Home visiting for first-time mothers and subsequent pregnancy spacing

Homelessness in the Perinatal Period and Associations With Reproductive Interconception Care: 2016-2019 Pregnancy Risk Assessment Monitoring System

OBJECTIVES

Women experiencing homelessness have higher rates of unintended pregnancy than stably housed women and may benefit from reproductive interconception care. How reproductive interconception care differs between women who did and did not experience perinatal homelessness is not known. We estimated prevalence ratios of reproductive interconception behaviors among US women experiencing homelessness during the perinatal period.

METHODS

We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System to calculate the prevalence of 5 reproductive interconception care outcomes: attending a maternal postpartum checkup, participating in a conversation with a health care provider about birth intervals, receiving family planning counseling, obtaining a prescription for short-acting contraception, and having a long-acting reversible contraceptive inserted. We used complex survey weights, stratified by perinatal homelessness, and converted adjusted logistic regression odds ratios between housing status and outcome variables to adjusted prevalence ratios (aPRs) and 95% CIs.

RESULTS

Among participants, approximately 2.4% (weighted percentage; unweighted 2953 of 100 706) experienced homelessness sometime in the 12 months before their children were born; the majority were non-Hispanic (83.2%) and White (69.4%), were not married (82.2%), and had public health insurance (56.8%). Perinatal homelessness was significantly associated with a lower prevalence of attending a postpartum maternal visit (aPR = 0.90; 95% CI, 0.87-0.94) and a higher prevalence of having a conversation about birth intervals with their health care providers (aPR = 1.13; 95% CI, 1.03-1.21).

CONCLUSIONS

Findings suggest that improving attendance at postpartum visits and evaluating birth interval conversations may strengthen interconception care practices while contextualizing social determinants such as housing stability. Improving uptake of postpartum visits may reduce unintended pregnancy, short birth intervals, and adverse birth outcomes in future pregnancies among women experiencing homelessness.

Reproductive Interconception Care Among Women Recently Pregnant and Homeless: A Qualitative Analysis

Reproductive interconception care provided at maternal postpartum visits may help reduce unintended pregnancies and elongate birth intervals for women experiencing homelessness. To improve interconception care uptake, this qualitative study aimed to identify barriers and facilitators to reproductive interconception care from the perspectives of women who were recently pregnant and homeless. A semi-structured interview guide and demographic survey were developed based on epidemiological findings, Information-Motivation-Behavioral Skill framework components, and a review by community health workers for content validity. After conducting 12 interviews with women recently pregnant and homeless in a local continuum of care in 2022, audio-recorded interviews were transcribed, iteratively coded using a priori and emerging codes, and thematically analyzed. Key themes were identified to determine implications and next steps to improving reproductive interconception care uptake. Interrelated themes focused on information (e.g., knowledge and misconceptions about pregnancy, birth intervals, contraception), motivation (e.g., attitudes about interconception care experiences, perinatal social influences), behavioral skills (e.g., objective ability to obtain interconception care and perceived self-efficacy related to attending maternal postpartum visits and increasing birth intervals), and macro-level factors (e.g., obtaining housing, contextualizing socioeconomic factors, navigating COVID-19). The findings suggest the need for flexible, streamlined, and personalized interconception care delivery that acknowledges pressing housing and relationship considerations and supports women's autonomy. Improvements to reproductive interconception care may reduce future unintended pregnancies, increase birth intervals, and improve birth outcomes among women experiencing homelessness.

Association between short birth spacing and child malnutrition in Bangladesh: a propensity score matching approach

OBJECTIVES

This study aimed to explore the effects of short birth spacing (SBS), which is defined as a period of less than 33 months between two successive births, on multiple concurrent forms of child malnutrition (MCFCM) and at least one form of child malnutrition (ALOFCM) using propensity score matching (PSM).

METHODS

This study used data extracted from the 2017-18 Bangladesh Demographic and Health Survey. PSM with four different distance functions, including logistic regression, classification and regression tree, single hidden layer neural network and random forest, were performed to evaluate the effects of SBS on MCFCM and ALOFCM. We also explored how the effects were modified in different subsamples, including women's empowerment, education and economic status (women's 3E index)-constructed based on women's decision-making autonomy, education level, and wealth index, and age at marriage, and place of residence.

