The impact of smoking and other substance use by urban women on the birthweight of their infants

Racial and ethnic disparities in chronic disease risk in adolescence after prenatal polydrug exposure: Examination of the Hispanic paradox

Racial disparities exist in fetal development which in turn can influence growth and development of chronic disease later in life. The purpose of this study was to explore potential racial and ethnic differences in chronic disease risk factors throughout the pediatric years given prenatal exposure to substance use. Data from the Maternal Lifestyle Study cohort was used for this analysis. Urine toxicology confirmed maternal substance use (y/n) and offspring height, weight, and systolic blood pressure (SBP) data at 16 years was analyzed. Linear mixed effects modeling with an interaction term for adolescent race/ethnicity and maternal drug use assessed growth trajectories (body mass index (BMI) percentile) and cardiovascular disease risk factors (elevated SBP). Of the sample (n = 1,388 mother/infant dyads), 23% (n = 319) of mothers used three substances during pregnancy and 14% (n = 200) used four or five. Controlling for BMI, Hispanic adolescents prenatally exposed to any singular substance had 13 mmHg higher SBP at age 16 than their unexposed counterparts (95% Confidence Interval [CI]: 12.24, 14.01). Prenatal exposure to >1 substance significantly lowered SBP in Hispanic adolescents only. Results here showed that Hispanic adolescents exposed to singular substance are at higher risk of elevated SBP in adolescence, but SBP decreased when exposed to >1 substance. The Hispanic paradox may play a role; future studies should continue to explore this. Additionally, barriers to prenatal care for Hispanic women should be addressed in order to prevent substance use during pregnancy which can reduce chronic disease risk in offspring adolescence.

Smoking during pregnancy in the United States, 2005-2014: The role of depression

BACKGROUND

Despite success of public health-oriented tobacco control programs in lowering the smoking prevalence over the past several decades, it is unclear whether similar reductions in smoking have been experienced among pregnant women, especially in vulnerable groups such as those with major depression and/or lower socioeconomic status.

OBJECTIVES

The purpose of this study is to examine the relationship between major depressive episode (MDE) and smoking among pregnant women overall, and by demographics and to estimate changes in the prevalence of cigarette smoking among pregnant women with and without MDE from 2005 to 2014.

STUDY DESIGN

Cigarette use among pregnant women with and without MDE was examined using logistic regression models in the National Survey on Drug Use and Health.

RESULTS

Prenatal smoking is more common among pregnant women with, compared to without, MDE (32.5% vs. 13.0%; (adjusted OR=2.50 (1.85, 3.40)), and greater disparities were revealed when also considering income, education and race. Over time, smoking during pregnancy increased significantly among women with MDE (35.9% to 38.4%; p=0.02)) and showed a decreasing trend among women without MDE (12.5% to 9.1%; p=0.07) from 2005 to 2014.

CONCLUSIONS

Over the past decade, smoking during pregnancy has increased among women experiencing a major depressive episode and is over four times more common among pregnant women with, than without, MDE. Disparities in smoking during pregnancy by MDE status and socioeconomic subgroups appear substantial. Given the multitude of risks associated with both MDE and smoking during the prenatal period, more work targeting this vulnerable and high-risk group is needed.

Tobacco smoking and breastfeeding: Effect on the lactation process, breast milk composition and infant development. A critical review

Approximately 10% of women report smoking during pregnancy. The number of breastfeeding women who relapse back to smoking is even greater. Smoking may cause adverse changes to the milk's composition by not only reducing its protective properties, but also by affecting the infant's health. The pathophysiological mechanisms underlying these adverse effects are not entirely known. This article is a review of previous reports about the effects of smoking on the lactation process, breast milk composition and infant development. A systematic search for English language articles published until 2015 was made, using a MEDLINE data. The key search terms were "smoking and breastfeeding", "smoking and lactation", "smoking and milk composition", "nicotine and breast milk". Studies have shown that nicotine levels in breast milk of women who smoke are three times higher than those in the plasma levels. Breast milk volume is reduced and the duration of lactation period is shorter. Smoking causes adverse changes to the milk's composition by not only reducing its protective properties, but also affecting infants' response to breastfeeding and to breast milk.

Maternal Marijuana Use and Adverse Neonatal Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE

To estimate whether marijuana use in pregnancy increases risks for adverse neonatal outcomes and clarify if any increased risk is attributable to marijuana use itself or to confounding factors such as tobacco use.

DATA SOURCES

Two authors performed a search of the data through August 2015 utilizing PubMed, Embase, Scopus, Cochrane reviews, ClinicalTrials.gov, and Cumulative Index to Nursing and Allied Health.

