relationship which was no longer significant after controlling for ethnicity. No other relationships were observed between infant birth outcomes and maternal MMPI scale scores. A higher infant Mental Developmental Index (MDI) was related to higher maternal masculinity-femininity and ego-strength scale scores and lower lie and hypochondriasis scale scores. Only the relationship between infant MDI and maternal masculinity-femininity scale score remained significant after controlling for ethnicity and socioeconomic index (beta = 0.104, p = 0.036).

CONCLUSIONS

Maternal personality characteristics, as determined by the MMPI, did not appear to be significantly related to the occurrence of preterm birth or low birthweight in this healthy, general population. Maternal personality characteristics reflected in the MMPI masculinity-femininity scale appeared to be related to infant mental development, above and beyond the effects of socioeconomic status and ethnicity.

Psychosocial predictors of low birthweight: a prospective study

OBJECTIVE

To examine the role of psychosocial risk factors for low birthweight.

DESIGN

A prospective study.

SETTING

Obstetric outpatient clinics of the University Hospital Vrije Universiteit, Amsterdam.

PARTICIPANTS

Three hundred and ninety-six nulliparous women.

METHODS

Questionnaires on background variables, daily stressors, psychological and mental wellbeing, social support and work factors were completed by the women in the first, second and third trimester of pregnancy. Low birthweight for gestational age was defined at different cut off points: 1. < or = 10th customised birthweight centile (n = 69); 2. < or = 5th customised birthweight centile (n = 54); 3. < 3rd customised birthweight centile (n = 35); and 4. < or = the 10th Dutch birthweight centile (n = 40). Multivariate logistic regression was applied and the results were expressed in odds ratios and their 95% confidence intervals.

RESULTS

When the cut off level was defined < or = 5th and < 3rd customised centile, the number of daily stressors in the first trimester was a statistically significant risk factor (OR 1.04, 95% CI 1.01-1.07 and OR 1.04, 95% CI 1.01-1.08). No significant psychosocial risk factors could be identified when low birthweight for gestational age was defined < or = the 10th customised birthweight centile. When low birthweight for gestational age was defined < or = the 10th Dutch birthweight centile, number of hours housekeeping per week in the first trimester (OR 1.59, 95% CI 1.03-2.46), low subjective severity rating of daily stressors in the first trimester (OR 0.41, 95% CI 0.17-0.97) and depressive mood in the first trimester (OR 1.12, 95% CI 1.01-1.24) were statistically significant psychosocial risk factors after controlling for maternal weight and height, number of cigarettes smoked per day and educational level.

CONCLUSIONS

In the first trimester of pregnancy maternal psychosocial factors are associated with an increased risk of low birthweight. The specific psychosocial risk factors found were different when the definition of low birthweight was changed. Therefore, in this field of research, we suggest use of the most valid outcome measure for low birthweight, being the customised birthweight centiles.

The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes

OBJECTIVES

The objectives were: (1) to investigate the association during pregnancy of sexual abuse before the age of 18 on depressive symptomatology in pregnancy, controlling for the presence of negative life events and challenges; and (2) to investigate the association of selected pregnancy outcomes (maternal labor and delivery factors, infant birth weight and gestational age) with sexual abuse before age 18.

METHODS

Three hundred fifty-seven primiparous women aged 18 years and older were interviewed between 28-32 weeks gestation with reference to current functioning and past history (Objective 1). Medical record information was abstracted after delivery for pregnancy, labor and delivery factors, and pregnancy outcomes (Objective 2).

RESULTS

Thirty-seven percent of the women reported past sexual abuse. Prevalence was not associated with ethnic background, educational level, or hospital payment source. Previously sexually-abused pregnant women reported significantly higher levels of depressive symptomatology, negative life events, and physical and verbal abuse before and during pregnancy. There were no significant associations found between past sexual abuse and labor or delivery variables or newborn outcomes.

CONCLUSIONS

Previously sexually-abused pregnant women reported a wider constellation of past and current functioning problems than nonabused women although past sexual abuse was not associated with pregnancy outcome. Prenatal care provides a unique opportunity to evaluate the impact of life history and current life events during pregnancy, and to develop a coordinated intervention plan.

Potential for abusive parenting by rural mothers with low-birth-weight children

PURPOSE

To describe factors influencing the potential for abusive parenting by rural mothers of low-birth-weight children (< 2,500 gm). Low-birth-weight (LBW) children are at risk for child abuse. However, little is known about the added risks created for these children by rural residency.

