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

The effect of antenatal depression on birth weight among newborns in South Gondar zone, Northwest Ethiopia: a population-based prospective cohort study

BACKGROUND

There is a high prevalence of antenatal depression and low birth weight (LBW) (< 2.5 kg) in Ethiopia. Prior evidence revealed that the association between antenatal depression and LBW in high- and low-income countries is conflicting. The effect of antenatal depression on birth weight is under-researched in Ethiopia. We aimed to examine the independent effect of antenatal depression on newborn birth weight in an urban community in Northwest Ethiopia.

METHODS

A total of 970 pregnant women were screened for antenatal depression in their second and third trimester of pregnancy through the use of the Edinburgh Postnatal Depression Scale (EPDS). A logistic regression model was used to adjust confounders and determine associations between antenatal depression and low birth weight. Information was collected on the birth weight of newborns and mother's socio-demographic, anthropometric, obstetric, clinical, psychosocial, and behavioral factors.

RESULTS

The cumulative incidence of LBW was found to be 27.76%. The cumulative incidence of LBW in those born from depressed pregnant women was 40% as compared to 21% in none depressed. While considering all other variables constant, mothers who had antenatal depression were 2.51 (COR = 2.51 (95 CI: 1.87, 3.37)) more likely to have a child with low birth weight. After adjusting for potential confounders, antenatal depression in the second and third trimester of pregnancy (AOR = 1.92 (95% CI: 1.31, 2.81)) remained significantly associated with LBW. Mid-Upper Arm Circumference (MUAC) ≤21, lack of ANC follow up, and preterm births were also associated with LBW.

CONCLUSION

This study showed that antenatal depression during the second and third trimester of pregnancy is associated with LBW of newborns and replicates results found in high-income countries. Linking early screening, detection, and treatment of antenatal depression into routine antenatal care could be essential to improve pregnancy outcomes.

Financial strain and birth weight: the mediating role of psychological distress

The effects of financial strain during pregnancy have received limited attention. In addition, data examining the pathways by which SES indicators contribute to birth weight are lacking. The objective of the current study was to examine the potential pathway of psychological distress in the relationship between financial strain and birth weight. Participants consisted of 138 pregnant women who completed measures assessing financial strain, depressive symptoms, pregnancy-specific distress, perceived stress, and general anxiety during pregnancy (mean gestational age = 18.5, SD = 7.2). Birth outcome data were obtained via medical record review. Simple and parallel mediation models were conducted using PROCESS. Simple mediation models showed that depressive symptoms (95% CI -24.65, -0.90) and pregnancy-specific distress (95% CI -37.31, -5.91), but not perceived stress (95% CI -31.17, 4.69) or anxiety (95% CI -25.84, 5.57), served as mediators in the relationship between financial strain and birth weight. When depressive symptoms and pregnancy-specific distress were included in the same mediation model, only pregnancy-specific distress remained significant. Financial strain was positively associated with all facets of psychological distress and negatively associated with birth weight during pregnancy. The current study demonstrated the mechanistic role of pregnancy-specific distress in the link between financial strain and birth weight in a racially diverse sample. Interventions targeting pregnancy-specific distress may mitigate the effects of financial strain on birth weight. Studies examining whether pregnancy-specific distress accounts for the relationship between other types of stressor exposures and birth weight would be informative.

Depressive Symptoms Prior to Pregnancy and Infant Low Birth Weight in South Africa

Despite improvements in service delivery and patient management, low birth weight among infants has been a persistent challenge in South Africa. The study aimed to explore the relationship between depression before pregnancy and the low birth weight (LBW) of infants in post-apartheid South Africa. This study utilized data from Waves 1 and 2 of the South African National Income Dynamics Study, the main outcome being a dichotomous measure of child LBW (<2500 g) drawn from the Wave 2 child questionnaire. Depressive symptoms of non-pregnant women was the main predictor drawn from the Wave 1 adult questionnaire. Depressive symptoms were screened using the 10-item four-point Likert version of the Center for Epidemiologic Studies Depression Scale (CES-D) instrument. A total score of 10 or greater on the CES-D indicates a positive screen for depressive symptoms. An adjusted logistic regression model was used to examine the relationship between women's depression before pregnancy and infant LBW. A sample size of 651 women in Wave 1 was linked to 672 newborns in Wave 2. The results of the adjusted logistic regression model indicated depressive symptoms (CES-D ≥ 10) prior to pregnancy were associated with infant LBW (adjusted OR 2.84, 95 % CI 1.08-7.46). Another significant covariate in the model was multiple childbirths. Our finding indicates that women's depressive symptoms prior to pregnancy are associated with the low birth weight of newborns and suggests that this association may not be limited to depression present during the ante-natal phase.

Prenatal depression and adverse birth outcomes: an updated systematic review

Complications related to preterm birth (PTB) and low birth weight (LBW) are leading causes of infant morbidity and mortality. Prenatal depression is a hypothesized psychosocial risk factor for both birth outcomes. The purpose of this systematic review was to examine evidence published between 1977 and 2013 on prenatal depression and risks of these primary adverse birth outcomes. A systematic search of the PUBMED and PsycINFO databases was conducted to identify studies testing the associations between prenatal depressive symptoms, or diagnoses of depression, and risk of PTB or LBW. We systematically selected 50 published reports on PTB and length of gestation, and 33 reports on LBW and BW. Results were reviewed by two independent reviewers and we evaluated the quality of the evidence with an established systematic review method, the Newcastle Ottawa Scale. We then undertook a narrative synthesis of the results following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Less than a quarter of 50 published reports found that prenatal depression was significantly associated with PTB or gestational age. In contrast, slightly more than half of the 33 reports found that prenatal depression was associated with LBW or BW. When weighing methodological features, we determined that the effects of prenatal depression on LBW are more consistent than effects on length of gestation or PTB. Although the evidence may not be strong enough to support routine depression screening for risk of adverse outcomes, screening to enable detection and timely treatment to reduce risk of postpartum depression is warranted. Further rigorous research on prenatal depression and adverse birth outcomes is needed.