METHODS OF STUDY SELECTION

We looked at observational studies that compared rates of prespecified adverse neonatal outcomes in women who used marijuana during pregnancy with women who did not.

TABULATION, INTEGRATION, AND RESULTS

Two authors independently extracted data from the selected studies. Primary outcomes were low birth weight (less than 2,500 g) and preterm delivery at less than 37 weeks of gestation. Secondary outcomes were birth weight, gestational age at delivery, small for gestational age, level II or greater nursery admission, stillbirth, spontaneous abortion, low Apgar score, placental abruption, and perinatal death. DerSimonian-Laird random-effects models were used. We assessed heterogeneity using the Q test and I statistic. Stratified analyses were performed for the primary outcomes and pooled adjusted estimates were calculated. We included 31 studies that assessed the effects of maternal marijuana use on adverse neonatal outcomes. Based on pooled unadjusted data, marijuana use during pregnancy was associated with an increased risk of low birth weight (15.4% compared with 10.4%, pooled relative risk [RR] 1.43, 95% confidence interval [CI] 1.27-1.62) and preterm delivery (15.3% compared with 9.6%, pooled RR 1.32, 95% CI 1.14-1.54). However, pooled data adjusted for tobacco use and other confounding factors showed no statistically significant increased risk for low birth weight (pooled RR 1.16, 95% CI 0.98-1.37) or preterm delivery (pooled RR 1.08, 95% CI 0.82-1.43).

CONCLUSION

Maternal marijuana use during pregnancy is not an independent risk factor for adverse neonatal outcomes after adjusting for confounding factors. Thus, the association between maternal marijuana use and adverse outcomes appears attributable to concomitant tobacco use and other confounding factors.

Community Level Correlates of Low Birthweight Among African American, Hispanic and White Women in California

OBJECTIVES

Racial and ethnic groups in the US exhibit major differences in low birthweight (LBW) rates. While previous studies have shown that community level social indicators associated with LBW vary by race and ethnicity, it is not known whether these differences exist among racial or ethnic groups who live in the same neighborhood or community. To address this question, we examined the association of community level features with LBW among African American, White and Hispanic women who live in similar geographic areas.

METHODS

The analysis is based on geocoded birth certificates for all singleton live births in the year 2000 to women residing in 805 California ZIP codes. Community level social and demographic data were obtained from U.S. Census data files for the year 2000 and surrogate indices of population level alcohol and drug abuse and dependence were derived from hospital discharge data (HDD). Tobit and bootstrap analyses were used to test associations with birth outcomes, maternal characteristics, and community level social and demographic features within and across the three groups of women living in similar geographic areas.

RESULTS

The results demonstrate major racial and ethnic differences in community level correlates of LBW. Rates of LBW among African Americans were lower if they lived in areas that were more densely populated, had greater income disparities, were more racially segregated, and had low rates of alcohol abuse or dependence. These associations were different or absent for Hispanic and White women.

CONCLUSIONS FOR PRACTICE

The results suggest that despite living in the same areas, major differences in neighborhood features and social processes are linked to birth outcomes of African American women compared to Hispanic and White women. Further research, especially using multilevel approaches, is needed to precisely identify these differences to help reduce racial and ethnic disparities in LBW.

Fetal sex and race modify the predictors of fetal growth

The objective of this study is unknown if fetal sex and race modify the impact of maternal pre-pregnancy body mass index (BMI), and smoking on fetal growth. The authors studied markers of fetal growth in singleton offspring of 8,801 primiparous, normotensive women, enrolled in the Collaborative Perinatal Project. The authors tested for departures from additivity between sex/race and each predictor. The head-to-chest circumference ratio (HCC) decreased more, while birthweight and ponderal index (PI) increased more for each 1 kg/m(2) increase in pre-pregnancy BMI among term females versus males (P = 0.07, P < 0.01 and P = 0.08, interaction respectively). For term offspring of White compared with Black women, smoking independent of "dose" was associated with larger reductions in growth (165 g vs. 68 g reduction in birthweight, P < 0.01, interaction), greater reduction in fetal placental ratio (P < 0.01, interaction), PI (P < 0.01, interaction), and greater increase in HCC (P = 0.02), respectively. The association of BMI and smoking with fetal size appeared to be reversed in term versus preterm infants. Our study provides evidence that the associations of pre-pregnancy BMI and smoking are not constant across sex and race. This finding may be relevant to sex and race differences in neonatal and long term health outcomes.

