Dysphoria among high-risk pregnant hospitalized women on bed rest: a longitudinal study

Prevalence and risk factors of postpartum depressive symptoms at 42 days among 2462 women in China

BACKGROUND

Postpartum depression is a common and serious mental health problem that is affecting an increasing percentage of the world's population. We aimed to evaluate the prevalence of postpartum depressive symptoms in Beijing, China, during the COVID-19 pandemic and identify several potential risk factors.

METHODS

This was a cross-sectional observational study conducted at Peking University First Hospital from 2020 to 2021. Women who delivered and had postpartum reviews at 42 days after delivery were invited to complete the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) under the guidance of trained nurses. A score of ≥10 was used as the threshold of postpartum depression. t-tests, chi-square tests or Mann-Whitney U tests were applied. A multivariate logistic regression analysis was conducted to assess the risk factors for postpartum depressive symptoms.

RESULTS

A total of 2462 mothers were included in this study, 20.2 % of whom were considered to have postpartum depressive symptoms. Multivariate logistic regression analysis showed that formula feeding (OR = 2.219, 95 % CI: 1.300-3.786, P = 0.013), preterm birth (OR = 1.619, 95 % CI: 1.108-2.367, P = 0.013), cervical insufficiency (OR 3.022, 95 % CI: 1.200-7.615, P = 0.019) and history of depression (OR = 6.519, 95 % CI: 1.537-27.659, P = 0.011) were associated with a high prevalence of postpartum depressive symptoms.

CONCLUSION

There is a high prevalence of postpartum depressive symptoms in developed regions of China during the COVID-19 pandemic. More attention should be given to mothers with risk factors for PPD, and follow-up care is needed.

Impact of Physical Activity Interventions on High-Risk Pregnancies: A Systematic Review and Meta-Analysis

Pregnant women with absolute contraindications may be advised against physical activity throughout pregnancy. In this context, bed rest elevates the short-term risk of neonatal complications, thereby exacerbating negative long-term effects on childhood development. The aim of the current study was to investigate the impact of various physical activity interventions during bed rest or activity restriction in pregnancy on factors such as birth weight, preterm birth, maternal hypertension, gestational age at delivery, and the incidence of cesarean sections. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was designed. The protocol was registered in the International Prospective Registry of Systematic Reviews (PROSPERO) (CRD42022370875). Nine studies, with a total sample of 3173 women, from six countries on four continents were included. There were significant differences in the relationship between bed rest status and birth weight (Z = 2.64; p = 0.008) (MD = 142.57, 95% CI = 36.56, 248.58, I2 = 0%, Pheterogeneity = 0.45) favourable to active groups. No significant differences were found in other analyzed outcomes. Pregnant women who experience this problem must maintain a minimum of daily activity to alleviate these physiological complications and the medical field must understand the consequences of physical inactivity during pregnancy.

Maternal anxiety forecasts shorter prolongation of pregnancies complicated by early-onset preeclampsia

PURPOSE

In early-onset preeclampsia, each additional day of pregnancy prolongation reduces offspring infant mortality about 9%. We evaluated if maternal stress at admission to hospital for early-onset preeclampsia predicted admission-to-delivery intervals in days.

METHODS

This prospective, longitudinal cohort-study involved 15 singleton pregnancies with a diagnosis of preeclampsia before 34 weeks gestation with intended expectant management. Upon hospital admission, maternal psychological stress was assessed with questionnaires and physiological stress with hair cortisol. Hair samples were analyzed in three hair segments representing the preconception period, and the first and second trimester of pregnancy.

RESULTS

Mean pregnancy prolongation was 16.2 days. Higher maternal anxiety at hospital admission significantly correlated with shorter admission-to-delivery intervals (r = - 0.54, p = 0.04). Chronically increased hair cortisol concentrations (i.e. from preconception through the second trimester) of pregnancy tended to be related to shorter admission-to-delivery intervals (p <. 10).

CONCLUSION

Higher reported anxiety is, and chronically high hair cortisol tended to be, related with fewer days of prolongation from admission to delivery in women with early-onset preeclampsia. These findings suggest that maternal stress might be a potential determinant of disease progression. Future research into early innovative stress-reducing interventions for early-onset preeclampsia may shed more light on the etiology and treatment of this disease.

Effects of Recreational Therapy and 3D Ultrasonography for High-Risk Pregnancies on Psychological Well-Being during Hospitalization and in the Puerperal Phase

Hospitalization during pregnancy often produces psychosocial distress for pregnant women. In this study, 3D ultrasound and recreational therapy were compared to the standard treatment for their influence on depressive symptoms and anxiety. In this prospective one-year intervention study, women who were admitted to the hospital for any pregnancy complication, other than psychiatric, were included. A control group, with standard clinical treatment, and two intervention groups, both additionally receiving either 3D ultrasound or recreational therapy, were established. Psychological well-being was assessed at defined times by the PHQ-health-questionnaire. A total of 169/211 women were included: control group n = 79, 3D ultrasound group n = 43, and crochet group n = 83. A higher than estimated underlying depression was seen for all women on admission. The intervention groups showed less depression (p = 0.02762). No difference was seen between the intervention groups (p = 0.23029). Anxiety decreased throughout intervention, but not significantly. On admission, all women showed similar results of underlying depression, indicating that hospitalization itself already causes mild psychological stress. Both interventions decreased depressive symptoms. Intervention with either recreational therapy or 3D ultrasound can prevent the development of mild and major depression and decrease anxiety disorders, and therefore has a positive effect on well-being during hospitalization. These results emphasize the need to implement forms of interventions to improve the well-being of women, as this might improve pregnancy and neonatal outcome.

Do prenatal depressive symptoms developed by hospitalized women with high-risk pregnancy persist to post-partum?

This study aims to explore the level of depressive symptoms during pregnancy and after childbirth comparing women hospitalized due to high-risk pregnancy (clinical group) and women with low-risk pregnancy (control group). Seventy pregnant women (26 clinical group and 44 control group) filled in the Edinburgh Postnatal Depression Scale both during pregnancy and three months after childbirth. Results showed that the clinical group reported significant higher levels of prenatal depression than the control group, while no differences were found on postnatal depression. Data highlighted that hospitalization could represents a significant stressor that can exacerbate depression in women with high-risk pregnancy.