RESULTS

The prevalence of SBS was 22.16% among the 4652 complete cases. The matched samples of size 2062 generated by PSM showed higher odds of MCFCM (adjusted OR (AOR)=1.25, 95% CI=1.02 to 1.56, p=0.038) and ALOFCM (AOR=1.20, 95% CI=1.01 to 1.42, p=0.045) for the SBS children compared with their counterparts. In the subsample of women with 3E index≥50% coverage, the SBS children showed higher odds of MCFCM (AOR: 1.43, 95% CI=1.03 to 2.00, p=0.041] and ALOFCM (AOR: 1.33, 95% CI=1.02 to 1.74, p=0.036). Higher odds of MCFCM (AOR=1.27, 95% CI=1.02 to 1.58, p=0.036) and ALOFCM (AOR=1.23, 95% CI=1.02 to 1.51, p=0.032) for SBS children than normal children were also evident for the subsample of mothers married at age≤18 years.

CONCLUSION

SBS was significantly associated with child malnutrition, and the effect was modified by factors such as women's autonomy and age at marriage.

Using probabilistic record linkage and propensity-score matching to identify a community-based comparison population

In retrospective cohort studies of interventions disseminated to communities, it is challenging to find comparison groups with high-quality data for evaluation. We present one methodological approach as part of our study of birth outcomes of second-born children in a home visiting (HV) program targeting first-time mothers. We used probabilistic record linkage to link Connecticut's Nurturing Families Network (NFN) HV program and birth-certificate data for children born from 2005 to 2015. We identified two potential comparison groups: a propensity-score-matched group from the remaining birth certificate sample and eligible-but-unenrolled families. An analysis of interpregnancy interval (IPI) is presented to exemplify the approach. We identified the birth certificates of 4822 NFN families. The propensity-score-matched group had 14,219 families (3-to-1 matching) and we identified 1101 eligible-but-unenrolled families. Covariates were well balanced for the propensity-score-matched group, but poorly balanced for the eligible-but-unenrolled group. No program effect on IPI was found. By combining propensity-score matching and probabilistic record linkage, we were able to retrospectively identify relatively large comparison groups for quasi-experimental research. Using birth certificate data, we accessed outcomes for all of these individuals from a single data source. Multiple comparison groups allow us to confirm findings when each method has some limitations. Other researchers seeking community-based comparison groups could consider a similar approach.

Interpregnancy Interval and Birth Outcomes: A Propensity Matching Study in the California Population

INTRODUCTION

Previous studies that used traditional multivariable and sibling matched analyses to investigate interpregnancy interval (IPI) and birth outcomes have reached mixed conclusions about a minimum recommended IPI, raising concerns about confounding. Our objective was to isolate the contribution of interpregnancy interval to the risk for adverse birth outcomes using propensity score matching.

METHODS

For this retrospective cohort study, data were drawn from a California Department of Health Care Access and Information database with linked vital records and hospital discharge records (2007-2012). We compared short IPIs of < 6, 6-11, and 12-17 months to a referent IPI of 18-23 months using 1:1 exact propensity score matching on 13 maternal sociodemographic and clinical factors. We used logistic regression to calculate the odds of preterm birth, early-term birth, and small for gestational age (SGA).

RESULTS

Of 144,733 women, 73.6% had IPIs < 18 months, 5.5% delivered preterm, 27.0% delivered early-term, and 6.0% had SGA infants. In the propensity matched sample (n = 83,788), odds of preterm birth were increased among women with IPI < 6 and 6-11 months (OR 1.89, 95% CI 1.71-2.0; OR 1.22, 95% CI 1.13-1.31, respectively) and not with IPI 12-17 months (OR 1.01, 95% CI 0.94-1.09); a similar pattern emerged for early-term birth. The odds of SGA were slightly elevated only for intervals < 6 months (OR 1.10, 95% CI 1.00-1.20, p < .05).

DISCUSSION

This study demonstrates a dose response association between short IPI and adverse birth outcomes, with no increased risk beyond 12 months. Findings suggest that longer IPI recommendations may be overly proscriptive.

Birth-Related Outcomes for Second Children Following Home Visiting Program Enrollment for New Parents of First Children

Introduction

Home visiting (HV) programs aim to promote child and family health through perinatal intervention. HV may benefit second children through improving subsequent pregnancy and birth outcomes. However, HV impacts on birth outcomes of second children have not been examined in a naturalistic setting.

Methods

Using data from Connecticut Nurturing Families Network (NFN) home visiting program of families enrolled from 2005 to 2015, we compared birth-related outcomes (birthweight, preterm birth, Cesarean section delivery, prenatal care utilization) of second children (n = 1758) to demographically similar propensity-score-matched families that were not enrolled in NFN (n = 5200). We examined whether the effects of NFN differed by maternal age, race and ethnicity, or visit attendance pattern.