DESIGN

Data for this descriptive and exploratory study were collected using a cross-sectional design. A convenience sample of 48 rural mothers delivering LBW children participated in 1994.

METHODS

In-home interviews were conducted using structured questionnaires to assess mothers' everyday stressors, depressive symptoms, social resources, and child abuse potential.

FINDINGS

The prevalence of high depressive symptoms among the mothers was 54%. Higher everyday stressors and less functional social support predicted greater depressive symptoms. Everyday stressors had a direct effect on the mothers' potential for child abuse and an indirect effect via maternal depressive symptoms.

CONCLUSIONS

Rural mothers of LBW children are at risk for abusive parenting. Health care providers should pay particular attention to the mental health of mothers living in rural, isolated areas. Assistance with mobilization of community resources, including social support and child care, may provide needed help for these mothers to improve parenting and thus child health outcomes.

The measurement of stress in pregnancy

Stress is thought to be one of the biopsychosocial factors that contribute to adverse pregnancy outcomes, such as preterm labor and low birthweight. Identification of these factors (as in total number), and measurement of their individually perceived importance (severity) could lead to opportunities for intervention, and improved pregnancy outcome. A pilot study of the Daily Hassles Scale, was conducted in order to determine the appropriateness of its use among pregnant women. Daily hassles were thought to be a valid proxy for prenatal stress. Content and construct validity were determined among a sample of four content experts and 30 pregnant women. The Daily Hassles Scale proved to be a reliable (internally consistent) measure of stress (alpha reliability coefficient of 0.90). Further adaptation of the scale to include hassles specific to pregnancy and further testing of its usefulness among diverse multicultural and ethnic populations is warranted.

Mothers' potential for child abuse: the roles of childhood abuse and social resources

BACKGROUND

The mechanism by which some victims of childhood abuse become abusive parents, whereas others do not, is not well understood. Previous empirical evidence indicates that social resources may modify the cycle of abuse or maladaptive parenting; however, the effects of different dimensions of social resources have not been compared.

OBJECTIVES

To determine whether a measure of mothers' potential for physical child abuse was related to their retrospective reports of physical and sexual abuse before 18 years of age and to investigate the potential buffering effects of multiple dimensions of social resources on the relationship between childhood abuse and mothers' potential for physical child abuse.

METHODS

The potential role of social resources as a moderator of the relationship between a history of childhood abuse and potential for physical child abuse was investigated in 206 low-income single mothers of young children.

RESULTS

The levels of physical and sexual abuse in childhood were positively associated with the mothers' child abuse potential; sexual abuse displayed the strongest association. Compared with mothers who were not sexually abused in childhood, those reporting violent sexual abuse as children were almost six times more likely to have high potential for physically abusing their children. There was no evidence that any of the social resources modified the relationship of either type of childhood abuse with the mothers' potential for abuse. However, all four dimensions of social resources demonstrated significant main effects on child abuse potential.

CONCLUSIONS

Low-income mothers face many stressors because of their lack of economic resources. This, coupled with a lack of social resources and a history of childhood abuse, makes low-income, single mothers particularly at risk for abusive parenting. The lives of these women and their children may be enhanced by assisting the women to improve their social resources which, ultimately, may reduce their potential for child abuse. Future research should focus on identifying factors that predict and/or modify the potential for abusive parenting as well as actual abuse.

Detroit's East Side Village Health Worker Partnership: community-based lay health advisor intervention in an urban area

In recent years, there have been few reports in the literature of interventions using a lay health advisor approach in an urban area. Consequently, little is known about how implementation of this type of community health worker model, which has been used extensively in rural areas, may differ in an urban area. This article describes the implementation of the East Side Village Health Worker Partnership, a lay health advisor intervention, in Detroit, Michigan, and notes how participatory action research methods and principles for community-based partnership research are being used to guide the intervention. Findings are presented on how the urban context is affecting the design and implementation of this intervention. Implications of the findings for health educators are also presented and include the utility of a participatory action research approach, the importance of considering the context and history of a community in designing a health education intervention, and the importance of recognizing and considering the differences between rural and urban settings when designing a health education intervention.

Drug prevention with high risk families and young children

The effects of a school and home-based drug prevention program on risk factors for subsequent alcohol, tobacco, and other drug (ATOD) use among children were studied. Data on parent and child risk factors for ATOD use were collected from fifty-six low-income parents and their children, ages four to six years, using a pretest-posttest design. The parent-child intervention was conducted over a two-month period. The intervention had no effect on parent or child risk factors. However, the program was favorably received by parents and children. Almost two-thirds of the parents at the experimental school were involved in the program. Almost half of the parents had high depressive symptoms. The high rates of ATOD use and depressive symptoms among these parents are cause for concern.