Adherence to recommended physical activity restrictions due to threatened preterm delivery - a descriptive multi-center study

BACKGROUND

Threatened preterm delivery is a serious obstetrical complication and has for decades been prescribed physical activity restrictions (AR). Adherence to the recommended level of physical AR is however unknown. This study aimed to assess the objectively measured different physical positions and activities of pregnant women recommended AR due to threatened preterm delivery complications, compared to a reference group of uncomplicated pregnant women without restrictions, and to explore if admission status influenced adherence to AR.

METHODS

A Danish descriptive, clinical multi-center study included singleton pregnancies between 22-33 gestational weeks admitted to an antenatal ward or during midwife consultations either prescribed AR due to threatened preterm delivery or uncomplicated controls without restrictions. For seven days participants wore two tri-axial accelerometric SENS® monitors. Accelerometric data included time spent in five different positions, activities, and step counts. At inclusion demographic and obstetric information was collected.

RESULTS

Seventy-two pregnant women participated; 31% were prescribed strict AR, 15% moderate, 3% light, 8% unspecified, and 43% had no AR. Strict AR participants rested in the supine/lateral position for 17.7 median hours/day (range:9.6-24.0); sat upright 4.9 h/day (0.11-11.7); took 1,520steps/day (20-5,482), and 64% were inpatients. Moderate AR participants rested in the supine/lateral position for 15.1 h/day (11.5-21.6); sat upright 5.6 h/day (2.0-9.3); took 3,310steps/day (467-6,968), and 64% were outpatients. Participants with no AR rested 10.5 h/day (6.3-15.4) in supine/lateral position; sat upright 7.6 h/day (0.1-11.4) and took 9,235steps/day (3,225-20,818). Compared to no restrictions, participants with strict or moderate AR spent significant more time in physical resting positions and took significant fewer mean steps. Among strict AR admission status did not alter time spent in the physical positions, nor the step count.

CONCLUSIONS

Overall, participants adhered highly to the recommended AR. However, discriminating between strict and moderate AR recommendations did not alter how physical resting positions and activities were carried out. The admission status did not influence how participants adhered to strict AR.

Beneficial Effects of Maternal Physical Activity during Pregnancy on Fetal, Newborn, and Child Health: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

The objective of this work is to synthesize current knowledge about the effects of maternal physical activity during pregnancy on children's health. During the prenatal and postnatal periods, maternal physical activity has protective effects against the risks of macrosomia, obesity, and other associated cardiometabolic disorders. Even though longitudinal studies in humans are still necessary to validate them, these effects have been consistently observed in animal studies. A remarkable effect of maternal physical activity is its positive role on neurogenesis, language development, memory, and other cognitive functions related to learning.

Animal Crossing and COVID-19: A Qualitative Study Examining How Video Games Satisfy Basic Psychological Needs During the Pandemic

The COVID-19 pandemic has affected the way many people live their lives. The increasing amount of time spent indoors and isolated during periods of lockdown has been accompanied by an increase in the time people spend playing video games. One such game which soared in popularity during the early stages of the pandemic was Animal Crossing: New Horizons. Through semi-structured interviews with players, and using a theory-informed qualitative analysis, we document and examine players’ motivations and experiences playing Animal Crossing: New Horizons during the pandemic. Findings suggest that playing the game helped satisfy various psychological needs—autonomy, relatedness, and competence—as described by Self-Determination Theory. Conversely, players stopped playing the game when they found that their psychological needs were thwarted or better met through other activities. Our findings offer support that video games can offer psychological relief in stressful contexts by providing opportunities for people to satisfy key psychological needs. Theoretical and practical implications are discussed.

Special Considerations Regarding Antenatal Care and Pregnancy Complications in Dichorionic Twin Pregnancies

Twin pregnancies account for about 3.3% of all deliveries in the United States with the majority of them being dichorionic diamniotic (DCDA). Maternal physiological adaption in twin pregnancies is exaggerated and the rate of almost every maternal and fetal complication is higher when compared to singleton pregnancies. Therefore, twin pregnancies necessitate closer antenatal surveillance by care providers who are familiar with the specific challenges unique to these pregnancies, and there is evidence that following women with twins in a specialized twin clinic can result in improved obstetrical outcomes. The importance of the first antenatal visit in twin pregnancies cannot be over emphasized and should preferably take place early in gestation as it is the optimal period to correctly identify the number of fetuses and the type of placentation (chorionicity and amnionicity). This will allow the patients, families, and caregivers to make the appropriate modifications and to tailor an optimal antenatal follow-up plan. This plan should focus on general recommendations such as weight gain and level of activity, education regarding complications specific to twin pregnancies along with the relevant symptoms and indications to seek care, as well as on close maternal and fetal monitoring. In this review, we summarize available evidence and current guidelines regarding antenatal care in DCDA twin pregnancies.

Prevalence of Depression or Anxiety During Antepartum Hospitalizations for Obstetric Complications: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the prevalence of antenatal depression and anxiety in women hospitalized in an antepartum unit for obstetric complications.

DATA SOURCES

We searched PubMed, EMBASE, CINAHL, PsycINFO, and ClinicalTrials.gov for English-language articles published from database inception through March 2020.

METHODS OF STUDY SELECTION

We included cross-sectional, cohort, case-control, quasi-experimental, and randomized controlled studies from any country that reported the proportion of pregnant women with an elevated depression or anxiety screening scale or diagnostic interview during antepartum hospitalization of any duration and at any gestational age.

TABULATION, INTEGRATION, AND RESULTS

We identified 8,799 articles and reviewed 79, 39 of which were included in a systematic review and 18 in meta-analysis of the primary outcome. Two raters independently assessed quality of individual studies using a 14-question tool. A random effects meta-analysis model was used to estimate prevalence and 95% CI of depression or anxiety. Heterogeneity was examined with the I2 test, and funnel plots were used to assess publication bias. After meta-analysis, the estimated prevalence of depression was 34% (95% CI 27-41%) and of anxiety 29% (95% CI 16-43%). There was expected substantial clinical and methodologic heterogeneity between studies that persisted even after planned a priori subgroup analyses and meta-regression. Even so, the direction of effect was consistent across studies. No publication bias was found.