Results

There was no program effect for the full sample. The effect of NFN did not differ by maternal age or visit attendance pattern but did differ by maternal race and ethnicity. Black women in NFN were more likely to receive adequate prenatal care during their second pregnancy (OR 1.05; 95% CI 1.01, 1.09) and Hispanic women in NFN were less likely to deliver by Cesarean section for their second birth (OR 0.97; 95% CI 0.94, 0.99), compared to Black and Hispanic women in the comparison group respectively. There was a protective program effect on prematurity of the second child (OR 0.92; 95% CI 0.85, 0.996) for women with a preterm first birth.

Discussion

These findings suggest that benefits of HV extend to subsequent birth-related outcomes for women from marginalized racial/ethnic groups. HV may help buffer some harmful social determinants of health.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10995-021-03365-3.

Effects of home visits for pregnant and postpartum women on premature birth, low birth weight and rapid repeat birth: a meta-analysis and systematic review of randomized controlled trials

BACKGROUND

Home visits seem promising for improving the health of women and infants during pregnancy and postpartum. This review aimed to quantitatively analyse the effects of home visits delivered during pregnancy and postpartum on premature birth (PTB), low birth weight (LBW) and rapid repeat birth (RRB).

METHODS

Literature was retrieved from PubMed, EMBASE, Web of Science and the Cochrane Library from January 1960 to October 2018 and the references lists of related studies and reviews were also screened. Eligible papers were randomized controlled trials (RCTs) that focussed on home visits conducted with women during pregnancy or postpartum and reported at least one of the following results: PTB, LBW and RRB. Fixed- or random-effects models were used to analyse the pooled results.

RESULTS

Fourteen RCTs were included. Pooled estimates showed a beneficial effect on LBW (odds ratio (OR) = 0.83; P = 0.03; low-quality evidence) and RRB in the professional-visit subgroup (OR = 0.62; P = 0.003; moderate-quality evidence). However, there was insufficient evidence to support the favourable effects of home visits on PTB (OR = 0.96; P = 0.59, moderate-quality evidence) and RRB in the non-professional-visit subgroup (OR = 0.86; P = 0.53, moderate-quality evidence). The overall methodological quality was moderate. Egger's test suggested no publication bias for PTB and LBW.

CONCLUSION

This meta-analysis is the first to suggest that home visits can prevent and decrease LBW and RRB; however, it remains unclear whether home visits benefit PTB. Therefore, home visits can be an alternative and complementary part of primary health care for women, especially those with risk factors.

Birth outcomes of second children after community-based home visiting: A research protocol

Birth-related outcomes, such as birth weight, have lifelong impacts on health. Home visiting (HV) is an established approach to improve the health of children and families, parenting practices, and connections to social and health services. Many HV programs target first-time mothers, in part because HV activities related to a first-birth may improve birth outcomes for subsequent children, but few researchers have examined these effects. We will link data from a statewide HV program (Nurturing Families Network [NFN]) to birth certificate data to create comparison groups and measure outcomes in this observational study. Specifically, we will compare birth outcomes for NFN second-children (n = 3000) to those for: (a) first-child older siblings whose birth/gestation led to NFN enrollment (n = 3000); (b) second children of families who were screened as eligible for NFN, but not offered the program due to home visitor availability and other logistical reasons (n = 650); and (c) non-NFN second children in a propensity-score-matched group created using the likelihood of enrollment in NFN based on maternal health, demographics, and neighborhood characteristics (n = 6000). The outcomes we will examine are birth spacing, prenatal care received, cesarean section rate, gestational age, and birth weight in second-children. We will also examine the associations between program attendance (i.e., missed visits, dropout) and birth outcomes, that will generate evidence that may be used in programmatic decisions regarding continued funding and/or modification of NFN, prioritization of specific retention efforts, and targeting of first-time mothers. Use of this evidence should improve outcomes for future NFN families and may inform similar programs.

Invited Commentary: Promise and Pitfalls of the Sibling Comparison Design in Studies of Optimal Birth Spacing

Numerous observational studies have shown that infants born after short interpregnancy intervals (the interval between birth and subsequent conception) are more likely to experience adverse perinatal outcomes than infants born following longer intervals. Yet it remains controversial whether the link between short interpregnancy interval and adverse outcomes is causal or is confounded by factors such as low socioeconomic position, inadequate access to health care, and unintended pregnancy. Sibling comparison studies, which use a woman as her own control by comparing exposure and outcome status of her different pregnancies (i.e., comparing sibling offspring), have gained popularity as a strategy to reduce confounding by these difficult-to-measure factors that are nevertheless relatively stable within women. A variant of this approach, used by Regan et al. (Am J Epidemiol. 2019;188(1):9-16) and reported in this issue of the Journal, is a maternally matched design based on a single interpregnancy interval per woman. Using real and simulated data, we highlight underappreciated shortcomings of these designs that could limit the validity of study findings. In particular, we illustrate how the single-interval variant appears to derive estimates from comparisons between different mothers, not within mothers. Future studies of optimal birth spacing using sibling comparison designs should examine in detail the potential consequences of these methodological limitations.

