Understanding Pregnancy and Postpartum Health Using Ecological Momentary Assessment and Mobile Technology: Protocol for the Postpartum Mothers Mobile Study

Leveraging Experience Sampling/Ecological Momentary Assessment for Sociological Investigations of Everyday Life

Experience sampling (ES) - also referred to as ecological momentary assessment (EMA) - is a data collection method that involves asking study participants to report on their thoughts, feelings, behaviors, activities, and environments in (or near) real time. ES/EMA is typically administered using an intensive longitudinal design (repeated assessments within and across days). Although use of ES/EMA is widespread in psychology and health sciences, uptake of the method among sociologists has been limited. We argue that ES/EMA offers key advantages for the investigation of sociologically relevant phenomena, particularly in light of recent disciplinary emphasis on investigating the everyday mechanisms through which social structures and micro (individual and relational) processes are mutually constitutive. We describe extant and potential research applications illustrating advantages of ES/EMA regarding enhanced validity, disentangling short-term dynamics, and the potential for linkage with spatially and temporally referenced data sources. We also consider methodological challenges facing sociological research using ES/EMA.

Feasibility of continuous smart health monitoring in pregnant population: A mixed-method approach

The utilization of smart monitoring technology offers potential for enhancing health outcomes, yet its feasibility and acceptance among Hispanic pregnant individuals remain uncertain. This is particularly crucial to investigate within the context of apparently healthy individuals identified as low risk, who still face a 10% likelihood of complications. Given their frequent underrepresentation in healthcare services and relative lack of attention, improving the feasibility of remote monitoring in this population could yield significant benefits. To address this gap, our study aimed to adapt and evaluate the practicality of a smart monitoring platform among healthy Hispanic pregnant women during the second and third trimesters of pregnancy, as well as one week following childbirth, a period when complications often arise. This longitudinal study followed n = 16 participants for an average of 17 weeks. Participants were instructed to wear the Oura ring for objective data collection, including activity, sleep, and heart rate, and to complete survey questions through REDcap to assess mental health and lifestyle factors. The study framework utilized the RE-AIM approach, with acceptability and adherence as key components of the feasibility evaluation. Our findings revealed that completion rates for biweekly and monthly surveys remained consistently high until after childbirth (approximately 80%), while daily question completion remained above 80% until 38th week of gestation, declining thereafter. The wearing rate of the Oura ring remained consistently above 80% until the 35th gestational week, decreasing to around 31% postpartum. Participants cited barriers to wearing the ring during the postpartum period, including difficulties managing the newborn, forgetfulness, and concerns about scratching the baby's skin. The enrollment rate was 71.42%, with an attrition rate of 6.25%. Thematic analysis of one-on-one interviews identified three main themes: personal desire for health improvement, social acceptability and support, and conditions influencing device/platform efficiency. In conclusion, while adherence varied based on gestational week and survey frequency, the study demonstrated strong acceptability of the smart monitoring platform among the study population, indicated by the high enrollment rate. Qualitative insights underscored the significance of personal motivation, social support, and device/platform efficiency in enhancing patient engagement with digital health monitoring during pregnancy, offering valuable considerations for future healthcare interventions in this domain.

A multilevel developmental psychopathology model of childbirth and the perinatal transition

Despite recent applications of a developmental psychopathology perspective to the perinatal period, these conceptualizations have largely ignored the role that childbirth plays in the perinatal transition. Thus, we present a conceptual model of childbirth as a bridge between prenatal and postnatal health. We argue that biopsychosocial factors during pregnancy influence postnatal health trajectories both directly and indirectly through childbirth experiences, and we focus our review on those indirect effects. In order to frame our model within a developmental psychopathology lens, we first describe "typical" biopsychosocial aspects of pregnancy and childbirth. Then, we explore ways in which these processes may deviate from the norm to result in adverse or traumatic childbirth experiences. We briefly describe early postnatal health trajectories that may follow from these birth experiences, including those which are adaptive despite traumatic childbirth, and we conclude with implications for research and clinical practice. We intend for our model to illuminate the importance of including childbirth in multilevel perinatal research. This advancement is critical for reducing perinatal health disparities and promoting health and well-being among birthing parents and their children.