CONCLUSION

The current meta-analysis suggests that one in three women hospitalized during pregnancy for obstetric complications report clinical levels of depression or anxiety symptoms, twice the reported prevalence of antenatal depression or anxiety in the general obstetric population.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020172111.

Community-based, population-focused preterm birth prevention programs - a review

PURPOSE

Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality worldwide. Being born too early contributes to approximately 70% of neonatal mortality and approximately half of long-term neurodevelopmental disabilities. Various PTB prevention programs have been described going back more than 30 years, and some have described possible success in decreasing the rate of PTB. In addition, there are also PTB prenatal care clinics in many parts of the world, each with the singular goal of reducing the PTB rate in their region. Interventions can be directed at all women for primary prevention and reducing the risk of PTB or used to mitigate risk in women identified to be at increased risk.

METHODS

A Medline and ClinicalTrials.gov ( www.clinicaltrials.gov ) search was performed (1982-2018), using preterm birth prevention program as the primary medical subject heading, reporting randomized clinical trials, quasi-experimental trials, and analytic studies (including retrospective and prospective cohort studies). We also searched Google for preterm birth prevention programs and prenatal care clinics published on-line.

RESULTS

Some prevention programs have reported success in lowering rates of PTB, principally using historical controls although the majority were not followed by improved outcomes.

CONCLUSION

Increasing knowledge and the use of social media to enhance education should now enable greater effectiveness of new programs. Development of regional and national PTB prevention programs should now be considered.

Society for Maternal-Fetal Medicine Consult Series #50: The role of activity restriction in obstetric management: (Replaces Consult Number 33, August 2014)

Despite current recommendations against its use, activity restriction remains a common intervention used to prevent preterm birth in multiple clinical settings. Hypertensive disorders of pregnancy, preterm premature rupture of membranes, multiple gestations, vaginal bleeding, short cervical length, placenta previa, and fetal growth restriction are also common reasons for antepartum hospital admission and frequently lead to a recommendation for activity restriction. However, numerous reports have shown that activity restriction does not prevent adverse obstetrical outcomes but does confer significant physical and psychosocial risks. This consult reviews the current literature on activity restriction and examines the evidence regarding its use in obstetrical management. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we recommend against the routine use of any type of activity restriction in pregnant women at risk of preterm birth based on preterm labor symptoms, arrested preterm labor, or shortened cervix (GRADE 1B); (2) we recommend against the use of routine inpatient hospitalization and activity restriction for the prevention of preterm birth in women with multiple gestations (GRADE 1A); and (3) given the lack of data definitively demonstrating that activity restriction improves perinatal outcome in pregnancies complicated by fetal growth restriction, preterm premature rupture of membranes, or hypertensive diseases of pregnancy, coupled with evidence of adverse effects of activity restriction, we suggest that activity restriction not be prescribed for the treatment of pregnancies complicated by fetal growth restriction, preterm premature rupture of membranes, or hypertensive disease (GRADE 2B).

Experiences of interactive ultrasound examination among women at risk of preterm birth: a qualitative study

BACKGROUND

Pregnant women who are at risk of preterm birth are often stressed, anxious and depressed because of worries and fears related to the health of the unborn baby, their own health and uncertainty about the future. Only a few studies have assessed the types of psychological support that would relieve these stress symptoms among women with high-risk pregnancies. The aim of this study was to describe 1) how women at risk of preterm birth experienced an interactive 3/4-dimensional (3/4D) ultrasound examination, and 2) their need for psychological support during the antenatal period.

METHODS

This qualitative study was conducted at one university hospital in Finland in 2017. Women with a singleton pregnancy of 26-32 gestational weeks (gwks) were included in the study. The interactive 3/4D ultrasound included a joint observation of the baby, based on the mother's wishes, with an obstetrician and psychologist. After the examination, the experiences were explored with a semi-structured interview. The data was analyzed using inductive thematic analysis.

RESULTS

The women enjoyed the fact that the staff were focused on her fetus and genuinely present during the session and also enabled the women to actively participate. Watching the baby and her/his activities made the baby more concrete and relieved their concerns. The need for additional psychological support varied individually.

CONCLUSIONS

Interactive ultrasound examination is an interesting way to awaken mental images, increase attachment, and reduce stress. The results imply that an interactive way of jointly looking at the fetus supports pregnant women at risk of preterm birth and may be useful in clinical practice.

ON BEING MOTHER AND PATIENT: DIALECTICAL STRUGGLES DURING MEDICALLY HIGH-RISK PREGNANCY

Medically high-risk pregnancy (MHRP) affects 3 to 10% (diagnosis-dependent) of pregnant women in the United States (National Institute of Child Health Development, 2015), threatening maternal and fetal well-being. Although mothers' prenatal distress and mother-infant attachment after birth have been quantitatively researched, little research has examined women's lived experiences of MHRP in the United States. We examined 16 women's experiences of MHRP during hospitalization at an urban, Northeastern U.S. hospital using an interpretive phenomenological approach. Our qualitative findings provide new understanding of how women expend tremendous energy simultaneously navigating new roles of mother and patient. While negotiating these roles, they experienced dialectical struggles and uncertainty relating to emotion management, locus of control, appraisals of self/others, and relational self. Women managed these conflicts within the contexts of their emerging maternal identity, patient-provider relationships, and social relationships. Women struggled as they managed emotion, determined their level of responsibility for fetal outcomes, appraised others and themselves, and worried about how they were perceived. This amplified distress and contributed to women's emotional exhaustion, sense of being overwhelmed, and stress burden. New explication of these energy-depleting dynamic processes underlying women's experiences of MHRP and their impact on the future mother-infant relationship is considered, and strategies for psychosocial support are identified.

NICU Network Neurobehavioral Scale: 1-month normative data and variation from birth to 1 month

BackgroundThe Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) is a standardized method for infant neurobehavioral assessment. Normative values are available for newborns, but the NNNS is not always feasible at birth. Unfortunately, 1-month NNNS normative data are lacking.AimsTo provide normative data for the NNNS examination at 1 month and to assess birth-to-one-month changes in NNNS summary scores.Study designThe NNNS was administered at birth and at 1 month within a longitudinal prospective study design.SubjectsA cohort of 99 clinically healthy full-term infants were recruited from a well-child nursery.Outcome measuresBirth-to-1-month NNNS variations were evaluated and the association of neonatal and sociodemographic variables with the rate of change of NNNS summary scores were investigated.Results and conclusionsNNNS scores from the 10th to the 90th percentile represent a range of normative performance at 1 month. A complex pattern of stability and change emerged comparing NNNS summary scores from birth to 1 month. Orienting, Regulation, and Quality of movements significantly increased, whereas Lethargy and Hypotonicity significantly decreased. Birth-to-1-month changes in NNNS performance suggest improvements in neurobehavioral organization. These data are useful for research purposes and for clinical evaluation of neurobehavioral performance in both healthy and at-risk 1-month-old infants.