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.

Prenatal maternal depression is associated with low birth weight through shorter gestational age in term infants in Korea

BACKGROUND

Maternal prenatal depression is associated with lower offspring birth weight, yet the impact of gestational age on this association remains inadequately understood.

AIMS

We aimed to investigate the effect of prenatal depression on low birth weight, gestational age, and weight for gestational age at term.

STUDY DESIGN

Prospective cohort study.

SUBJECT

Data were collected from 691 women in their third trimester of pregnancy who went on to give birth to a singleton at term without perinatal complications. One hundred and fifty-two women had a Center for Epidemiologic Studies Depression Scale-10 score ≥10 and were classed as prenatally depressed.

OUTCOME MEASURES

Low birth weight (<2500g), gestational age at birth, and birth weight percentile for gestational age.

RESULTS

Offspring of prenatally depressed women were more likely to be low birth weight (Odds ratio [OR] 2.94, 95% confidence interval [CI] 1.14-7.58) than offspring of prenatally non-depressed women, but the association was attenuated (OR 1.66, 95% CI 0.55-5.02) when adjusted for gestational age. Offspring of prenatally depressed women had lower gestational age in weeks (OR for one week increase in gestational age: 0.66, 95% CI 0.47-0.93) than offspring of prenatally non-depressed women. There was no association between prenatal depression and birth weight percentile for gestational age.

CONCLUSIONS

Prenatal depression was not associated with low birth weight at term, but was associated with gestational age, suggesting that association between maternal depression and birth weight may be a reflection of the impact of depression on offspring gestational age.

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 impact of air pollution on low birth weight and infant mortality

This article discusses the impact of environmental factors on birth outcomes during the last two decades. It reiterates the correlation between air pollutants and adverse pregnancy including low birth weight (LBW) and infant mortality. Data sets are assembled for many OECD countries consisting of yearly air pollutants emissions including sulfur dioxide, nitrogen dioxide, carbon monoxide, and volatile organic compounds. Various health data are illustrated to suggest that countries with high emission levels of air pollutants seemed to increase with LBW and infant mortality. This article reports the association of pollutants, including particles and gases, on mortality in general and infant mortality in particular. To assess air pollution impact on infant mortality, Spearman's correlation is used to summarize and interpret data. This statistical method is used to assess the relationship between air pollution and infant mortality in many OECD countries between 2000 and 2009 using a monotonic function. The results illustrate a positive correlation between air pollution and infant mortality, and in some cases, Spearman's ρ-value is >0.9 and the p-value is <0.001. This article also backs up the association between some air pollutants and LBW and proposes the importance to design novel models for monitoring, controlling, and reducing air pollutants especially within cities and ultimately improving the well-being of communities worldwide.

Income gains and very low-weight birth among low-income black mothers in California

We test the hypothesis suggested in the literature that an acute income gain in the form of the earned income tax credit reduces the odds of a very low-weight birth among low-income non-Hispanic black mothers. We apply ecological time series and supplemental individual-level logistic regression methods to monthly birth data from California between 1989 and 1997. Contrary to our hypothesis, the odds of very low-weight birth increases above its expected value two months after mothers typically receive the credit. We discuss our findings in relation to the epidemiologic literature concerned with ambient events during pregnancy and recommend further investigation.

Insomnia and depressive symptoms in late pregnancy: a population-based study

A population-based questionnaire study of 2,816 women was conducted in week 32 of pregnancy to estimate the prevalence of and risk factors for insomnia and depressive symptoms. The Bergen Insomnia Scale (BIS) measured insomnia. The Edinburgh Postnatal Depression Scale (EPDS) measured depressive symptoms. The prevalence of insomnia (DSM-IV-TR criteria) was 61.9%, and mean BIS score 17.5 (SD = 10.5), significantly higher than among the general population. The prevalence of depressive symptoms (EPDS ≥ 10) was 14.6%. Depressive symptoms were strongly associated with insomnia during late pregnancy, especially with sleep durations <5 or >10 hours, sleep efficiency <75%, daytime impairment, and long sleep onset latency. Pelvic girdle pain and lower back pain was associated with insomnia, but not with depressive symptoms.

O impacto do baixo peso ao nascer relacionado à depressão gestacional para o financiamento federal da saúde pública: uma análise do Município de Pelotas, Rio Grande do Sul, Brasil

O baixo peso ao nascer está relacionado com morbimortalidade e sequelas no desenvolvimento infantil, impactando nos custos dos sistemas de saúde, por isso é importante avaliar fatores que o influenciam, estimando seu impacto no Sistema Único de Saúde (SUS). Este é um estudo prospectivo aninhado a uma coorte de gestantes que realizaram pré-natal e parto exclusivamente pelo SUS nos hospitais com UTI da cidade de Pelotas, Rio Grande do Sul, Brasil. Entre os resultados, concluiu-se que mães com episódios de depressão gestacional apresentam quase quatro vezes mais chances de ter um filho com baixo peso ao nascer (RP = 3,94; IC: 1,49-10,36). Valendo-se do cálculo da fração atribuível na população, estima-se que, na população geral, 36,17% dos bebês com baixo peso ao nascer são filhos de mães que tiveram episódio depressivo, estimando-se um custo que pode chegar a mais de R$ 76 milhões no Brasil. Sugere-se que se ampliem as ações preventivas e curativas para as gestantes na área da saúde mental, possibilitando melhor desfecho de saúde dos recém-nascidos, e que se utilizem adequadamente os recursos do SUS.