The Relationship between Body Mass Index, Body Dissatisfaction and Mood Symptoms in Pregnant Women

Background: High body mass and adiposity during pregnancy can contribute to psychological distress, and body dissatisfaction may be a potential underlying mechanism of this association. Objective. This study aimed to evaluate the mediational role of body dissatisfaction in the relationship between body mass index (BMI) and depressive and anxious symptoms, respectively. Methods: Given the cross-sectional design of this study, two alternative models were investigated, positing that BMI was related to depressive (Model 1a) and anxious symptoms (Model 2a), which, in turn, predicted body dissatisfaction. Seventy-two pregnant women in the third trimester of pregnancy completed the Body Image Disturbance Questionnaire, the Beck Depression Inventory-II and the State-Trait Anxiety Inventory, as well as a demographic form assessing their BMI. Results: As hypothesized, body dissatisfaction mediated the relationship between BMI and psychopathological symptoms. Moreover, the alternative models of reverse mediation were also significant, suggesting that psychopathological symptoms mediated the relationship between BMI and body dissatisfaction. Findings from both the hypothesized and alternative models suggested that, on the one hand, higher distress symptoms associated with body dissatisfaction would result from high BMI and, on the other hand, that body dissatisfaction may result from the effect of BMI on distress symptoms. Conclusions: The present study suggests that body image theory and practice should be implemented by the inclusion of evidence-based clinical interventions for promoting psychological well-being during the antenatal period.

Examining the Perceptions of mHealth on Racial and Ethnic Disparities in Postpartum Health for Black Women: A Scoping Review

Background. Several disparities exist for Black mothers during the postpartum period, including but not limited to increased maternal mortality and morbidity rates, decreased access to care, and limited access to resources. Given the racial discrepancies in attention to postpartum care, coupled with the critical importance of the postpartum period for preventing adverse maternal health outcomes, research is warranted to explore how mobile health (mHealth) applications may help to alleviate maternal health disparities by optimizing postpartum care and addressing barriers to care for postpartum Black women. Thus, this review examines the perceptions of mHealth applications and their utility in health outcomes among postpartum Black women. Methods. We undertook a comprehensive literature search using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We included peer-reviewed articles published between 2010 and 2022 that were written in English, utilized mHealth as a primary intervention, and focused on postpartum health and access to resources, primarily among Black women in the United States. Results. A total of eight articles were included in our synthesis, encompassing mobile phone-based interventions for Black women. Cultural tailoring was included in five studies. Interventions that incorporated tailored content and fostered interactions reported high rates of follow-up. Conclusions. Tailored mHealth interventions can effectively promote behavior change and improve health care outcomes for Black women. However, there is a critical need for more research to assess user engagement and retention and whether these improvements indicate long-term sustainability.

Comparative Assessment of Exclusive Breastfeeding Rates From 24-Hour Recall and Since Birth Methods in Southwestern Pennsylvania Using Ecological Momentary Assessment

BACKGROUND

Accurate measurement of exclusive breastfeeding is important in maternal and child health research. Exclusive breastfeeding is often measured using the 24-hour recall or the since birth method for the first 6 months. These methods can produce different estimates, introducing problems in interpreting breastfeeding behavior and making accurate comparisons across settings or countries.

RESEARCH AIM

Our aim was to compare the exclusive breastfeeding rates between the 24-hour recall and since birth methods among a diverse cohort of birthing people using the ecological momentary assessments method. In addition, we compared the exclusive breastfeeding rates between the two methods across race and other maternal characteristics.

METHODS

This study is a secondary analysis using data from the Postpartum Mothers Mobile Study (PMOMS), a prospective longitudinal study which recruited participants during pregnancy and followed them for 12 months after delivery. Participants completed surveys in real-time via ecological momentary assessment. Individual exclusive breastfeeding rates from months 1-6 were computed using 24-hour recall and since birth methods for 284 participants. We calculated the percentage point difference between the two methods across child age and maternal characteristics. We used a two-sample test of proportions to determine if the differences observed in the proportions were significant.

RESULTS

Exclusive breastfeeding rates from the 24-hour recall were higher than the since birth rates across all ages and maternal characteristics. The difference between the two methods at 3 months was 25.7 percentage points and at 6 months was a 17.2 percentage points. Irrespective of the method used to measure exclusive breastfeeding, White participants had higher exclusive breastfeeding rates than Black participants.