Health-care Needs of High-risk Pregnant Women Hospitalized in Maternal-Fetal Intensive Care Units: A Mixed-methods Design

PURPOSE

To identify the characteristics and health-care needs of high-risk pregnant women in maternal-fetal intensive care units (MFICU).

METHODS

mixed-methods design was adopted. Data were collected from 78 high-risk pregnant women admitted to the MFICU. Qualitative data included ten participants' experiences with hospitalization and childbirth, which were analyzed using mixed content analysis. Quantitative data were analyzed using at-test and one-way ANOVA testing.

RESULTS

The average score for pregnancy and childbirth health-care needs was 3.54 points. Average score by area was before-admission health care (3.70), health care of baby (3.67), health of childbirth (3.61), postpartum health (3.51), and pregnancy health care during hospitalization (3.48). Qualitative results showed diverse feelings and experiences of high-risk pregnant women and their need for health care, which was expressed in three themes and 11 sub-themes.

CONCLUSION

Nurses should recognize high-risk mothers' feelings and needs for pregnancy and childbirth-focused health care to help patients accept their vulnerability and cope positively.

Special features of high-risk pregnancies as factors in development of mental distress: a review

Introduction:

Approximately 22% of all pregnant women are classified as having high-risk pregnancies, which may involve feelings of vulnerability because of having a high-risk pregnancy, resulting in greater exposure to stressful feelings.

Objective:

To review aspects of high-risk pregnancy that can have a negative impact on the these women's mental health status.

Method:

Original articles were identified by conducting searches of the PubMed/MEDLINE, LILACS and SciELO databases, followed by a manual search of references to select articles and additional bibliographic material. Articles from the last 22 years were included in the review (1992-2014).

Results:

Fifteen articles were found that specifically studied high-risk pregnancies and mental health outcomes. Women with high-risk pregnancies exhibited a significantly higher level of stress and reported negative emotions as they dealt with stress and had worse emotional status than women with normal pregnancies. Researchers found that hospitalized pregnant women had higher levels of anxiety than non-hospitalized women. Studies of women going through normal and high-risk pregnancies show that women with normal pregnancies had good self-perceived quality of life.

Conclusion:

Special features of high-risk pregnancies could be factors in development of mental distress, in addition to psychological and social factors. Therefore, only a biopsychosocial research study would be able to identify the factors that can affect the quality of mental health during high-risk pregnancy.

Antepartum Bed Rest: Maternal Weight Change and Infant Birth Weight

Despite lack of evidence for effectiveness, obstetricians in the United States prescribe antepartum bed rest for more than 700,000 women per year. However, in nonpregnant samples, bed rest treatment produces weight loss. This study assessed maternal weight change (gain) during antepartum hospitalization for bed rest treatment; compared appropriateness of infant birth weights for gestational age, race, and gender; and determined whether maternal weight change predicted infant birth weight. The convenience sample for this longitudinal study consisted of 141 women with high-risk pregnancies who were treated with hospital bed rest. Weekly rate of pregnancy weight change by body mass index was compared with Institute of Medicine recommendations for rate of pregnancy weight gain. Infant birth weight was compared with current US infant birth weights for matching gestational age, gender, and race. Weekly antepartum weight change was significantly lower than Institute of Medicine recommendations (P < 0.001). Infant birth weights were also significantly lower than the national mean when matched for each infant’s gestational age, race, and gender ( P < 0.001). Maternal weight change predicted infant birth weight ( P = 0.05). Bed rest treatment is ineffective for improving pregnancy weight gain. Lower infant birth weights across all gestational ages suggest that maternal weight loss during bed rest may be associated with an increased risk of fetal growth restriction. A randomized trial comparing women with high-risk pregnancies who are ambulatory with those on bed rest is needed to determine whether bed rest treatment, underlying maternal-fetal disease, or both influence inadequate maternal weight gain and poor intrauterine growth.

Multiple Gestation: Side Effects of Antepartum Bed Rest

The birth rate for higher order multiples has dramatically increased in recent decades. Multiple gestation pregnancies are considered to be at high obstetric risk. Antepartum bed rest is often prescribed to offset complications despite the lack of evidence for its effectiveness in preventing complications. This longitudinal repeated-measures study identified side effects of antepartum bed rest treatment for 31 hospitalized women with twin or triplet gestation. Maternal weight gain and infant birth weight were recorded. Antepartum stressors were measured by the Antepartum Stressors Hospital Inventory, and depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale (CES-D). Antepartum and post-partum side effects of bed rest were also assessed by the Antepartum and Postpartum Symptom Checklists. The weekly rate of maternal weight gain during hospitalization was significantly less than recent recommendations for multiple gestation weight gain (t =– 2.14,p = .04). Infant birth weights were appropriate for gestational age. There were fewer than expected small-for-gestational-age infants. Concerns regarding family status and separation from family were the major antepartum stressors. Women reported a high number of symptoms during bed rest (M= 22), which did not significantly change across 2 weeks. CES-D scores for depressive symptoms were high on antepartum hospital admission. Postpartum symptoms were initially high but had significantly declined by 6 weeks: F(1, 27)= 15.68, p = .00. These findings suggest that interventions are needed to reduce antepartum maternal weight loss, stress, physiologic and psychosocial symptoms, and depressive symptoms, as well as reduce postpartum symptoms of maternal morbidity.