The retirement transition and the later life family unit

The purpose of this investigation was to determine to what extent family worldview and problem-solving communication style influence individual and family unit adaptation during retirement. A cross-sectional correlational survey design utilized Pearson correlations and stepwise multiple regressions. The sample consisted of 368 individuals representing 184 later life family units. Operationalized as family unit data, family worldview and family problem-solving communication style were examined in two series: (1) with outcome variable of family unit adaptation and (2) with outcome variable of individual adaptation. Scoring of family unit data was conceptually, procedurally, and analytically congruent. The investigation extended McCubbins' work into the later life family unit giving empirical support for two propositions of the Resiliency Model (M.A. McCubbin & H.I. McCubbin, 1993). This investigation also extended A. Antonovsky's (1987) work as the second study to apply the Antonovsky Sense of Coherence Scale to a family measurement. Conclusions are that although the way the family views the world is important during retirement, being affirmed by family members is more important. The investigation highlights the importance of a positive problem-solving communication style for a positive level of family adaptation. Individual adaptation during retirement was more influenced by family worldview.

Stressful events among pregnant Salvadoran women: a cross-cultural comparison

OBJECTIVE

To compare stressful events, including violent episodes, experienced by pregnant Salvadoran women with those experienced by two other groups of low-income, pregnant women living in the United States (non-Salvadoran Hispanics and non-Hispanics) and to examine the association between episodes of violence and drug or alcohol use among the three groups.

DESIGN

Comparative, descriptive study.

SETTING

Public health prenatal clinics.

PARTICIPANTS

One hundred four Salvadoran, 69 non-Salvadoran Hispanic, and 187 non-Hispanic pregnant women.

MAIN OUTCOME MEASURES

Difficult Life Circumstances (DLC) scale and psychosocial history assessment.

RESULTS

Statistically significant differences were found among the three groups in total DLC scores, F(2, 357) = 14.98, p < .001; reported episodes of violence, F(2, 357 = 17.82, p < .001; and drug or alcohol use, F(2, 357) = 6.33, p < .001. A significant difference was found to the extent that alcohol or drug use accounted for the variance in violence among the three groups, F(3, 360) = 6.28, p < .001.

CONCLUSIONS

Cross-cultural comparisons revealed group differences in the number of stressful events, including episodes of violence and alcohol or drug use.

Prenatal biopsychosocial risk assessment and low birthweight

A double-blind prospective study was conducted to compare the predictive value of a prenatal biomedical risk scale (PBRS) and a prenatal biopsychosocial risk assessment (PBRAS) with respect to low birthweight. All obstetric patients at seven health centers located in Argentina, Colombia, Honduras, and Uruguay from November 1992 through January 1994 whose initial prenatal visits occurred between the 14th and 28th week of gestation were invited to participate. Information was obtained on 979 mother-infant pairs. High PBRS scores showed sensitivity of 62.1% and specificity of 81.3%, positive predictive value (PPV) of 45.3% and negative predictive value (NPV) of 89.5%, with respect to low birthweight. With the addition of the psychosocial factors (PBRAS), sensitivity of 75.7% and specificity of 76.1%, PPV of 55.1% and NPV of 88.9% were observed. The prospective cohort design of this study provides a strong basis for conclusion that an evaluation of the prenatal biopsychosocial risk (as operationalized by the PBRAS) adjusted for other variables such as length of gestation, neonatal APGAR, perinatal mortality, socioeconomic status, drinking and smoking improves the positive predictive value of the assessment of women who may give birth to newborns with low birthweight (P < 0.01).

Stress, social support and pregnancy outcome: a reassessment based on recent research

We present an assessment of studies published in the last decade that consider the relationship of stress and social support to preterm delivery or fetal growth retardation. Included in the review are all reports on the direct effects of stressors or psychological distress; the indirect effects of stressors or distress through health behaviours such as smoking; and the direct and buffering effects of social support. Although an important stimulus for recent stress research has been the attempt to explain racial and social class differences in birth outcome, the recent data show that stressful life events during pregnancy, though more common in disadvantaged groups, do not increase the risk of preterm birth. In contrast, intimate social support from a partner or family member appears to improve fetal growth, even for women with little life stress. Questions unanswered by the research to date are whether elevated levels of depressive symptoms affect pregnancy outcome, either directly or by encouraging negative health behaviours, and whether chronic (vs. acute) stressors are harmful. Additional research is also needed to determine whether psychosocial factors interact with specific clinical conditions to promote adverse pregnancy outcomes. Focusing on intimate support and how it benefits pregnancy outcome could lead to the design of more effective interventions.