Maternal prenatal state anxiety symptoms and birth weight: A pilot study

Many women suffer from new or worsening anxiety during pregnancy. In this pilot study, we investigated the effect of timing and severity of prenatal state anxiety symptoms on reduced birth weight. We hypothesized that: (1) Women with state anxiety symptoms during mid-gestation would deliver newborns with lower birth weight in comparison to participants with symptoms in early gestation and (2) compared to women with lower anxiety symptoms (< 50th percentile), women with medium-to-high state anxiety symptoms (> 50th percentile) would have lower birth weight offspring. The sample consisted of the first 30 pregnant women who agreed to participate in this pilot study. We assessed anxiety symptoms, using the State-Trait Anxiety Inventory during early and mid-gestation. We obtained birth weight from clinical charts. A hierarchical multiple regression showed that, after controlling for covariates, state anxiety symptoms in mid-gestation were associated with lower infant birth weight [F(9, 7) = 20.30, p<.001]. However, birth weight did not differ as a function of the severity of maternal state anxiety [F(1, 23)=.14, p=.71 and F(1, 24)=1.76, p=.20., respectively]. Clearly, our pilot data need replication. Once statistical significance is established with larger samples, it will be informative to examine the clinical significance of those findings.

Prenatal hazardous substance use and adverse birth outcomes

OBJECTIVE

Assess the relative effects of a variety of illicit and licit drugs on risk for adverse birth outcomes.

METHODS

We used data from two large prospective investigations, and a novel analytic method, recursive partitioning class analysis to identify risk factors associated with preterm birth and delivering a small for gestational age infant.

RESULTS

Compared to cocaine and opiate non-users, cocaine users were 3.53 times as likely (95% CI: 1.65-7.56; p = 0.001) and opiate users 2.86 times as likely (95% CI: 1.11-7.36; p = 0.03) to deliver preterm. The odds of delivering a small for gestational age infant for women who smoked more than two cigarettes daily was 3.74, (95% CI: 2.47-5.65; p<0.0001) compared to women who smoked two or less cigarettes daily and had one previous child. Similarly, less educated, nulliparous women who smoked two or fewer cigarettes daily were 4.12 times as likely (95% CI: 2.04-8.34; p < 0.0001) to have a small for gestational age infant.

CONCLUSIONS

Among our covariates, prenatal cocaine and opiate use are the predominant risk factors for preterm birth; while tobacco use was the primary risk factor predicting small for gestational age at delivery. Multi-substance use did not substantially increase risk of adverse birth outcomes over these risk factors.

Interpersonal trauma exposure and cognitive development in children to age 8 years: a longitudinal study

BACKGROUND

Childhood trauma exposure has been associated with deficits in cognitive functioning. The influence of timing of exposure on the magnitude and persistence of deficits is not well understood. The impact of exposure in early development has been especially under-investigated. This study examined the impact of interpersonal trauma exposure (IPT) in the first years of life on childhood cognitive functioning.

METHODS

Children (N=206) participating in a longitudinal birth cohort study were assessed prospectively for exposure to IPT (physical or emotional abuse or neglect, sexual abuse, witnessing maternal partner violence) between birth and 64 months. Child intelligent quotient (IQ) scores were assessed at 24, 64 and 96 months of age. Race/ethnicity, gender, socioeconomic status, maternal IQ, birth complications, birth weight and cognitive stimulation in the home were also assessed.

RESULTS

IPT was significantly associated with decreased cognitive scores at all time points, even after controlling for socio-demographic factors, maternal IQ, birth complications, birth weight and cognitive stimulation in the home. IPT in the first 2 years appeared to be especially detrimental. On average, compared with children not exposed to IPT in the first 2 years, exposed children scored one-half SD lower across cognitive assessments.

CONCLUSION

IPT in early life may have adverse effects on cognitive development. IPT during the first 2 years may have particular impact, with effects persisting at least into later childhood.

A pilot study of the nutritional status of opiate-using pregnant women on methadone maintenance therapy

Pregnant women in methadone maintenance therapy may have poor nutrition during pregnancy. In 2006-2008, methadone-treated pregnant women (n = 22) were recruited at an urban academic medical center and compared with nondrug-using pregnant women (n = 119) at 20-35 weeks' gestation. We measured adiposity using prepregnancy body mass index (BMI), dietary intake using a food frequency questionnaire, and micronutrient and essential fatty acid status using biomarkers. Methadone-treated women had lower BMI, consumed more calories, had lower serum carotenoid concentrations, and higher plasma homocysteine concentrations than controls. The study's limitations and implications for future research are discussed.