Hospitalization History and Differences in Self-Rated Pregnancy Risk

High-risk pregnancies affect a significant number of women each year. Limited information exists on how these women appraise the risk to their pregnancy. This descriptive study of expectant women who were medically categorized as high risk examined differences in women's self-appraisal of risk to themselves and their babies, based on hospitalization history, and differences among risk appraisals made by women and their health care providers. Women who were currently hospitalized had significantly lower self-appraised mother risk scores than both the women who were previously hospitalized and those never hospitalized. Women who were never hospitalized had significantly lower self-appraised baby risk scores than the women in both the currently and previously hospitalized groups. Women who were previously hospitalized scored highest on self-appraised risk to mother and risk to baby. Women reported significantly lower self-appraised risk to mother scores than their nurses.

Changing prevalence and the risk factors for antenatal obstetric hospitalizations in Denmark 2003-2012

Purpose

Population-based studies evaluating the use and extent of antenatal obstetric hospitalizations (AOH) are sparse. The objective of the present study was to describe the prevalence, time trend, and risk factors for AOH in Denmark.

Materials and methods

A retrospective national register-based cohort study was conducted that included all pregnancies with delivery after 22 gestational weeks in Denmark from 2003 to 2012. The outcomes were AOH and the diagnoses leading to these hospitalizations. AOH was defined as an antenatal hospitalization for at least 1 day with at least one obstetric International Classification of Diseases-10 diagnosis and admission date more than 3 days before delivery.

Results

The study included 617,906 pregnancies; 48,366 (7.8%) pregnancies were associated with 64,072 AOH before delivery. The percentage of pregnancies with AOH decreased from 8.6% to 7.1%. The median length of stay decreased from 3 to 2 days, and admission for at least 7 days was almost halved. Threatened preterm delivery was the most frequent diagnostic category for AOH. A decline was seen in all diagnostic categories except maternal diseases. Significant risk factors for AOH were multiple pregnancies, low or high maternal age and body mass index, nulliparity, lower educational levels, unemployment or being outside the workforce, single partner status, and smoking. The relative risk of very preterm delivery before gestational age of 34 weeks was higher in pregnancies with AOH compared with pregnancies without AOH (relative risk 15.2; 95% confidence interval: 14.6–15.8).

Conclusion

This study shows a shift toward less use and shorter duration of antenatal hospitalization in Denmark. The most common indication used in pregnancies with AOH was threatened preterm delivery, and more than one-third resulted in very preterm deliveries.

Perceptions of guided imagery for stress management in pregnant African American women

Maternal stress during pregnancy has been associated with numerous adverse pregnancy, birth, and health outcomes. Pregnant African American women have been reported to have higher levels of stress compared to other ethnic or racial groups underscoring the need for effective interventions to reduce stress in this population. The purpose of this study was to gain an in-depth understanding of the perceptions of guided imagery (GI) as a technique for stress management in a cohort of pregnant African American women who participated in a GI intervention as part of a larger mixed methods randomized controlled trial. The 12week intervention was a professionally recorded compact disc with four tracks developed and sequenced to reduce stress and associated symptoms. The findings from this descriptive phenomenologic study were derived from daily logs and interviews from 36 participants randomized to the GI group. Participants described the stressful nature of their lives. Results demonstrated pregnant African American women perceived the intervention as beneficial in reducing stress and the associated symptoms. The emergent themes suggested the intervention offered a respite from their stressful lives, reduced the negative emotional responses to stress and enhanced well-being, benefited other areas of their daily life, and provided an opportunity to connect with their baby. The study results support the perceived efficacy of GI as a stress coping intervention. GI is an economic as well as easy to implement, access and use technique that has potential stress coping benefits as perceived by pregnant African American women.

Relationship between Health Promoting Lifestyle and Perceived Stress in Pregnant Women with Preeclampsia

INTRODUCTION

Lifestyle during pregnancy has long-term effects on health of mother and child. Having previous illness or unexpected maternal or fetal conditions such as preeclampsia can complicate pregnancy and interfere with health-promoting behaviors and cause stress might interfere with health-promoting behaviors. This study was carried out to examine the relationship between health-promoting lifestyles and perceived stress in women with preeclampsia.

METHODS

This study is a descriptive correlation design that was conducted on 182 pregnant women with preeclampsia attending in the high risk clinics of Al-Zahra and Talegani hospitals in Tabriz 2014. Data gathering tools were three: demographics, health-promoting lifestyle (HPLP-II), and perceived stress questionnaires. SPSS Ver. 13 was used for data analysis.

RESULTS

The mean (SD) of health promoting lifestyle among pregnant women with preeclampsia was 2.4 (0.4). Among the dimensions of health promoting life style, the highest mean score was for sub domain of nutrition, i.e. 2.8 (0.5), and the lowest score was achieved by the sub-domains of physical activity, i.e. 1.5 (0.5).The mean (SD) score of perceived stress was 27.3 (7.1). There was reverse relationship between perceived stress and health -promoting behaviors.

CONCLUSION

Based upon the results, health promoting behaviors were decreased by increment of perceived stress. Therefore, midwives can help women with preeclampsia by promoting health behaviors to reduce their stress and increase health-promoting behaviors.

Predictors of anxiety among pregnant New Zealand women hospitalised for complications and a community comparison group

OBJECTIVE

to investigate predictors of anxiety for women experiencing hospitalisation during pregnancy and a comparison group of pregnant women (with or without medical complications) in the community.

DESIGN

correlational, cross-sectional observational questionnaire study.

SETTING

regional antenatal inpatient unit and community-based settings in New Zealand in 2009 and 2010.

PARTICIPANTS

118 pregnant women in hospital and 114 pregnant women in community.

MEASUREMENTS AND FINDINGS

women in hospital and community groups completed a battery of questionnaires on pregnancy and health history, life events, anxiety, optimism, coping, and relationship factors. Midwives caring for the women provided ratings of health status and psychological distress. Both groups of women had scores on state anxiety significantly above local norms; women in the hospital were significantly higher than those in the community on state anxiety and worry about their pregnancy. The groups did not differ on factors such as life events, optimism, and coping self-efficacy. Ratings of health and distress made by women and their midwives showed poor agreement. Predictors of acute anxiety differed across the groups: for hospitalised women, anxiety was predicted by their rating of their health and their dispositional optimism; for women in the community, anxiety was predicted by stressful life events, dispositional optimism, and coping self-efficacy.

KEY CONCLUSIONS

many women hospitalised during pregnancy are extremely anxious, and those most vulnerable are those who are less optimistic and see their health as poor. Health care professionals may not be aware of how anxious women are, and women and their hospital caregivers had poor agreement on ratings of the woman׳s health status.