Very preterm birth is reduced in women receiving an integrated behavioral intervention: a randomized controlled trial

This study examines whether an integrated behavioral intervention with proven efficacy in reducing psycho-behavioral risks (smoking, environmental tobacco smoke exposure (ETSE), depression, and intimate partner violence (IPV)) in African-Americans is associated with improved pregnancy outcomes. A randomized controlled trial targeting risks during pregnancy was conducted in the District of Columbia. African-American women were recruited if reporting at least one of the risks mentioned above. Randomization to intervention or usual care was site and risk specific. Sociodemographic, health risk and pregnancy outcome data were collected. Data on 819 women, and their singleton live born infants were analyzed using an intent-to-treat approach. Bivariate analyses preceded a reduced logistical model approach to elucidate the effect of the intervention on the reduction of prematurity and low birth weight. The incidence of low birthweight (LBW) was 12% and very low birthweight (VLBW) was 1.6%. Multivariate logistic regression results showed that depression was associated with LBW (OR = 1.71, 95% CI = 1.12-2.62). IPV was associated with preterm birth (PTB) and very preterm birth (VPTB) (OR 1.64, 95% CI = 1.07-2.51, OR = 2.94, 95% CI = 1.40-6.16, respectively). The occurrence of VPTB was significantly reduced in the intervention compared to the usual care group (OR = 0.42, 95% CI = 0.19-0.93). Our study confirms the significant associations between multiple psycho-behavioral risks and poor pregnancy outcomes, including LBW and PTB. Our behavioral intervention with demonstrated efficacy in addressing multiple risk factors simultaneously reduced VPTB within an urban minority population.

A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction

CONTEXT

Maternal depressive symptoms during pregnancy have been reported in some, but not all, studies to be associated with an increased risk of preterm birth (PTB), low birth weight (LBW), and intrauterine growth restriction (IUGR).

OBJECTIVE

To estimate the risk of PTB, LBW, and IUGR associated with antenatal depression.

DATA SOURCES AND STUDY SELECTION

We searched for English-language and non-English-language articles via the MEDLINE, PsycINFO, CINAHL, Social Work Abstracts, Social Services Abstracts, and Dissertation Abstracts International databases (January 1980 through December 2009). We aimed to include prospective studies reporting data on antenatal depression and at least 1 adverse birth outcome: PTB (<37 weeks' gestation), LBW (<2500 g), or IUGR (<10th percentile for gestational age). Of 862 reviewed studies, 29 US-published and non-US-published studies met the selection criteria.

DATA EXTRACTION

Information was extracted on study characteristics, antenatal depression measurement, and other biopsychosocial risk factors and was reviewed twice to minimize error.

DATA SYNTHESIS

Pooled relative risks (RRs) for the effect of antenatal depression on each birth outcome were calculated using random-effects methods. In studies of PTB, LBW, and IUGR that used a categorical depression measure, pooled effect sizes were significantly larger (pooled RR [95% confidence interval] = 1.39 [1.19-1.61], 1.49 [1.25-1.77], and 1.45 [1.05-2.02], respectively) compared with studies that used a continuous depression measure (1.03 [1.00-1.06], 1.04 [0.99-1.09], and 1.02 [1.00-1.04], respectively). The estimates of risk for categorically defined antenatal depression and PTB and LBW remained significant when the trim-and-fill procedure was used to correct for publication bias. The risk of LBW associated with antenatal depression was significantly larger in developing countries (RR = 2.05; 95% confidence interval, 1.43-2.93) compared with the United States (RR = 1.10; 95% confidence interval, 1.01-1.21) or European social democracies (RR = 1.16; 95% confidence interval, 0.92-1.47). Categorically defined antenatal depression tended to be associated with an increased risk of PTB among women of lower socioeconomic status in the United States.

CONCLUSIONS

Women with depression during pregnancy are at increased risk for PTB and LBW, although the magnitude of the effect varies as a function of depression measurement, country location, and US socioeconomic status. An important implication of these findings is that antenatal depression should be identified through universal screening and treated.

[Depression during pregnancy and low birth weight: a systematic literature review]

A systematic review was conducted, focusing on the relationship between depression during pregnancy and increased risk of low birth weight. The review covered articles published in PubMed, SciELO, and ISIWEB using the key words 'depression', 'pregnancy', 'birth weight' and 'low birth weight'. Ninety-nine studies were located, but after reading the abstracts only 10 articles were selected. According to criteria proposed by Downs & Black (1998) to assess the quality of the selected studies, only one was considered excellent, since it reached the maximum score of 20. Depression during pregnancy was associated with low birth weight in seven studies. Contradictions in the findings are due to differences in the scales used to evaluate depression, sample size, and insufficient control of important limiting factors for evaluating the results. Carefully designed studies are thus needed to elucidate the association between intra-gestational depression and low birth weight.

The association between prenatal depression and obstetric outcome in Taiwan: a prospective study

BACKGROUND AND METHODS

The present follow-up study aims to assess the association between depressive symptomatology during the second or third trimester of pregnancy and obstetric-neonatal outcomes in Taiwan. Follow-up evaluations of delivery and birth records in the immediate postpartum period were carried out on 265 nondepressed, 107 mildly to moderately depressed, and 59 severely depressed women and their newborns in three hospitals in Southern Taiwan. Prenatal depression was identified using the Edinburgh Perinatal Depression Scale (EPDS). The medical records of the participant women and their newborns were reviewed after delivery.

RESULTS

Prenatally depressed women reported significantly lower marital satisfaction than nondepressed women. Follow-up examination of the women's obstetric birth records revealed that prenatal depression had no statistically significant association with obstetric outcome (type of delivery, use of epidural anesthesia, or instrument-assisted delivery), nor did depression influence the neonatal outcome (incidence of prematurity, birth weight, and Apgar score).

CONCLUSIONS

Prenatal depression does not lead to unfavorable obstetric outcomes. However, the finding between marital satisfaction and prenatal depression may have implications in terms of social support.