CONCLUSION

The 24-hour recall and the since birth methods of assessing exclusive breastfeeding provided substantially different estimates. These findings highlight the importance of specificity in measuring and reporting exclusive breastfeeding.

Examining demographic and psychosocial factors related to self-weighing behavior during pregnancy and postpartum periods

Black childbearing individuals in the US experience a higher risk of postpartum weight retention (PPWR) compared to their White counterparts. Given that PPWR is related to adverse health outcomes, it is important to investigate predictors of weight-related health behaviors, such as self-weighing (i.e., using a scale at home). Regular self-weighing is an evidence-based weight management strategy, but there is minimal insight into sociodemographic factors related to frequency. The Postpartum Mothers Mobile Study (PMOMS) facilitated longitudinal ambulatory weight assessments to investigate racial inequities in PPWR. Our objective for the present study was to describe self-weighing behavior during and after pregnancy in the PMOMS cohort, as well as related demographic and psychosocial factors. Applying tree modeling and multiple regression, we examined self-weighing during and after pregnancy. Participants (N = 236) were 30.2 years old on average (SD = 4.7), with the majority being college-educated (53.8%, n = 127), earning at least $30,000 annually (61.4%, n = 145), and self-identifying as non-Hispanic White (NHW; 68.2%, n = 161). Adherence to regular self-weighing (at least once weekly) was highest among participants during pregnancy, with a considerable decline after giving birth. Low-income Black participants (earning < $30,000) were significantly less likely to reach a completion rate of ≥ 80% during pregnancy (AOR = 0.10) or the postpartum period (AOR = 0.16), compared to NHW participants earning at least $30,000 annually. Increases in perceived stress were associated with decreased odds of sustained self-weighing after delivery (AOR = 0.79). Future research should consider behavioral differences across demographic intersections, such as race and socioeconomic status, and the impact on efficacy of self-weighing.

Infant crying predicts real-time fluctuations in maternal mental health in ecologically valid home settings

Exposure to infant crying is a well-established predictor of mothers' mental health. However, this association may reflect many potential mechanisms. Capturing dynamic fluctuations in mothers' states simultaneously with caregiving experiences is necessary to identify the real-time processes influencing mental health. In this study, we leveraged ecological momentary assessments (EMAs) and infant-worn audio recorders to capture variability in mothers' mental health symptoms and their exposure to infant crying over one week in a racially and socio-economically diverse urban North-American sample (N = 53). We use multilevel modeling to characterize within- and between-person effects of crying on maternal negative affect and symptoms of depression and anxiety. Within participants, when infants cried more than average in the 10 min, 1 hr, and 8 hr prior to an EMA report, mothers' negative affect subsequently increased, controlling for mean levels of infant crying. In contrast to findings from laboratory studies, in everyday settings crying exposure did not immediately increase feelings of depression. Only when crying was above average for 8 hr prior to EMA did mothers report increases in subsequent depression symptoms, suggesting that the effects of crying on maternal mental health take hours to unfold in ecologically valid home settings. Between participants, mothers of infants who cried more on average did not report higher negative affect or symptoms of depression or anxiety. Overall, our findings reveal that crying exposure dynamically influences maternal negative affect and depression but not anxiety in ecologically valid real-world settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Stress, social support, and racial differences: Dominant drivers of exclusive breastfeeding

Exclusive breastfeeding is recommended for 6 months; however, many childbearing people wean their infants before 6 months. Psychosocial factors such as stress, social support and race are significant determinants of breastfeeding; however, few studies have longitudinally explored the effect of perceived stress and various forms of social support on exclusive breastfeeding. We used quantitative methodologies to examine exclusive breastfeeding, perceived stress and social support among 251 participants from the Postpartum Mothers Mobile Study. Participants between 18 and 44 years were recruited during pregnancy (irrespective of parity) and completed surveys in real-time via Ecological Momentary Assessment up to 12 months postpartum from December 2017 to August 2021. We measured perceived stress with the adapted Perceived Stress Scale and perceived social support with the Multi-dimensional Social Support Scale. Received social support was measured using a single question on breastfeeding support. We conducted a mixed-effects logistic regression to determine the effect of stress, race and social support on exclusive breastfeeding over 6 months. We examined the moderation effect of perceived social support and breastfeeding support in the relationship between perceived stress and exclusive breastfeeding. Black, compared with White, participants were less likely to breastfeed exclusively for 6 months. Participants who reported higher perceived stress were less likely to breastfeed exclusively for 6 months. Perceived social support moderated the relationship between perceived stress and exclusive breastfeeding (odds ratio: 0.01, 95% confidence interval: 0.001-0.072). However, breastfeeding support directly increased the likelihood of exclusive breastfeeding over 6 months. Perceived stress is negatively associated with exclusive breastfeeding. Birthing people who intend to breastfeed may benefit from perinatal support programs that include components to buffer stress.