IMPLICATIONS FOR RESEARCH AND PRACTICE

women hospitalised during pregnancy are at risk for high levels of anxiety. Midwives are well placed to help women by recognising their distress, supporting informed optimism, and guiding women toward realistic coping strategies and using existing social support networks. Research is needed on strategies for implementation and effectiveness of brief interventions to support women to manage anxiety and stress during pregnancy both in hospital and in the community.

Bed rest in singleton pregnancies for preventing preterm birth

BACKGROUND

Bed rest in hospital or at home is widely recommended for the prevention of preterm birth. This advice is based on the observation that hard work and hard physical activity during pregnancy could be associated with preterm birth and with the idea that bed rest could reduce uterine activity. However, bed rest may have some adverse effects on other outcomes.

OBJECTIVES

To evaluate the effect of prescription of bed rest in hospital or at home for preventing preterm birth in pregnant women at high risk of preterm birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 December 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014, Issue 12), MEDLINE (December 2014), EMBASE (December 2014), LILACS (December 2014), and bibliographies of relevant papers.

SELECTION CRITERIA

Randomized, cluster-randomized and quasi-randomized controlled trials with reported data that assess clinical outcomes in women at high risk of spontaneous preterm birth who were prescribed bed rest in hospital or at home for preventing preterm birth, and their babies.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, trial quality and extracted data.

MAIN RESULTS

Two studies met the inclusion criteria. One study was not considered for the meta-analysis, since data combined singleton and multiple pregnancies. No differences in any maternal and perinatal outcomes were reported by the authors. This study was at low risk of selection, performance, detection and attrition bias. Only data from one study were included in the meta-analysis (1266 women). This study was at unclear risk of bias for most domains due to lack of reporting. Four hundred and thirty-two women were prescribed bed rest at home and a total of 834 women received a placebo (412) or no intervention (422). Preterm birth before 37 weeks was similar in both groups (7.9% in the intervention group versus 8.5% in the control group; risk ratio (RR) 0.92, 95% confidence interval (CI) 0.62 to 1.37). No other results were reported for any of the other primary or secondary outcomes.

AUTHORS' CONCLUSIONS

There is no evidence, either supporting or refuting the use of bed rest at home or in hospital, to prevent preterm birth. Although bed rest in hospital or at home is widely used as the first step of treatment, there is no evidence that this practice could be beneficial. Due to the potential adverse effects that bed rest could have on women and their families, and the increased costs for the healthcare system, clinicians should discuss the pros and cons of bed rest to prevent preterm birth. Potential benefits and harms should be discussed with women facing an increased risk of preterm birth. Appropriate research is mandatory. Future trials should evaluate both the effectiveness of bed rest, and the effectiveness of the prescription of bed rest, to prevent preterm birth.

Depression and anxiety among high-risk obstetric inpatients

OBJECTIVE

To assess the following among women hospitalized antenatally due to high-risk pregnancies: (1) rates of depression symptoms and anxiety symptoms, (2) changes in depression symptoms and anxiety symptoms and, (3) rates of mental health treatment.

METHODS

Sixty-two participants hospitalized for high-risk obstetrical complications completed the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder 7-item scale (GAD-7) and Short-Form 12 weekly until delivery or discharge, and once postpartum.

RESULTS

Average length of total hospital stay was 8.3 ± 7.6 days for women who completed an initial admission survey (n = 62) and 16.3 ± 8.9 (n = 34), 25.4 ± 10.2 (n = 17) and 35 ± 10.9 days (n = 9) for those who completed 2, 3 and 4 surveys, respectively. EPDS was ≥ 10 in 27% (n=17) and GAD-7 was ≥ 10 in 13% (n = 8) of participants at initial survey. Mean anxiety (4.2 ± 6.5 vs. 5.2 ± 5.1, p = .011) and depression (4.4 ± 5.6 vs. 6.9 ± 4.8, p = .011) scores were lower postpartum compared to initial survey. Past mental health diagnosis predicted depression symptoms [odds ratio (OR) = 4.54; 95% confidence interval (CI) 1.91-7.17] and anxiety symptoms (OR = 5.95; 95% CI 3.04-8.86) at initial survey; however, 21% (n = 10) with no diagnostic history had EPDS ≥ 10. Five percent (n = 3) received mental health treatment during pregnancy.

CONCLUSION

Hospitalized high-risk obstetrical patients may commonly experience depression symptoms and/or anxiety symptoms and not receive treatment. A history of mental health treatment or diagnosis was associated with depression symptoms or anxiety symptoms in pregnancy. Of women with an EPDS ≥ 10, > 50% did not report a past mental health diagnosis.

Depression and anxiety in Singaporean high-risk pregnancies - prevalence and screening

OBJECTIVE

Data on psychiatric morbidity in high-risk pregnant Singaporean women are limited. This study aimed to establish the prevalence of antenatal depression and anxiety in high-risk pregnancies, compare the prevalence of antenatal depression in high-risk pregnancies vs. pregnancies of unspecified obstetric risk and examine the Edinburgh Postnatal Depression Scale (EPDS) and State Trait Anxiety Inventory (STAI) as screening tools for these disorders.

METHOD

Two hundred high-risk pregnant inpatients at a national public maternity hospital were included. Three psychometric assessment tools were used to evaluate all participants: the diagnostic Mini International Neuropsychiatric Interview and the screening EPDS and STAI.

RESULTS

Rates of major depression, minor depression, anxiety disorder (agoraphobia, generalized anxiety disorder, panic disorder), and comorbid depression and anxiety were 11%, 7%, 12.5% and 5%, respectively. Major depression was more prevalent in high-risk pregnancies than in the historical cohort of unspecified obstetric risk (11% versus 4.3%). EPDS (cutoff 8/9) screens well for depression and anxiety in high-risk pregnancies (area under the receiver operating characteristic curve=0.82-0.87).

CONCLUSION

Antenatal depression and anxiety are highly prevalent in a sample of high-risk pregnant Singaporean women. EPDS performs well in screening for depression and anxiety in high-risk pregnant women, with further psychiatric assessment recommended for women with score ≥ 9.