Maternal symptoms of anxiety during pregnancy affect infant neuromotor development: the generation R study

Several studies found that maternal symptoms of anxiety or depression are related to functioning and development of the offspring. Within a population-based study of 2,724 children, we investigated the effect of maternal anxiety or depression on infant neuromotor development. Symptoms of anxiety and depression were measured during pregnancy and after giving birth; infant neuromotor development was assessed by trained research nurses during a home visit at the age of 3 months. The current study showed that mothers who were anxious during pregnancy had an elevated risk of having an infant with non-optimal neuromotor development.

The association of daily physical activity and birth outcome: a population-based cohort study

The potential relationship between daily physical activity and pregnancy outcome remains unclear because of the wide variation in study designs and physical activity assessment measures. We sought to prospectively quantify the potential effects of the various domains of physical activity on selected birth outcomes in a large unselected population. The sample consisted of 11,759 singleton pregnancies from the Avon longitudinal study of parents and children, United Kingdom. Information on daily physical activity was collected by postal questionnaire for self-report measures. Main outcome measures were birth weight, gestational age at delivery, preterm birth and survival. After controlling for confounders, a sedentary lifestyle and paid work during the second trimester of pregnancy were found to be associated with a lower birth weight, while ‘bending and stooping’ and ‘working night shifts’ were associated with a higher birth weight. There was no association between physical exertion and duration of gestation or survival. Repetitive boring tasks during the first trimester was weakly associated with an increased risk of preterm birth (<37 weeks) (adjusted odds ratio [OR] = 1.25, 95% CI 1.04–1.50). ‘Bending and stooping’ during the third trimester was associated with a reduced risk of preterm birth (adjusted OR = 0.73, 95% CI 0.63–0.84). Demanding physical activities do not have a harmful effect on the selected birth outcomes while a sedentary lifestyle is associated with a lower birth weight. In the absence of either medical or obstetric complications, pregnant women may safely continue their normal daily physical activities should they wish to do so.

Prediction of birth weight by cotinine levels during pregnancy in a population of black smokers

OBJECTIVE

The goal was to investigate the association between maternal salivary cotinine levels (SCLs) and pregnancy outcomes among black smokers.

METHODS

In a randomized, controlled trial conducted in 2001-2004 in Washington, DC, 714 women (126 active smokers [18%]) were tested for SCLs at the time of recruitment and later in pregnancy. Sociodemographic health risks and pregnancy outcomes were recorded.

RESULTS

Birth weights were significantly lower for infants born to mothers with baseline SCLs of > or =20 ng/mL in comparison with <20 ng/mL (P = .024), > or =50 ng/mL in comparison with <50 ng/mL (P = .002), and > or =100 ng/mL in comparison with <100 ng/mL (P = .002), in bivariate analyses. In linear regression analyses adjusting for sociodemographic and medical factors, SCLs of > or =20 ng/mL were associated with a reduction in birth weight of 88 g when SCLs were measured at baseline (P = .042) and 205 g when SCLs were measured immediately before delivery (P < .001). Corresponding results were 129 g (P = .006) and 202 g (P < .001) for > or =50 ng/mL and 139 g (P = .007) and 205 g (P < .001) for > or =100 ng/mL. Gestational age was not affected significantly at any SCL, regardless of when SCLs were measured.

CONCLUSIONS

Elevated SCLs early in pregnancy or before delivery were associated with reductions in birth weight. At any cutoff level, birth weight reduction was more significant for the same SCL measured in late pregnancy. Maintaining lower levels of smoking for women who are unable to quit may be beneficial.

Reducing psychosocial and behavioral pregnancy risk factors: results of a randomized clinical trial among high-risk pregnant african american women

OBJECTIVES

We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, secondhand smoke exposure, depression, and intimate partner violence).

METHODS

Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-up.

RESULTS

Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021).

CONCLUSIONS

In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.

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.

Prevalência e fatores associados a sintomas de ansiedade em uma coorte de gestantes atendidas em um centro de saúde do município do Rio de Janeiro

OBJETIVOS: determinar a prevalência e a associação entre variáveis sócio-demográficas, obstétricas, nutricionais e sintomas de ansiedade em gestantes. MÉTODOS: trata-se de estudo prospectivo com cinco ondas de seguimento. A presente análise é transversal e foi realizada com 151 gestantes. A variável dependente foi a presença ou ausência de ansiedade na gestação, medida entre a 19ª e 21ª semana de gestação. Utilizou-se o Inventário de Ansiedade Traço-Estado (IDATE) para avaliar a ansiedade traço (a-traço). As variáveis independentes foram extraídas de um questionário com dados sócio-demográficos, obstétricos e nutricionais. A análise estatística foi realizada por meio da técnica de regressão multivariada de Poisson com variância robusta. RESULTADOS as gestantes tinham em média 25 anos e nove anos de escolaridade. A prevalência de ansiedade foi de 64,9% (IC95%: 56,7-72,5). No modelo multivariado observou-se que mulheres mais jovens (entre 18 e 24,9 anos, RP=1,35; IC95%: 1,06-1,71) e de menor escolaridade (um a oito anos, RP=1,39; IC95%: 1,11-1,73) apresentaram maior chance de desenvolver ansiedade. CONCLUSÕES: a prevalência de ansiedade foi elevada nesta amostra de gestantes acompanhadas em uma unidade básica de saúde. O conhecimento dos fatores associados à ansiedade é de fundamental importância para que a equipe multidisciplinar possa intervir de forma precoce e adequada no tratamento das gestantes.