Maternal smoking during pregnancy and risk of alcohol use disorders among adult offspring

OBJECTIVE

The aim of this study was to evaluate the association between maternal smoking during pregnancy (MSP) and lifetime risk for alcohol use disorder (AUD) and to explore possible mechanisms through which MSP may be related to neurobehavioral conditions during infancy and childhood, which could, in turn, lead to increased risk for AUD.

METHOD

A sample of 1,625 individuals was followed from pregnancy for more than 40 years. Capitalizing on the long follow-up time, we used survival analysis to examine lifetime risks of AUD (diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) in relation to levels of MSP (none, <20 cigarettes/day, and ≥20 cigarettes/day). We then used structural equation modeling to test hypotheses regarding potential mechanisms, including lower birth weight, neurological abnormalities, poorer academic functioning, and behavioral dysregulation.

RESULTS

Relative to unexposed offspring, offspring of mothers who smoked 20 cigarettes per day or more exhibited greater risks for AUD (hazard ratio = 1.31, 95% CI [1.08, 1.59]). However, no differences were observed among offspring exposed to fewer than 20 cigarettes per day. In structural equation models, MSP was associated with neurobehavioral problems during infancy and childhood, which, in turn, were associated with an increased risk for adult AUD.

CONCLUSIONS

MSP was associated with an increased lifetime risk for AUD. Adverse consequences were evident from birth to adulthood. A two-pronged remedial intervention targeted at both the mother (to reduce smoking during pregnancy) and child (to improve academic functioning) may reduce the risk for subsequent AUD.

The relationship between pregnancy intention and preconception health behaviors

OBJECTIVE

To describe smoking, heavy drinking, and folic acid supplementation in preconception women and determine if the likelihood of healthy preconception behaviors differs by whether and when women intend future pregnancy.

METHODS

Analysis was based on 35,351 nonpregnant women who participated in the 2004 Behavioral Risk Factor Surveillance System who were of reproductive age (18-44 years), sexually active, and capable of future pregnancy. The association between future pregnancy intention and preconception behaviors was determined adjusting for diabetes, weight category, age group, race/ethnicity, marital status, education, income, and children living in household.

RESULTS

Eighty percent of women were non-smokers, 94.3% were non-heavy drinkers, and 42.6% were daily folic acid users. In adjusted analysis, only the odds of folic acid supplementation remained higher in women intending pregnancy in the next 12 months (adjusted odds ratio, 1.57; 95% confidence interval, 1.21-2.04) compared with women not intending future pregnancy. Women intending pregnancy later or ambivalent about future pregnancy were no more likely to be engaging in healthy preconception behaviors than women not intending future pregnancy.

CONCLUSION

Women intending pregnancy within 12 months were more likely to use folic acid, but pregnancy intention was not associated with preconception smoking or heavy drinking.

Health status and birth outcomes among pregnant women in substance abuse treatment

PURPOSE

We sought to examine the physical and mental health status and low birthweight and preterm birth among low-income pregnant women in substance abuse treatment.

METHODS

A prospective correlational design was used with 84 pregnant women enrolled in a university-affiliated, comprehensive, hospital-based substance abuse treatment program. The majority of the sample reported heroin as their primary substance of abuse.

RESULTS

Approximately 39% of the infants were born preterm and 27.5% were low birthweight. Poorer perception of current health, cocaine as the primary substance of abuse, and number of prior substance abuse treatment admissions were independently associated with preterm birth. Being African American and a poorer perception of current health were independently associated with low birthweight.

CONCLUSION

Asking about perceptions of their current health is a useful addition to comprehensive assessment for pregnant women with substance abuse problems in any setting. Further knowledge of women's physical and mental health status will improve identification of those who are at even greater risk in a group at high risk overall.

Pregnancy intention and health behaviors: results from the Central Pennsylvania Women's Health Study cohort

OBJECTIVE

Our objective was to determine whether intention for future pregnancy affects selected preconception health behaviors that may impact pregnancy outcomes.

METHODS

Analyses are based on data from a population-based cohort study of women ages 18-45 residing in Central Pennsylvania. A subsample of 847 non-pregnant women with reproductive capacity comprise the analytic sample. We determined the associations between intention for future pregnancy and the pattern in the following health behaviors over a 2-year period: nutrition (fruit and vegetable consumption), folic acid supplementation, physical activity, binge drinking, smoking, and vaginal douching. Multivariable analyses controlled for pregnancy-related variables, health status, health care utilization, and sociodemographic variables.

RESULTS

At baseline, 9% of women were considering pregnancy in the next year, 37% of women were considering pregnancy some other time in the future, and 53% of women were not considering future pregnancy. In multivariable analyses, there were no associations between intention for future pregnancy and maintaining healthy behavior or improving behavior for any of the seven longitudinal health behaviors studied.