Low birthweight in a public prenatal care program: behavioral and psychosocial risk factors and psychosocial intervention

A retrospective, observational study of 3073 low income African American, Latina, and White women receiving comprehensive prenatal care at 26 provider sites was completed. The purpose of the study was to test three hypotheses. First, after adjustment for biomedical complications, the presence of maternal behavioral and psychosocial factors would be associated with an increased rate of low birthweight infants. Second, increased time spent in psychosocial services would negate the relationship between maternal psychosocial factors and low birthweight. Third, after adjusting for biomedical, behavioral, and psychosocial factors, rates of low birthweight would no longer differ by race. Maternal smoking (over five cigarettes per week), maternal low weight for height and/or weight gain, negative mood (depression, anxiety, and/or hostility) and rejection of the pregnancy were found to be related to an increased rate of low birthweight birth (< 2500 g). Receiving more than 45 min of psychosocial services was related to a reduced rate of low birthweight birth for all women regardless of risk profile. The rate of low birthweight remained higher in African American women after adjusting for all significant maternal biomedical, behavioral, and psychosocial risk and intervention factors. Further analyses revealed that the strength and direction of the relationship between time spent in psychosocial services and low birthweight remained after controlling for the number of prenatal care visits, the time spent in nutrition or health educational services, and gestational age. Also, the time spent in psychosocial services was related to a reduced rate of low birthweight even after excluding time spent in psychosocial services in the third trimester of pregnancy or excluding women who received their first psychosocial assessment in the third trimester from the analysis. Although definitive evidence from randomized trials of psychosocial services is lacking, receiving over 45 min of psychosocial services was related to a reduced risk of low birthweight for all women in this study. Therefore, general psychosocial services appears to be an important component of prenatal care for all low income women.

Psychosocial factors and pregnancy outcome: a review with emphasis on methodological issues

This review focuses on the research concerning the relation between psychosocial factors and pregnancy outcome. The following four outcome measures are dealt with: (1) birth weight, (2) preeclampsia, (3) preterm labour, and (4) intrapartum complications. The most consistent finding concerns the association between maternal exposure to taxing situations and preterm delivery. Three possible pathways are hypothesized: (1) an indirect influence via unhealthy coping and life style behaviour, (2) a direct influence via stress-dependent hormones, and (3) an additional direct influence via psycho-immunological factors. Intervention studies aimed at improving pregnancy outcome show fairly mixed results. It is recommended that studies on the relationship between psychosocial factors and pregnancy outcome should employ a prospective design with due attention to chronic stressors, should include appropriate biochemical assessments, and multivariate techniques are applied.

Relationship of anxiety, stress, and psychosocial development to reproductive health

In this review of articles on prenatal stress, anxiety, development, and reproductive health outcomes in pregnancy, the focus is on recent research in which the relationships among the major types of stressors, anxiety, and development, on the one hand, and maternal, fetal, and neonatal problems or complications, on the other hand, were examined. Available and effective treatment measures, although limited, are introduced and discussed at length in a follow-up article. Recommendations for policy development based on current research and treatment methods and directions for future research and treatment studies are presented in a third article.

Treatment strategies for anxiety, stress, and developmental conflict during reproduction

In the preceding article, I reviewed the literature and analyzed psychophysiological and psychosocial foundations of reproductive health outcomes. In this article, I focus on treatment strategies and considerations for policy formation pertaining to the care of women, children, and families during reproduction. I discuss (a) cognitive and behavioral strategies for decreasing anxiety and promoting relaxation during gestation and parturition; (b) educational and other activities to prepare women for the childbirth event and alternatives to current practice; (c) methods of providing support and enhancing the mother's capacity for coping with events occurring during labor and delivery; and (d) current national and international programs and pilot projects that have effectively promoted health and adaptation to pregnancy and have reduced the occurrence of reproductive complications.

Conceptualizations, measurement, and effects of prenatal maternal stress on birth outcomes

This article analyzes the conceptual and methodological approaches which have been used to investigate effects of prenatal maternal stress on birth outcomes and highlights the major findings of this research. By viewing the most widely used operational definitions of prenatal stress in a broader theoretical framework, it can be seen that most studies have failed to conceptualize stress reliably. This, in addition to common methodological and design flaws which are described in the article, has produced equivocal findings about the role of stress in adverse birth outcomes such as preterm delivery and low birth weight. Recent studies using more powerful, multidimensional approaches to stress definition and measurement provide more definitive evidence and suggest some precise effects. Implications and strategies for future research are presented.