Application of disease management principles to pregnancy and the postpartum period

Pregnancy and newborn care rank among the top health care expenditures for health plans and employers. Traditionally treated as episodic conditions, maternity and newborn clinical management is most often reactive in nature, event driven, and not perceived as a continuum. Existing models of pure disease management are not suited for addressing this continuum because the condition of pregnancy is not a disease, is not chronic, and is self-limited. Wellness approaches may be applicable for prenatal care, but they fail to fully engage the complexities and intervention needed for high-risk pregnancies. Case management alone is too comprehensive to focus on the high volume of pregnancies, which must be screened and accommodated at the health plan level. Alternatively, the management of a pregnant population through a continuum starting with early prenatal care and commencing with newborn and maternal postpartum care is optimal. We describe a total maternal-newborn solution (TMNS) that considers pregnancy as a unique, high-volume condition with infrequent, but costly, complications that can benefit from primary and secondary preventive efforts to avoid or reduce the impact of complications in a cost-effective manner. A TMNS helps to improve the quality of care delivered as participants and their health care providers are encouraged to follow standardized clinical guidelines and monitored for compliance. A TMNS is made possible with the use of an enterprise information technology platform that provides a common infrastructure to track participant encounters and interventions and measure and report on maternal and newborn care delivered. Preliminary outcomes for the TMNS program prove it to be a promising approach for addressing the clinical and cost management of the pregnancy continuum.

Psychosocial stress and pregnancy outcome

This article is intended to help clinicians better understand the ever-expanding body of research on whether psychosocial stress (both acute and chronic) is linked to 2 major adverse pregnancy outcomes: preterm birth and low birth weight. We summarize the existing literature and then review assessment tools commonly used to diagnose various types of psychosocial stress, with attention to how and when assessments should be made. After discussing the physiologic mechanisms hypothesized to underlie these relationships, we examine the range of existing interventions aimed at reducing psychosocial stress and review their efficacy at improving birth outcomes. Future directions for prevention of adverse pregnancy outcomes are discussed and suggest that an entirely new approach may be necessary.

The design, implementation and acceptability of an integrated intervention to address multiple behavioral and psychosocial risk factors among pregnant African American women

BACKGROUND

African American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format.

METHODS

Six academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported.

RESULTS

Forty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended > or = 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed.

CONCLUSION

While implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.

Determinants of birthweight: gender based analysis

The objective of this cross sectional study is to look at determinants of birth weight and their association with the gender of the baby in 2,795 full term children living in the occupied Palestinian territory, derived from a stratified random sample of 2,994 households in the West Bank and 2,234 households in the Gaza Strip. The response rate was 85%. Multivariable analysis using analysis of variance for mixed models showed that sex and birth order, maternal age and education and to a lesser extent region were determinants of birth weight for all children. The effect of maternal education on birth weight differed for female and male infants, tending to be relatively unchanged for male infants and with mean birth weights increasing with maternal education in female infants. The effect of birth order differed by maternal age, with mean birth weight increasing with maternal age for first and second births; but being unaffected by maternal age for infants of birth order greater than two. We conclude that birth weight is influenced by common biological determinants across cultures, but is also influenced by social, ethnic, and environmental factors that are culture specific, of which some might be gender related.

Association between antenatal depression and low birthweight in a developing country

OBJECTIVE

There is a high prevalence of depression in south Asian women. We aimed to examine the association between antenatal depression and low birthweight (LBW) in infants in a rural community in Rawalpindi, Pakistan.

METHOD

A total of 143 physically healthy mothers with ICD-10 depression in the third trimester of pregnancy and 147 non-depressed mothers of similar gestation were followed from birth. Infant weight was measured and information collected on socioeconomic status, maternal body-mass index and sociodemographic factors.

RESULTS

Infants of depressed mothers had lower birthweight (mean 2910 g) than infants of non-depressed mothers (mean 3022 g). The relative risk for LBW (< or =2500 g) in infants of depressed mothers was 1.9 (95% CI 1.3-2.9). The association remained significant after adjustment for confounders by multivariate analyses.

CONCLUSION

Low birthweight is a major public health problem in developing countries. Maternal depression during pregnancy predicts LBW. Interventions aimed at maternal depression may help improve infant outcomes.

Ansiedade na gestação, prematuridade e baixo peso ao nascer: uma revisão sistemática da literatura

O objetivo desta revisão é examinar publicações que investigaram o efeito da ansiedade no maior risco de prematuridade e/ou baixo peso ao nascer. Os bancos de dados MEDLINE versão PubMed, BVS, CINAHL e HEALTHSTAR, referentes aos anos de 1966 a 2006, foram rastreados usando-se a combinação dos seguintes descritores: anxiety, pregnancy, low birth weight e prematurity. Foram localizados 13 estudos: 11 coortes, 1 transversal e 1 caso-controle. A maioria (7/13) dos estudos foi realizado nos Estados Unidos. Quatro estudos foram considerados de excelente qualidade, pois excluíram adolescentes e/ou mulheres acima de 34 anos, aferiram a ansiedade a partir do primeiro e/ou segundo trimestre de gestação, utilizaram escalas validadas para medir ansiedade, apresentaram perdas de seguimento inferiores a 30% e controlaram os mais importantes fatores de confusão. A ansiedade na gestação foi associada à prematuridade e/ou ao baixo peso ao nascer em oito estudos. Os valores de razão de chance e risco relativo variaram de 1,08 a 2,31. São necessários estudos cuidadosamente desenhados para esclarecer a relação entre ansiedade na gestação, prematuridade e baixo peso ao nascer, já que as evidências observadas ainda são contraditórias.

Circumstances of pregnancy: low income women in Georgia describe the difference between planned and unplanned pregnancies

INTRODUCTION AND BACKGROUND

The United States has a higher rate of unintended pregnancies than many other developed countries despite the availability of effective contraception. Using Azjen's Theory of Planned Behavior and Luker's Theory of Contraceptive Risk Taking this qualitative study explores the reasons for the high rate of unintended pregnancy among low income women in Georgia.