CONCLUSIONS

The importance of nutrition, folic acid supplementation, physical activity, avoiding binge drinking, not smoking, and avoiding vaginal douching in the preconception period needs to be emphasized by health care providers and policy makers.

Risk factors for low birth weight infants of Hispanic, African American, and White women in Bexar County, Texas

OBJECTIVES

The aim of this study was to compare the risk factors in women who delivered an infant of low birth weight (LBW, <2,500 g) versus women who delivered an infant weighing >2,500 g in a large metropolitan county (Bexar) in South Texas.

DESIGN

An exploratory case comparison design was used to identify factors related to LBW outcomes in women receiving prenatal care.

SAMPLE

The cases were obtained from community hospitals. A stratified random sample was selected from a population of 38,064 infant births, of which 2,910 were identified as LBW. The final sample size was N=321 (<2,500 g, n=151; >or=2,500 g, n=170).

MEASUREMENTS

Dependent variable of infant birth weight; independent variables of maternal age, maternal race/ethnicity, education, smoking, prior pregnancy history, timing of and number of prenatal visits, prepregnancy body mass index and weight gain during pregnancy, and past medical history and medical problems during pregnancy.

RESULTS

Independent variables found to be predictive of LBW in this study included maternal race/ethnicity, timing of first prenatal visit, number of prenatal visits, prior pregnancy history, and maternal weight gain.

CONCLUSIONS

This study confirmed previous findings that African American women are at a higher risk for LBW deliveries and demonstrated that Anglo and Hispanic women have similar rates of LBW deliveries.

Illicit drug use and adverse birth outcomes: is it drugs or context?

Prenatal drug use is commonly associated with adverse birth outcomes, yet no studies have controlled for a comprehensive set of associated social, psychosocial, behavioral, and biomedical risk factors. We examined the degree to which adverse birth outcomes associated with drug use are due to the drugs versus surrounding factors. Data are from a clinical sample of low-income women who delivered at Johns Hopkins Hospital between 1995 and 1996 (n = 808). Use of marijuana, cocaine, and opiates was determined by self-report, medical record, and urine toxicology screens at delivery. Information on various social, psychosocial, behavioral, and biomedical risk factors was gathered from a postpartum interview or the medical record. Multivariable regression models of birth outcomes (continuous birth weight and low birth weight ([LBW] < 2,500 g)) were used to assess the effect of drug use independent of associated factors. In unadjusted results, all types of drug use were related to birth weight decrements and increased odds of LBW. However, only the effect of cocaine on continuous birth weight remained significant after adjusting for all associated factors (-142 g, p = 0.05). No drug was significantly related to LBW in fully adjusted models. About 70% of the unadjusted effect of cocaine use on continuous birth weight was explained by surrounding psychosocial and behavioral factors, particularly smoking and stress. Most of the unadjusted effects of opiate use were explained by smoking and lack of early prenatal care. Thus, prevention efforts that aim to improve newborn health must also address the surrounding context in which drug use frequently occurs.

An investigation of paternity status and other factors associated with racial and ethnic disparities in birth outcomes in Milwaukee, Wisconsin

OBJECTIVE

To examine factors associated with preterm birth and low birthweight and the role of paternity status in birth outcomes among racial/ethnic groups in Milwaukee.

METHODS

Retrospective analysis of data on 151,869 singleton live births (1993-2006) from the City of Milwaukee, Wisconsin. Multivariate logistic regression models were used to examine demographic and medical factors associated with racial/ethnic disparities in preterm birth and low birthweight.

RESULTS

African-Americans, whites, Hispanics, and women of "other" racial groups accounted for 46%, 33%, 16%, and 5% of births, respectively. Preterm birth and low birthweight rates were three times greater for African-American women compared to whites. Compared to white women, the odds of preterm birth were 82% and 35% greater for African-American and other minority women, respectively. All minority women had greater adjusted odds of low birthweight than whites, with African-American women at greatest risk (OR 2.36:2.23-2.49). Across racial/ethnic groups, significant predictors of both outcomes included being unmarried with no child's father on record, maternal smoking, chronic hypertension, previous preterm birth, and inadequate and adequate plus prenatal care. Paternity status had a gradient effect for whites and Hispanics with unmarried women with no child's father's name on record at greatest risk, followed by those with court-established paternity and those with paternity statement at lowest risk for both outcomes.

CONCLUSIONS

Implementing policies/programs that promote smoking cessation, proper management of maternal conditions, targeted interventions for women with previous preterm birth, and paternal involvement have the potential to reduce disparities in birth outcomes.