Racial and ethnic disparities in postpartum weight retention: A narrative review mapping the literature to the National Institute on Minority Health and Health Disparities Research Framework

PLAIN LANGUAGE SUMMARY

A Review of the Literature Using the National Institutes of Health, National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to Create a Roadmap of the Studies Investigating Racial and Ethnic Disparities in Excess Weight Retained After Pregnancy.

WHY WAS THIS STUDY DONE?

Three out of four people who give birth retain excess weight at 1-year post-pregnancy. This is concerning, as weight that is retained following pregnancy is associated with increased risk for the development of disease. People from racial and ethnic minority groups experience weight retention more frequently post-pregnancy. Black and Hispanic/Latina/o/x birthing people are more likely to begin pregnancy overweight or obese. They are also more likely to retain excess weight following pregnancy. Investigating these risks in people from racially/ethnically diverse backgrounds may be an important way to address disparities in excess weight retained post-pregnancy.

WHAT DID THE RESEARCHERS DO?

This review of the literature used a tool called the National Institute on Minority Health and Health Disparities (NIMHD) Research Framework to map the literature to date on racial and ethnic disparities in excess weight retained post-pregnancy.

WHAT DID THE RESEARCHERS FIND?

We used the NIMHD Research Framework as a visual guide of the existing research about excess weight retained following pregnancy. Results illustrate the levels and domains at which research has been investigated. These results reveal that efforts have been focused at the individual level, with most attention given to diet and activity. Mapping the literature to the NIMHD Research Framework sheds light on gaps in the research.

WHAT DO THE FINDINGS MEAN?

Mapping the literature has revealed a need for investigations that make connections between the levels and domains of the Framework, so that we may understand underlying factors that contribute to health disparities.

Neighborhood disadvantage and the racial disparity in postpartum hypertension

BACKGROUND

Postpartum hypertension is the leading cause of postpartum readmission and has long-lasting cardiovascular effects. Black patients have higher incidence rates of hypertensive disorders after delivery and subsequent severe maternal morbidity. Neighborhood advantage, a marker of social determinants of health, has not been studied concerning postpartum hypertension. Moreover, the interplay between race and neighborhood advantage and their effect on postpartum hypertension have not been previously explored.

OBJECTIVE

This study aimed to evaluate the association between neighborhood-level social determinants of health and postpartum hypertension and explore whether these factors explain previously documented racial disparities.

STUDY DESIGN

This study included a retrospective cohort of people enrolled in a remote monitoring program of postpartum hypertension at the time of delivery within 1 health network from March 2019 to September 2021. Patients were eligible for enrollment after a diagnosis of hypertensive disorder during pregnancy or delivery. We further limited the cohort to self-reported Black and White patients with blood pressures recorded at 3 weeks and 6 weeks postpartum. The neighborhood advantage for each person at the time of delivery was classified using the area deprivation index, an accepted surrogate of social determinants of health and our primary exposure. The secondary exposure was self-reported race. Study outcomes of interest were hypertensive status (stage 1 hypertension: ≥130 to 139/80 to 89 mm Hg; stage 2 hypertension: ≥140/90 mm Hg) at 3 and 6 weeks after delivery. In addition, hypertensive status by neighborhood area deprivation index using logistic regression was molded. In secondary analyses, a case-control cohort matched on the area deprivation index was created, and conditional logistic regression was used to evaluate race. Finally, mixed-effects models modeling hypertension by race and clustering within the area deprivation index were used.