METHODS

Six focus groups (N=39) were conducted at county health department clinics. Women were recruited at the clinics to participate in a discussion of Pregnancy and Motherhood. All English or Spanish speaking women between the ages of 18 and 49 were eligible for participation.

RESULTS

Three dimensions of pregnancy planning emerged-the decision to have a child, taking specific behaviors to increase the likelihood of conception, and making plans to care for a child. Planned pregnancies may occur when a couple or a woman decides that they are ready to have a child, but also occur in less stable situations that pose risks for the family and the child. Unplanned pregnancies may be welcomed or be unwanted depending on the circumstances. Women perceive advantages and disadvantages to planned and unplanned pregnancies.

DISCUSSION

There are major differences between the definition and values of planned and unplanned pregnancies promoted by public health practitioners and those of the women in our study. This suggests the need for research on the circumstances in which pregnancies occur, as well as targeted interventions and policies that help women and men define and achieve the circumstances in which they would like to bear and rear children.

Reproductive outcomes among Mexico-born women in San Diego and Tijuana: testing the migration selectivity hypothesis

Mexican immigrants to the United States have better reproductive outcomes than do U.S.-born non-Latina whites. Explanations offered for this "epidemiologic paradox" include (1) poor outcomes among Mexican women may be hidden by their return to Mexico; (2) Mexican women may have a higher fetal death rate that alters the pattern of live birth outcomes; (3) Mexican women may have socioeconomic characteristics which, if properly measured, would explain the outcome; (4) Mexican women may have personal characteristics which would explain the outcome, if properly measured; (5) there may be ameliorative or salutogenic "protective" effects of culture; and (6) migration may be selective of healthier women who are thus more prone to positive outcomes. We test these explanations, with an emphasis on the last one, using a data set that combines reproductive histories and birth outcomes for Mexico-born women delivering in San Diego, California and Mexican women delivering in Tijuana, Mexico. These data are compared with U.S.-born Latinas and U.S.-born non-Latina Whites. Multivariate logistic regression analysis suggests that when controlling for birth history (stillbirths and miscarriages), socioeconomic characteristics (education and prenatal visits), personal characteristics (age, parity, time in area, history of family problems), and health characteristics (history of smoking, alcohol use, drug use, anemia, vaginal bleeding, urinary infection), the adjusted odds of a positive birth outcome (measured as a live birth of 2500 grams or more) is highest for women delivering in Tijuana, implying that migrants may not be so selective when compared to the country of origin. The number of prenatal visits was an important explanatory variable.

Effects of maternal prenatal stress on infant outcomes: a synthesis of the literature

There is growing evidence that maternal prenatal stress may be hazardous to infant health. Changes in maternal hormonal and immune function as a result of stress may adversely affect the immune function and neurodevelopment of the fetus. Prenatal stress in the mother may produce lasting effects on the (1) infant's health status, (2) development and function of the infant's immune system, and (3) neurocognitive development of the infant. This article provides a synthesis of current human and animal literature on the effects of maternal prenatal stress on the developing fetus and the infant, with the resulting model evolving out of the framework of psychoneuroimmunology. The intent of the authors is an integrative review. The authors examined the following research question: What effect does maternal prenatal stress have on infants' immune development and neurodevelopment? All relevant studies were reviewed with no exclusion criteria. Major databases (CINAHL, MEDLINE, PsychINFO) were searched using a combination of the following key words: prenatal stress, cytokines, thymus, and infant neurodevelopment.

Reducing low birthweight by resolving risks: results from Colorado's prenatal plus program

OBJECTIVES

We examined low-birthweight (LBW) rates among participants in Colorado's Prenatal Plus program by prenatal risk factors (smoking, inadequate weight gain during pregnancy, and psychosocial problems) and the effect of successful resolution of these risks during pregnancy.

METHODS

Data for 3569 Medicaid-eligible women who received care coordination, nutritional counseling, or psychosocial counseling through the Prenatal Plus Program in 2002 were analyzed to determine the prevalence of specific risks, the proportion of women who resolved each specific risk, and the low birthweight rates for births to women who did and did not resolve risk. LBW rates were analyzed with chi(2) tests of significance.

RESULTS

Women who quit smoking had an LBW rate of 8.5%, compared with an LBW rate of 13.7% among women who did not. Women with adequate weight gain had an LBW rate of 6.7%, compared with 17.2% among women with inadequate weight gain. Women who resolved all of their risks had a low-birthweight rate of 7.0%, compared with a rate of 13.2% among women who resolved no risks. Women who had at least 10 Prenatal Plus visits were more likely to resolve their risks than were women who had fewer visits.

CONCLUSIONS

Multidisciplinary prenatal interventions targeted toward specific risks demonstrate success at significantly improving infant birthweight.

Neonatal outcomes in offspring of women with anxiety and depression during pregnancy. A linkage study from The Nord-Trøndelag Health Study (HUNT) and Medical Birth Registry of Norway

BACKGROUND

The presence of mental disorder during pregnancy could affect the offspring.

AIMS

To examine the effects of anxiety disorder and depression in pregnant women on neonatal outcomes, and to compare neonatal outcomes between offspring of attendees and non-attendees in a general population-based health survey.

METHOD

Pregnant women (n = 680) were identified from the population-based health study of Nord-TrØndelag County (HUNT-2) by linkage with the Medical Birth Registry of Norway. The women rated themselves on the Hospital Anxiety and Depression Rating Scale (HADS). Outcome variables were gestational length, birth weight, and Apgar scores.

RESULTS

HADS-defined anxiety disorder during pregnancy was associated with lower Apgar score at one minute (score < 8; odds ratio = 2.27; p = .03) and five minutes (score < 8; odds ratio = 4.49; p = .016). No confounders were identified. Anxiety disorder and depression during pregnancy was not associated with low birth weight or preterm delivery. Offspring of non-attendees had a lower birth weight (77 g; t = 3.27; p = 0.001) and a shorter gestational length (1.8 days; t = 2.76; p = 0.006) than that of offspring of attendees, a difference that may be explained by a higher load of psychosocial risk factors among the non-attendees.