Healthy newborns' neurobehavior: norms and relations to medical and demographic factors

OBJECTIVE

To generate neurobehavioral norms for an unselected random sample of clinically healthy newborns by examining the newborns with use of the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS).

STUDY DESIGN

We recruited 344 healthy mothers and newborns from a well-child nursery. The NNNS, a 128-item assessment of infant neurobehavior, was used to examine newborn performance. Associations between 11 NNNS summary scales and the stress/abstinence scale, as well as medical and demographic variables, were evaluated. Mean, SD, and 5th and 95th percentile values for the summary scores of the NNNS are presented.

RESULTS

NNNS scores from the 10th to the 90th percentile represent a range of normative performance. Performance on different neurobehavioral domains was related to marital status, ethnicity, prenatal, intrapartum and neonatal risk factors, complications during labor/delivery, cesarean delivery, gestational age, the age of the newborn at testing, and infant sex.

CONCLUSION

These data provide clinicians and researchers with normative data for evaluation of newborn neurobehavior. Even in a low-risk sample, medical and demographic factors below clinical cut-offs were related to newborn performance. Infants with scores outside the ranges for the 11 NNNS summary scores and the stress/abstinence scale may need further observation and, if necessary, early intervention.

Bed-rest exercise, activity restriction, and high-risk pregnancies: a feasibility study

This feasibility study investigated the response of maternal heart rate, blood pressure, and uterine contractions to a 30-min bed-rest exercise session (while listening to music) in hospitalized women with varying diagnoses of high-risk pregnancy. Eleven antenatal women who were hospitalized for activity restriction were assigned randomly to either a bed-rest exercise and music group (n = 6) or a bed-rest and music group (n = 5) that involved no exercise. The key findings were that there were no changes in maternal blood pressure or in the number of uterine contractions following the exercise intervention. A supervised bed-rest exercise intervention may, therefore, provide minimal risks and help alleviate the physiological effects of hospital activity restriction.

Lack of evidence for prescription of antepartum bed rest

Antepartum bed-rest treatment is based on assumptions that it is both effective and safe for mother and fetus. However, research indicates, that bed-rest treatment is ineffective for preventing preterm birth and fetal growth restriction, and for increasing gestational age at birth and infant birthweight. Studies of women treated with pregnancy bed-rest identify numerous side effects, including muscle atrophy, bone loss, weight loss, decreased infant birthweight in singleton gestations and gestational age at birth, and psychosocial problems. Studies conducted by aerospace scientists who have used bed rest as a model for the study of weightlessness in space using nonpregnant individuals report similar results. Antepartum bed-rest treatment should be discontinued until evidence of effectiveness is found.

Antepartum bed rest for pregnancy complications: efficacy and safety for preventing preterm birth

Preterm birth is the major maternal-child health issue across developed nations and the leading cause of perinatal mortality and morbidity. Of all deaths of infants <1 year of age in the United States in 2005, 68.6% occurred in infants born prior to term. Although the preterm birth rate in European countries is 5-7%, the U.S. preterm birth rate is 12.7%, representing an increase of 9% since 2000. Antepartum bed rest/activity restriction (ABR/AR) has been a mainstay of treatment to prevent preterm birth for the past 30 years prescribed for nearly 1 million women in the United States annually, despite a lack of evidence for its effectiveness. In fact, there is increasing evidence that ABR causes several adverse physiologic and psychological side effects among women and their infants. Unfortunately, these findings have had little impact on clinical practice. This integrative review of literature provides a comprehensive analysis of the evidence for the practice of prescribing ABR and its physiologic, behavioral, and experiential side effects. It also presents a model to guide continuing research about the effects of maternal bed rest as well as evidence supporting the use of home care with bed rest, a different, safe, and feasible model of prenatal care for treating women with pregnancy complications used particularly in other countries. Finally, suggestions to improve the health of high-risk pregnant and postpartum women and their infants are provided.

Factors associated with tocolytic hospitalizations in Taiwan: evidence from a population-based and longitudinal study from 1997 to 2004

BACKGROUND

The use of tocolytic hospitalization in antenatal care is controversial and worthy of more research. We investigated individual, institutional, and area factors that affect the use of tocolytic hospitalizations in Taiwan where fertility has rapidly declined.

METHODS

Longitudinal data from the 1996 to 2004 National Health Insurance Research Database in Taiwan were used to identify tocolytic hospitalizations. The probit model was used to estimate factors associated with tocolytic hospitalizations.

RESULTS

The decline in fertility was significantly associated with the probability of tocolytic hospitalizations. Several physician and institutional factors-including physician's age, hospital ownership, accreditation status, bed size, and teaching status-were also significantly correlated to the dependent variables.

CONCLUSIONS

The provision of inpatient tocolysis is influenced not only by clinical considerations but also by physician, institutional, and area factors unrelated to clinical need. Fertility declines in Taiwan may have led obstetricians/gynecologists to provide more tocolysis to make up for their lost income. If the explanation is further validated, reimbursement policies may need to be reviewed to correct for overuse of inpatient tocolysis. The correlation could also be explained by the increasing use of artificial reproductive technologies and higher social value of newborns. In addition, the physician and institutional variations observed in the study indicate potential misuse of inpatient tocolysis that warrant further investigation.

Prenatal depression in women hospitalized for obstetric risk

OBJECTIVE

Little is known about depression during pregnancy in women with high maternal or fetal risk, as this population is often excluded from research samples. The aim of this study was to evaluate depressive symptoms and known risk factors for depression in a group of women hospitalized with severe obstetric risk.

METHOD

In the antenatal unit, 129 inpatients completed the Edinburgh Postnatal Depression Scale (EPDS), the Dyadic Adjustment Scale (DAS), and the Maternal Antenatal Attachment Scale (MAAS) from October 2005 through December 2006. A subset of women were administered the Mood Disorders module of the Structured Clinical Interview for DSM-IV Axis I Disorders based on a score of > or = 11 on the EPDS. Obstetric complications were classified according to the Hobel Risk Assessment for Prematurity.

RESULTS

Fifty-seven of the 129 women (44.2%) scored 11 or greater on the EPDS, and at least 25/129 (19.4%) met the DSM-IV criteria for major depressive disorder. Mothers reporting high attachment to the fetus on the MAAS reported lower severity of depressive symptoms (rho = -0.33, p < .0001); those reporting interpersonal relationship dissatisfaction on the DAS endorsed higher depressive severity (rho = -0.21, p = .02). Severity of obstetric risk was unrelated to depression, but one complication, incompetent cervix, was positively associated with level of depressive symptomatology.