Perceived risk of preterm and low-birthweight birth in the Central Pennsylvania Women's Health Study

OBJECTIVE

Engaging women in preconception prevention may be challenging if at-risk women do not perceive increased risk. This study examined predictors of perceiving increased risk for preterm/low birthweight birth.

STUDY DESIGN

Using the Central Pennsylvania Women's Health Study, a population-based sample of reproductive-age women, we analyzed whether sociodemographics, health and pregnancy history, health behaviors, attitudes, or health care utilization predicted risk perception of preterm/low-birthweight birth.

RESULTS

Of the 645 women analyzed, 157 (24%) estimated their risk of preterm/low-birthweight birth to be very or somewhat likely. Higher perceived risk was associated with being underweight, previous preterm/low-birthweight birth, having a mother with previous preterm/low-birthweight birth, lower perceived severity of preterm/low birthweight, and smoking.

CONCLUSIONS

Several factors known to predict preterm/low birthweight did influence risk perception in this study, whereas others did not. Further research on how these factors have an impact on participation in preconception care programs is warranted.

Illicit drug use and neonatal outcomes: a critical review

Although the neonatal consequences of tobacco and alcohol exposure are well established, the evidence related to prenatal illicit drug use is less consistent despite prevalent views to the contrary. The many social, psychosocial, behavioral, and biomedical risk factors for adverse birth outcomes associated with illicit drug use complicate the evaluation of neonatal effects. Placing emphasis on recent research, this review summarizes the epidemiologic literature on the neonatal impact of marijuana, opiate, and cocaine use. Of these drugs, cocaine use is most consistently related to fetal growth decrements and dose-response effects have been observed. However, studies to date have largely failed to control for associated social, psychosocial, and contextual factors. Additional recommendations for future research are provided. It is likely that interventions will need to address the factors surrounding drug use to greatly improve neonatal outcomes (e.g., social circumstances, poor nutrition, stress, infections).

Environmental injustice: childhood lead poisoning, teen pregnancy, and tobacco

PURPOSE

This study investigates the persistent relationships between childhood lead exposure, repeat teen pregnancy, and tobacco use in a sample of teenage females in Syracuse, NY.

METHODS

We analyzed the association of childhood lead poisoning with repeat pregnancy and tobacco use among 536 teens (aged 15-19 years) in Syracuse, NY, who received services at Syracuse Healthy Start between 1998 and 2002.

RESULTS

The mothers' childhood lead exposure, controlling for race, age, and Medicaid status, was associated with repeat teen pregnancy and tobacco use.

CONCLUSION

Long-term negative health outcomes associated with childhood lead exposure should not be underestimated. This study helps to shore up prior research that found lead poisoning to have a long-lasting impact on children's functioning and healthy development. Policy efforts focused on neighborhood development and health education continue to be sorely needed.

Organizational change in a perinatal treatment setting: integration of clinical practice and policies on tobacco and smoking cessation

Perinatal smoking presents serious health risks to the fetus, mother, and child. Despite extensive evidence of risk and high rates of smoking among in-treatment perinatal women substance abusers, tobacco-related practice and policy change has not been widely transferred for application in drug abuse treatment programs for pregnant and parenting women. This qualitative study investigated the process of change and the resultant adoption of clinical policy and treatment innovation in a residential drug abuse treatment program that converted from tobacco-tolerant to tobacco-free with provision of smoking cessation services. Informed by the Organizational Readiness for Change Model, staff interviews and data analysis were conducted to examine program characteristics affecting adoption. An organizational climate of openness to change and the program's clarity of mission, expressed in perinatal-specific motivators for change, influenced the adoption of tobacco-related clinical practice and policy. Re-allocation of time, previously occupied by smoking behaviors, allowed for added promotion of maternal-child interaction and positive role-modeling for children.

Evaluating the social and economic impact of community-based prenatal care

OBJECTIVE

This article describes the evaluation and findings of a community-based prenatal care program, Omaha Healthy Start (OHS), designed to reduce local racial disparities in birth outcomes.

DESIGN

This evaluative study used a comparative descriptive design, and Targeting Outcomes of Programs was the conceptual framework for evaluation.

SAMPLE

The evaluation followed 3 groups for 2 years: OHS birth mothers (N=79; N=157); non-OHS participant birth mothers (N=746; N=774); and Douglas County birth mothers (N=7,962; N=7,987).

MEASUREMENT

OHS provided case management, home visits, screening, referral, transportation, and health education to participants. Program outcome measures included low birth weight, infant mortality, adequacy of care, trimester of care, and costs of care.