CONCLUSION

In our study that may be biased towards the healthier among pregnant women, anxiety disorder or depression during pregnancy were not strong risk factors for adverse neonatal outcomes although low Apgar score in offspring of women with anxiety disorder may indicate poor neonatal adaptation.

Assessment of Risk Factors for Low Birth Weight Deliveries

Recognition of a higher than average incidence of low birth weight (LBW) deliveries in areas of Eastern Pennsylvania led to an analysis of more than 5,500 deliveries in one of the region's hospital systems to investigate the predictors of LBW in that population. Results of multivariate analysis indicate key variables that contribute to LBW: in particular, racial/ethnic background and specific medial problems during pregnancy, including preeclampsia, incompetent cervix, bleeding, low BMI and lack of adequate weight gain. Results were incorporated into training in best practices for prenatal care in the city's prenatal clinics.

Primary predictors of preterm labour

Spontaneous preterm birth accounts for 60% of all preterm births in developed countries. With the increase in multiple pregnancies, induced preterm birth and the progress in neonatal care for extremely preterm neonates, spontaneous preterm birth for singleton pregnancies in developed countries has probably decreased over the past 30 years. This decrease is likely to be related to better prenatal care for all pregnant women because the recognition of primary risk factors in early or late pregnancy remains a basic part of prenatal care. The failure to distinguish between induced and spontaneous preterm labour in most population-based studies makes it difficult to interpret results with respect to the primary predictors of preterm labour. Many such primary predictors of preterm labour have been used over the past 20-30 years. These include individual factors, socio-economic factors, working conditions and obstetric and gynaecological history. Risk scores have been proposed in order to produce these data. Unfortunately, the predictive value of these scores, especially their specificity, is poor, mainly because all of these factors are indirect. We still cannot identify the mechanisms that lead to preterm labour and birth. New markers more directly related to preterm labour have recently been proposed, some of which relate to direct causes of preterm labour such as cervical ultrasound measurement, fetal fibronectin (FFN), salivary estriol, serum CRH and bacterial vaginosis. Several of these have predictive values, which are potentially useful for clinical practice. Nonetheless, pregnant women in developed countries are already closely monitored throughout pregnancy. Before proposing new screening tests to be applied systematically to all pregnant women, their advantages and drawbacks must be fully evaluated.

Risk factors for low birth weight: a review

Low birth weight (LBW) is one of the main predictors of infant mortality. The global incidence of LBW is around 17%, although estimates vary from 19% in the developing countries (countries where it is an important public health problem) to 5-7% in the developed countries. The incidence in Spain in the decade 1980-1989 was about 5.7%. LBW is generally associated with situations in which uterine malnutrition is produced due to alterations in placental circulation. There are many known risk factors, the most important of which are socio-economic factors, medical risks before or during gestation and maternal lifestyles. However, although interventions exist to prevent many of these factors before and during pregnancy, the incidence of LBW has not decreased.

Psychosocial pathways to prematurity: changing our thinking toward a lifecourse and community approach

The purpose of this article is to explore the psychosocial antecedents of prematurity. Emphasis is on conceptual areas and supporting literature for (a) the contexts in which prematurity occurs and the diversity of women's experiences; (b) a lifecourse approach to prematurity that highlights allostatic load and the accumulation of trauma and loss in possible prematurity pathways; and (c) diverse psychosocial/biological pathways and mechanisms of prematurity processes. Pathways examining psychosocial and prematurity connections will be explicated, including antecedents and outcomes other than stress proneness and vulnerability. Implications for research are logically derived from a focus on the impact of social context on individual outcomes through multilevel models and methods. Clinical implications are derived from the social contexts, lifecourse, and multiple pathways focus of the article and include increasing social cohesion in communities, population health strategies, particular psychosocial interventions, and attentive listening.

Characteristics of preterm delivery and low birthweight among 113,994 infants in Alberta: 1994-1996

This study examined the impact of infant and maternal factors on preterm delivery and low birthweight (LBW) in Alberta between January 1, 1994 and December 31, 1996. Data on 113,994 births were collected from vital statistics registration birth data. Logistic regression models for preterm and LBW delivery suggested the key risk factors were multiple and still birth (odds ratios > 22.0). Other characteristics included female gender, birth defects, nulliparous women, maternal age 35 and greater, unmarried, history of abortion, maternal smoking, maternal street drug use, and having less than 4 prenatal visits (odds ratios 0.86-2.54). Interactions between smoking and alcohol, and smoking and parity were noted. Efforts to improve the currently low rates (8.2%) of smoking cessation during pregnancy are required. Social, economic and medical factors associated with delayed childbearing and birth outcomes should be investigated.

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.

An explanatory model of preterm labor

The purpose of this article is to describe women's explanatory model of their preterm labor (PTL) experiences. Fourteen young adult (20 to 23 years of age) women living in the southeast, who were hospitalized for the treatment of PTL, participated in this naturalistic study. Stress was the dominant theme that all participants used to explain what had precipitated PTL. All women described multiple stressors and chaos in their lives, which preceded their admission to the hospital for PTL. Meanings of PTL were intertwined with dysfunctional families and problematic relationships. All 9 women who delivered at term were able to find a friend or family member to provide support that allowed the women to relax and reduce the stress in their lives. In contrast, women who delivered preterm had no one in their lives that could provide help and support. Women's conceptualizations of PTL suggest that culturally appropriate interventions to reduce stress and mobilize support may help improve birth outcomes after an episode of PTL.