Validity and reliability testing of the Prenatal Psychosocial Profile

Two studies of low-income pregnant women (N = 179) were done to examine the validity and reliability of the Prenatal Psychosocial Profile (PPP). The PPP, a composite of the Rosenberg Self-Esteem Scale, the Support Behaviors Inventory, and a newly developed measure of stress, is a brief, comprehensive clinical assessment of psychosocial risk during pregnancy. Construct validity of the stress scale was supported by theoretically predicted negative correlations with self-esteem, partner support, and support from others (N = 91). Convergent validity of the stress scale was demonstrated by a correlation of .71 with the Difficult Life Circumstances Scale. Adequate levels of internal consistency were found. Interrelationships between the four subscales were consistent with the underlying conceptualization, and there was beginning evidence of the factorial independence of the subscales.

The Latin American trial of psychosocial support during pregnancy: a social intervention evaluated through an experimental design

Perinatal health problems are a public health priority in Latin America. Among the identified risk factors, psychological and social conditions play a crucial role. However, care during pregnancy and delivery in the region is usually hospital-centered and does not address women's psychological and social conditions. The preeminence of research on perinatal health, along with the necessity for testing interventions that represent alternative models to improve women's health, gave the Latin American Network for Perinatal and Reproductive Research grounds to develop a multicenter randomized controlled trial to evaluate a program of social support and health education during pregnancy. The conceptual framework for this study was based on an ecological model of social support, i.e. a model in which social support and health education play a synergistic role and are meant to modify stressful situations and negative health-related behaviors. The target population consisted of women attending obstetric hospitals before the 22nd gestational week, at high psychological and social risk (n = 2236). The intervention consisted of four to six home visits, carried out by social workers, and had four main components: the reinforcement of pregnant women's social support network, emotional support, health education, and the improvement of health services utilization. The main foci of the intervention were determined after an ethnographic study was carried out to identify stress-producing situations and needs for support during pregnancy. Besides the home visits, the program also offered a hot-line, an office in the hospital, a specially designed poster and booklet, and a 'guided tour' of the health institution. Since this was a multicenter trial, the program's standardization was a crucial methodological aspect that was achieved through the training course for the home-visitors team. Biological and psychosocial outcomes were measured in both experimental and control groups at the 36th week of gestational age, post-partum and at the 40th day after delivery. The attributes of the multicenter population showed an important variability, reflecting differences in the countries or hospitals' population prevalent attributes. The results of the program's implementation were analyzed, demonstrating that home visitors adapted topics discussed during the interviews to the women's conditions and the stage of pregnancy during which the visit took place.(ABSTRACT TRUNCATED AT 400 WORDS)

Marital status and infant health outcomes

Out-of-wedlock status has long been recognized as a demographic risk factor associated with infant mortality and low birthweight. However, the relationship between marital status and birth outcomes varies by maternal race and age. The negative impact of unmarried status is greatest for white women aged 20 and over. High infant mortality rates for married teen mothers challenge the assumption that marriage necessarily provides a protective environment for childbearing. Maternal and child health research and policy have been hindered by a deviance model of out-of-wedlock fertility, which is both biased and outdated. Inconsistencies in the effect of marital status indicate variations in both economic and social resources. Purely behavioral explanations for escalated risks to unmarried mothers are not justified by research findings. Alternative interpretations suggest the need for greater societal involvement in maternal health care created in part by changes in family structure.

Life events and low birthweight--analysis by infants preterm and small for gestational age

Social stress was assessed in 92 women with low-birthweight babies and 92 controls using the detailed LEDS measure of life events and severe chronic difficulties. The low-birthweight group was divided into preterm delivery (n = 40), small for gestational age (SGA) (n = 40) and mixed groups. Multivariate analysis was performed using a binomial-logit model to examine whether social factors were independently and significantly associated with low birthweight once the effect of demographic factors, obstetric factors and smoking/drinking were taken into account. Comparison of preterm births with controls indicated that three factors were significantly associated: a previous low-birthweight baby, severe life event/difficulty and bleeding during pregnancy. For SGA babies the factors were: previous low-birthweight baby, low social support and smoking. By using a reliable measure of life events and adequate numbers of low-birthweight babies, this study overcame the potential inaccuracies of previous studies and indicates a more specific relation between social stress and low birthweight.