RESULTS

OHS birth outcomes improved during year 2, and there was a 31% cost saving in the average hospital expenditure compared with the nonparticipant groups. Preliminary evaluative analysis indicates that prenatal case management and community outreach can improve birth outcomes for minority women, while producing cost savings.

CONCLUSIONS

Further prospective study is needed to document trends over a longer period of time regarding the relationship between community-based case management programs for minority populations, birth outcomes, and costs of care.

Modifiable risk factors for low birth weight and their effect on cerebral palsy and mental retardation

OBJECTIVE

to estimate the effect of modifiable risk factors on low birth weight and two of its sequelae-cerebral palsy and mental retardation.

METHODS

The population attributable risk percent (PARP) was used as a measure of effect. A literature search was conducted to determine estimates of the percent of CP and MR attributable to low birth weight. Data from the 1996-1997 Georgia Pregnancy Risk Assessment Monitoring System (PRAMS), a population based surveillance system, were used to estimate the percent of low birth weight attributable to modifiable risk factors. The PARP was calculated for smoking and unwanted conception.

RESULTS

Unwanted pregnancy and smoking were statistically significant risk factors for LBW. Four percent of all LBW births were attributable to unwanted pregnancy. If all unwanted pregnancies were prevented, 13% of cases of CP (27 cases per year in GA) and 14% of cases of MR (151 cases per year in GA) would be prevented. In wanted or mistimed pregnancies, 6% of LBW births were attributable to smoking. If all smoking during wanted or mistimed pregnancy was prevented, an additional 2.5% (5 cases) of CP and an additional 0.8% (8 cases) of MR would be prevented in Georgia each year. If all unwanted pregnancies and all smoking during wanted or mistimed pregnancies were prevented, 1692 LBW births could be prevented per year and the rate of LBW in Georgia would fall from 7.6% to 6.8%. Additionally, 32 cases of cerebral palsy and 159 cases of mental retardation could be prevented each year in Georgia.

CONCLUSIONS

The PARP approach is useful in estimating the benefit of evidence-based prevention services. Preventing unwanted pregnancy and smoking during pregnancy would substantially reduce the burden of cerebral palsy and mental retardation in Georgia.

Prenatal drug use and the production of infant health

We estimate the effect of illicit drug use during pregnancy on two measures of poor infant health: low birth weight and abnormal infant health conditions. We use data from a national longitudinal study of urban parents that includes postpartum interviews with mothers, hospital medical record data on the mothers and their newborns, and information about the neighborhood in which the mother resides. We address the potential endogeneity of prenatal drug use. Depending on how prenatal drug use is measured, we find that it increases low birth weight by 4-6 percentage points and that it increases the likelihood of an abnormal infant health condition by 7-12 percentage points.

Pre-eclampsia is associated with sleep-disordered breathing and endothelial dysfunction

Pre-eclamptic toxaemia (PET) may be associated with both endothelial dysfunction (ED) and sleep-disordered breathing (SDB). It was hypothesised that females with PET would demonstrate both SDB and ED, and that a correlation between these two would suggest a potential causative association. A total of 17 females with PET and 25 matched females with uncomplicated pregnancy were studied. They underwent a nocturnal ambulatory sleep study (using Watch_PAT100) and noninvasive evaluation of endothelial function utilising the reactive hyperaemia test (using Endo_PAT 2000). A higher ratio of post- to pre-occlusion pulse-wave amplitude (endothelial function index (EFI)) indicated better endothelial function. Females with PET had a significantly higher respiratory disturbance index (RDI) and lower EFI than controls (18.4+/-8.4 versus 8.3+/-1.3.h(-1), and 1.5+/-0.1 versus 1.8+/-0.1, respectively). Blood pressure significantly correlated with RDI and with EFI. EFI tended to correlate with RDI. In conclusion, these results suggest that both sleep-disordered breathing and endothelial dysfunction are more likely to occur in females with pre-eclamptic toxaemia than in females with uncomplicated pregnancies. The current authors speculate that respiratory disturbances contribute to the functional abnormality of the blood vessels seen in females with pre-eclamptic toxaemia, although causality cannot be determined based on this study.

Minor physical anomalies are not increased in the offspring of mothers with systemic lupus erythematosus

OBJECTIVE

To determine the incidence and type of minor physical anomalies (MPAs) in infants born to mothers with systemic lupus erythematosus (SLE).

METHODS

Each trimester, pregnant women with SLE were assessed for disease activity, prescribed drug use, and exposure to tobacco, alcohol, and illicit drugs through a self reported questionnaire. Infant examinations were performed on 30/39 (77%) live births in women with SLE and the incidence of MPAs determined.