Short interpregnancy intervals and adverse perinatal outcomes in high-resource settings: An updated systematic review

BACKGROUND

This systematic review summarises association between short interpregnancy intervals and adverse perinatal health outcomes in high-resource settings to inform recommendations for healthy birth spacing for the United States.

METHODS

Five databases and a previous systematic review were searched for relevant articles published between 1966 and 1 May 2017. We included studies meeting the following criteria: (a) reporting of perinatal health outcomes after a short interpregnancy interval since last livebirth; (b) conducted within a high-resource setting; and (c) estimates were adjusted for maternal age and at least one socio-economic factor.

RESULTS

Nine good-quality and 18 fair-quality studies were identified. Interpregnancy intervals <6 months were associated with a clinically and statistically significant increased risk of adverse outcomes in studies of preterm birth (eg, aOR ≥ 1.20 in 10 of 14 studies); spontaneous preterm birth (eg, aOR ≥ 1.20 in one of two studies); small-for-gestational age (eg, aOR ≥ 1.20 in 5 of 11 studies); and infant mortality (eg, aOR ≥ 1.20 in four of four studies), while four studies of perinatal death showed no association. Interpregnancy intervals of 6-11 and 12-17 months generally had smaller point estimates and confidence intervals that included the null. Most studies were population-based and few included adjustment for detailed measures of key confounders.

CONCLUSIONS

In high-resource settings, there is some evidence showing interpregnancy intervals <6 months since last livebirth are associated with increased risks for preterm birth, small-for-gestational age and infant death; however, results were inconsistent. Additional research controlling for confounding would further inform recommendations for healthy birth spacing for the United States.

Low birthweight in second children after nurse home visiting

OBJECTIVE

To examine low birthweight and preterm birth of second children born to home-visited first-time mothers.

SUBJECTS

Women were previously recruited for a randomized controlled trial of the home visiting model disseminated as Nurse-Family Partnership. 512 of these women had second children within 18 years of the first child's birth, and were included in our sample.

RESULTS

The intervention was associated with a lower likelihood of low birthweight for second children (odds ratio: 0.51, 95% CI: 0.27, 0.97), an effect apparent only if the first-born had low birthweight and mediated by close birth spacing. These moderation and mediation patterns were similar in the preterm birth outcome.

CONCLUSION

A home visiting program provided for first-born children reduced low birthweight for second-born children, if the first-born had low birthweight. This finding implies a broader impact than previously documented, because few studies have included these second children.

Evaluation of Early Childhood Home Visiting to Prevent Medically Attended Unintentional Injury

STUDY OBJECTIVE

We evaluated the influence of home visiting on the risk for medically attended unintentional injury during home visiting (0 to 3 years) and subsequent to home visiting (3 to 5 years).

METHODS

A retrospective, quasi-experimental study was conducted in a cohort of mother-child pairs in Hamilton County, OH. The birth cohort (2006 to 2012) was linked to administrative home visiting records and data from a population-based injury surveillance system containing records of emergency department (ED) visits and hospitalizations. Cox proportional-hazard regression was used to compare medically attended unintentional injury risk (0 to 2, 0 to 3, and 3 to 5 years) in a home-visited group versus a propensity score-matched comparison group. The study population was composed of 2,729 mother-child pairs who received home visiting and 2,729 matched mother-child pairs in a comparison group.

RESULTS

From birth to 2 years, 17.2% of the study population had at least one medically attended unintentional injury. The risk for medically attended unintentional injury from aged 0 to 2 and 0 to 3 years was significantly higher in the home-visited group relative to the comparison group (hazard ratio 1.17, 95% confidence interval 1.01 to 1.35; hazard ratio 1.15, 95% confidence interval 1.00 to 1.31, respectively). Additional injuries in the home-visited group were superficial, and the increased risk for medically attended unintentional injury was observed for ED visits and not hospitalizations.

CONCLUSION

Home-visited children were more likely to have a medically attended unintentional injury from birth to aged 3 years. This finding may be partially attributed to home visitor surveillance of injuries or greater health care-seeking behavior. Implications and alternative explanations are discussed.