Stress, pre-term labour and birth outcomes

Stress, pre-term labour and birth outcomes Preliminary studies have suggested that stress may be associated with the onset, treatment and outcomes of pre-term labour; however, a systematic comparison of the stress of women with and without pre-term labour has not been reported. Therefore, the purpose of this exploratory study was to compare the stress (daily hassles and mood states) and birth outcomes of black and white women who experienced pre-term labour (PTL) during pregnancy with those who did not. The convenience sample consisted of 35 pregnant women hospitalized in 1996-1997 for the treatment of PTL (24-35 weeks gestation) and 35 controls matched on age, race, parity, gestational age and method of hospital payment. Women in the PTL group had significantly higher tension-anxiety and depression-dejection on the Profile of Mood States (POMS), lower mean birthweight and mean gestational age, and a higher percentage of babies born <37 weeks and weighing 2500 g or less. Black women in the PTL group and white women in the control group had significantly higher scores on the fatigue sub-scale of the POMS and the work and future security sub-scales of the Daily Hassles Scale. Women in the PTL group whose babies weighed 2500 g or less had significantly higher scores on the health, inner concern and financial responsibility sub-scales of the Daily Hassles Scale. The findings from this study indicate the need for further exploration of the interaction of race and stress in understanding and preventing PTL and low birthweight and the need to examine the role of social support in preventing pre-term birth after an episode of PTL.

Increasing access to prenatal care: an evaluation of minority health coalitions' early pregnancy project

Early prenatal care utilization is a problem for racial and ethnic minority women in Indiana. Minority health coalitions in Indiana developed early pregnancy care coordination projects to address this need. To evaluate project outcomes, birth certificates of infants born to project mothers were matched with birth certificates of infants whose mothers did not receive care coordination. Results showed that project mothers were significantly more likely to start prenatal care earlier, had better prenatal care utilization as measured by the Kessner Index (Kessner, Singer, Kalk, & Schlesinger, 1973), and had better adequacy of care as measured by the APNCU Index (Kotelchuck, 1994) than the noncare-coordinated mothers. Although the project was successful in meeting its primary objective, specific recommendations are made for community health nurses to partner with the coalitions in improving the content of prenatal care, decreasing sociocultural barriers to care, and assisting in the evaluation of outcomes of future projects.

Maternal cigarette smoking during pregnancy is an independent predictor for symptoms of middle ear disease at five years' postdelivery

Although an increasing body of literature has demonstrated a link between in utero exposure to cigarette smoke and childhood morbidity, the extent to which such exposure is associated with middle ear disease (MED) is less certain. We hypothesized that in utero exposure to cigarette smoke was associated with an increased risk of MED and aimed to calculate the proportion of disease at 5 years' postdelivery attributable to cigarette exposure during pregnancy. Methods. At their first antenatal session, 8556 women were enrolled in a prospective study of pregnancy. Mothers were followed during pregnancy, at birth, at 6 months' and at 5 years' postdelivery and completed a detailed questionnaire aimed at assessing the frequency of acute (<1 month) and subacute (1-3 months) symptoms of MED and ear surgery. The relationship between MED and smoking status during pregnancy was then examined and subsequently adjusted simultaneously for smoking status at other times and for other potentially confounding variables. Results. In the adjusted analyses, acute ear infections were associated with consumption of 1 to 9 cigarettes (OR: 1.6; 95% CI: 1.1-2.5), 10 to 19 cigarettes (OR: 2.6; 95% CI: 1. 6-4.2) and 20+ cigarettes (OR: 3.3; 95% CI: 1.9-5.9) per day at the first clinic visit. For subacute ear infections, an association was present with consumption of 10 to 19 cigarettes (OR: 2.6; 95% CI: 1. 4-5.0) and 20+ cigarettes (OR: 2.8; 95% CI: 1.3-6.0) at the first clinic visit. In utero exposure to 20+ cigarettes per day at the first clinic visit was also associated with an increased risk of ear surgery by 5 years' postdelivery (OR: 2.9; 95% CI: 1.3-6.6). These associations were independent of smoking at 6 months and at 5 years, age and gender of the child, breastfeeding history, maternal age, maternal education, maternal employment at 5 years, marital status at 5 years, socioeconomic status, use of day care, and the number of siblings or children in the household. A population attributable risk percent at 5 years of 39.4% for acute ear infections, 37.9% for subacute ear infections, and 30.0% for previous ear surgery was found for in utero exposure to cigarette smoke at the first clinic visit. Conclusions. Smoking at the first clinic visit was associated with an increased risk of MED and ear surgery at 5 years of age. The frequency of maternal smoking in the general population gives rise to a high population attributable risk percent for MED. Therefore, it is a significant contributor to childhood morbidity and provides another reason why women should be encouraged to avoid smoking during pregnancy.

Mediators of ethnic-associated differences in infant birth weight

PURPOSE

To examine whether ethnic differences in low birth weight babies of low-income women may be explained in part by group differences in prenatal health behaviors and psychosocial factors.

METHODS

A prospective, survey of 1,071 low-income, primiparous African-American and Mexican-origin women was conducted in Los Angeles County, California. In face-to-face interviews, data were obtained on substance use, prenatal stress, social support, attitudes toward pregnancy, initiation of prenatal care, and medical risk. Medical chart data were abstracted regarding medical risk factors and labor, delivery, and neonatal data. Interview data were linked with birth outcome data retrieved from maternal medical records. Structural equation modeling was used to test a hypothesized model in which differences in birth weight were expected to be mediated by ethnic differences in substance use, psychosocial factors, and medical risk.

RESULTS

As expected, African-American women delivered babies of earlier gestational age and lower birth weight than did women of Mexican origin. Direct predictors of low birth weight were use of drugs and cigarettes, prenatal stress, and positive attitudes toward pregnancy; together, these factors accounted for the observed ethnic differences in birth weight.

CONCLUSION

These data contribute to our understanding of the factors that may account for ethnic-associated differences in low birth weight.