RESULTS

2/30 (7%) patients had three or more MPAs; 4 (13%) had two; 7 (23%) had one; and 17 (57%) had none. One in three women reported alcohol, tobacco, and illicit drug use. Facial anomalies were the most common MPAs. The relative risk and 95% confidence interval for any MPA were 2.05 (0.99 to 4.26) for tobacco use; 1.95 (0.92 to 4.11) for alcohol use; 1.36 (0.165 to 11.23) for maternal disease flare; 0.63 (0.27 to 1.47) for prednisone use; and 0.72 (0.21 to 2.44) for aspirin use.

CONCLUSION

13/30 (43%) infants had minor anomalies-a similar incidence to that of the general population. Counselling for preventable self reported exposure is advisable in addition to counselling specifically for lupus management during pregnancy.

Obstetricians, gynecologists and the anti-smoking campaign: a national survey

OBJECTIVE

To asses the role Jordanian obstetricians and gynecologists play as tobacco cessation counsellors through examining their smoking status, opinions on health risks, factors that influence tobacco use and their perceived barriers to providing effective counselling.

STUDY DESIGN

The setting is a tertiary referral university hospital. A pre-tested postal questionnaire survey was mailed to all 462 licensed obstetricians and gynecologists in Jordan. Descriptive statistics were generated and statistical significance was determined by the chi2-test.

RESULTS

Of 392 respondents, 37.9% were smokers. Most associated smoking with low birth weight and sudden infant death syndrome. Fewer associated smoking with infertility, ectopic pregnancy, placenta praevia, abruptio placentae and cancer of the uterine cervix. Friends, stress, parents' attitude, genetic predisposition, income and education were implicated factors for smoking. Current smokers were more likely to permit smoking in their practices. Non-smokers were most inclined to record their patients' tobacco habits. Only 54.3% provided cessation counselling. Lack of time and inadequate training were perceived barriers.

CONCLUSIONS

A high proportion of obstetricians and gynecologists are smokers. A training program is needed to equip health workers with the skills necessary for the implementation of a successful anti-smoking campaign.

Intrauterine growth retardation in full-term newborn infants with birth weights greater than 2,500 g

Intrauterine growth retardation (IUGR) is an overlooked problem in full-term infants with birth weights greater than 2,500 g. Birth weight less than the 10th percentile underestimates the presence of IUGR. The purpose of this study was to determine the prevalence of IUGR in full-term infants and to identify sociodemographic and maternal characteristics associated with IUGR. The Ohio Department of Health Vital Statistics database was used to obtain data related to sociodemographic and maternal characteristics. The fetal growth ratio (FGR) was used to determine the presence of IUGR. The sample consisted of 1,569 infants with normal ratios and 1,364 infants classified as IUGR. Infants with IUGR were more often male and African American or Asian American. Maternal characteristics associated with IUGR included history of smoking during pregnancy, lower pre-pregnancy weight, lower weight gain during pregnancy, and inadequate prenatal care. IUGR is present in a significant number of full-term infants with birth weights greater than 2,500 g. The long-term effects of IUGR in these infants remain to be determined.

Consumo de tabaco durante el embarazo en España: análisis por años, comunidades autónomas y características maternas

BACKGROUND AND OBJECTIVE

The information about the convenience of non-smoking during pregnancy has increased in recent years. For this reason, we studied weather there has been any variation in smoking habits by pregnant women in Spain.

SUBJECTS AND METHOD

We used data from 31,056 mothers of infants without congenital defects, from all the Spanish Autonomic Regions. These data had been collected with the same methodology all over the country. The evolution of maternal smoking habit was analyzed by years, Autonomic Regions and maternal characteristics.

RESULTS

During the last years of the study (1995-2002), 30.31% of mothers smoked during pregnancy, with variations among different ethnic groups. It was observed a secular increase in the prevalence of smoker mothers from 1978 to 1991, which was further stable in about 27-28%. There was no secular decrease in the analyses by maternal age, number of cigarettes, and Autonomic Regions. Only smoker mothers with higher educational levels diminished smoking in 1993, with it being stable in about 23%. Mothers younger than 25 years were the heaviest smokers in all the years of the study. We confirmed a close relationship between tobacco, alcohol and illegal drugs consumption.

CONCLUSIONS

Our data indicate that the prevalence of women smoking during pregnancy has not diminished over the years or by Autonomic Regions, although 19.19% of smoker pregnant women quit smoking during the first months of pregnancy. Moreover, the heaviest smoker mothers were the youngest ones in all the years of the study. These results show the need to increase the information for women so that they quit smoking before pregnancy.