CONCLUSION

Findings indicate a higher prevalence rate of major depressive disorder in women with severe obstetric risk than that reported in low-risk pregnancy samples, suggesting the need for routine depression screening to identify those who need treatment. Fewer depressive symptoms were reported by mothers reporting strong maternal fetal attachment and greater relationship satisfaction.

The relationship between perceived stress and health-promoting behaviors in high-risk pregnancy

OBJECTIVE

The purpose of this study was to examine the relationship between maternal perceived stress and health-promoting self-care behaviors in women experiencing high-risk pregnancies.

DESIGN

Descriptive correlational.

SAMPLE

Women (N=69) who had a complication in pregnancy that required referral to a perinatologist at a tertiary care center and ere in the third trimester of pregnancy.

MEASURES

The Perceived Stress Scale is a 14-item scale measuring the extent to which one appraises life situations as stressful. Health-Promoting Lifestyle Profile II is a 52-item scale from which scores for an overall health promotion scale and 6 subscales (health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management) are calculated.

RESULTS

There was a significant and negative relationship between perceived stress and health-promoting lifestyle. The relationships between perceived stress and spiritual growth, interpersonal relations, and stress management were significant and negative.

CONCLUSIONS

During a high-risk pregnancy, women who engage in more health-promoting behaviors may experience less stress; however, the causal relationship between stress and health promotion is not known. Nurses can offer stress management techniques and health-promoting self-care during this stressful time to encourage health in mother and neonate.

Women's responses to two models of antepartum high-risk care: Day stay and hospital stay

AIM

To replicate and extend previous research by examining women's responses to two current models of high-risk antenatal care that replaced the traditional bed rest model.

PARTICIPANTS

A sample of 61 women assigned to high-risk antenatal care: 29 in the Antenatal Hospital Unit (ANHU) and 32 in the Pregnancy Day Stay Unit (PDSU).

METHODS

A longitudinal study with data collected by a range of validated tools were used to assess mood, family functioning, stress and physical symptoms every 2 weeks from admission into antenatal high-risk care to birthing and at 3- and 6-weeks postpartum. Data were analysed for similarities and differences and change over time between the two groups of women.

FINDINGS

Stress from emotions was the highest antenatal stressor for both groups and highest for those in hospital. Stress about health increased over time for those in the PDSU and varied for those in ANHU. Anxiety was significantly different between the groups over time (p<0.01), being highest for the ANHU group and decreasing from admission to 6-weeks postnatal for both groups. Sensation Seeking (sensory deprivation) showed significant differences (p<0.05) with the highest scores in the ANHU group and increasing over time for both groups. Family relationships were most disrupted for those in ANHU. Both groups were satisfied with support from spouse, family and friends and those in ANHU acknowledged the support received from midwifery staff.

CONCLUSIONS AND IMPLICATIONS

The responses of both the woman and her family differ between the two models of care and vary with time. Midwives can use the patterns of response identified of these findings to address needs for assistance with family relationships, sensory stimulation, information and support and management of anxiety when care is required for complications of pregnancy.

Impact of uncertainty, social support, and prenatal coping on the psychological well-being of high-risk pregnant women

BACKGROUND

The effects of uncertainty and social support on the psychological well-being of high-risk pregnant women may be influenced by their prenatal coping strategies.

OBJECTIVE

The purpose of this study was to investigate whether prenatal coping strategies (preparation for motherhood, avoidance, positive interpretation of events, and prayer) mediate the effects of uncertainty and social support on the psychological well-being of high-risk pregnant women.

METHODS

A cross-sectional, descriptive, correlational design was used. The convenience sample consisted of 105 high-risk pregnant women 18-34 years of age and at 24-36 weeks gestation. The main measures were Mishel Uncertainty in Illness Scale, Medical Outcomes Study Social Support Survey, Prenatal Coping Inventory, and Psychological General Well-Being Index. Data analysis included descriptive statistics, correlational techniques, and path analyses.

RESULTS

The women reported low levels of uncertainty, moderate levels of distress, and high levels of social support. Prayer was the most frequently used prenatal coping strategy, whereas avoidance was used least often. Women who reported higher levels of uncertainty also reported less social support (r = -.45, p < .01), less psychological well-being (r = -.48, p < .01), less positive interpretation (r = -.30, p < .01), and more use of avoidance (r = .43, p < .01). The modified path analysis showed good fit with the data. Avoidance significantly mediated the effects of uncertainty on psychological well-being (z = -2.74, p < .01). Social support had a significant direct effect on preparation for motherhood (beta = .43, z = 3.94, p < .001).

DISCUSSION

Avoidance mediated the effect of uncertainty on psychological well-being for the high-risk pregnant women in this sample. The results of the study may help perinatal nurses to better understand how high-risk pregnancy affects these women.

Mood states and milk output in lactating mothers of preterm and term infants

The purpose of this study is to compare psychological distress via both negative and positive mood states between 2 different groups of lactating mothers during the first 6 weeks postpartum with a large sample. Mood states were measured using the Multiple Affect Adjective Check List-Revised by a convenience sample of newly delivered mothers from 4 tertiary care units in Illinois. Preterm mothers' negative mood states of anxiety, depression, hostility, and dysphoria were significantly greater than those reported for term mothers. For the positive mood states of positive affect and PASS (positive affect + sensation seeking), preterm mothers had significantly lower scores than term mothers; there were no differences for the positive mood state, Sensation Seeking. Maternal perceived mood states had no apparent effect upon lactation as measured by milk volume produced. Further study is warranted to determine what factors influence milk output in mothers of preterm and term infants who are at risk for lactation failure.

While You Are Waiting: a family-focused antepartum support program

While You Are Waiting is an antepartum support program developed for hospitalized, high-risk pregnant women. The goal of the program is to provide an atmosphere for the mother that will minimize the adverse effects of long-term activity restrictions and prolonged hospitalization. The program focuses on 4 key opportunities to promote optimal outcomes: education, support, recreation, and outreach. Details of the program and preliminary outcome data are provided.