RESULTS

Of 4193 people enrolled, 2722 were Black or White and had blood pressure data recorded at 3 weeks after delivery, and 1126 had blood pressure data recorded at 6 weeks after delivery. After accounting for prenatal body mass index, smoking status, type of hypertension, and antihypertensives prescribed at discharge, persons living in the most disadvantaged neighborhoods were twice as likely (adjusted odds ratio, 2.03; 95% confidence interval, 1.53-2.69) to develop stage 2 hypertension at 21 days after delivery and 1.67 times more likely (95% confidence interval, 1.06-2.64) to develop stage 2 hypertension at 6 weeks after delivery than persons living in the most advantaged neighborhoods. Both associations were attenuated after adjusting for race. When people with stage 2 hypertension were matched on area deprivation index with normotensive counterparts, Black patients were still 3 to 4 times more likely to develop stage 2 hypertension at 3 (adjusted odds ratio, 3.00; 95% confidence interval, 1.95-4.63) and 6 (adjusted odds ratio, 4.61; 95% confidence interval, 2.05-10.36) weeks after delivery. This association remained after clustering within a neighborhood at 3 (adjusted odds ratio, 3.12; 95% confidence interval, 2.41-4.06) and 6 (adjusted odds ratio, 2.99; 95% confidence interval, 1.96-4.54) weeks after delivery. There was no significant difference in stage 1 hypertension.

CONCLUSION

Neighborhood advantage was associated with the development of persistent hypertension at 3 and 6 weeks after delivery. This association did not explain the racial disparity in sustained high blood pressure.

Stress during pregnancy: An ecological momentary assessment of stressors among Black and White women with implications for maternal health

BACKGROUND

Stress can lead to adverse physiological and psychological outcomes. Therefore, understanding stress during pregnancy provides insight into racial disparities in maternal health, particularly Black maternal health.

OBJECTIVES

This study aimed to describe (1) daily exposure to self-reported stress levels during pregnancy, and (2) sources of stress among participants that identified as Black or White using data collected via ecological momentary assessment.

METHODS

We leveraged survey data from the Postpartum Mothers Mobile Study, a prospective longitudinal study using ecological momentary assessment data collection methods to describe patterns of stress during pregnancy. This article is descriptive and documents patterns of self-reported stress levels and sources of stress. Frequencies and percentages of stress responses were computed to describe these patterns.

RESULTS

The sample (n = 296) was 27% Black (n = 78) and 63% White (n = 184). Results were based on at least one measurement of that stress level during pregnancy. A similar number of Black and White participants reported no stress during pregnancy. White (85%-95%) and Black (60%-70%) participants reported low to moderate levels of stress. Black participants (38%) and White participants (35%) reported experiencing high stress. Black and White participants reported similar sources of stress: stress from a partner, too many things to do, a baby or other children, and financial concerns. White participants reported work as a top stressor, and Black participants reported financial issues as a top source of stress.

CONCLUSION

This study provides insight into daily exposure to stress that has implications for maternal health. We described patterns of self-reported stress and sources of stress among Black and White participants. The daily exposures to stress reported by this sample exist within a context of root causes of structural inequities in education, health care, income, wealth, and housing that must be addressed to achieve maternal health equity.

Development of Smart Postpartum Care Application Based on Community Health Centers, as a Method for Mentoring Postpartum Mothers: A Mixed Method Approach

BACKGROUND

Early detection of postpartum problems can help reduce maternal mortality in Indonesia. Early detection can be achieved by monitoring postpartum mothers using a guidance system. The purpose of this study was to describe the development of a guidance system, namely, Smart Postpartum Care (SMAP CARE) and present its functional and acceptance tests.

MATERIALS AND METHODS

This study was a development study conducted in 2019 using a mixed-method approach. Data were collected through Focus Group Discussions (FGDs) and a literature study. The FGD participants consisted of six doctors, six nurses, and midwives from six community health Public health center in Semarang City, Indonesia. The collected data were analyzed using the Colaizzi method. The content of the postpartum mentoring application was based on input from the experts in health education and health services. Before widely applied, a feasibility study on the application was carried out in community health centers involving postpartum mothers and health care teams.

RESULTS

Five themes were generated from FGDs: (1) postpartum monitoring facilities; (2) monitoring postpartum mothers through visits to health centers and home care; (3) problems with postpartum mothers (including problems with mothers, babies, and the environment); (4) management of high-risk postpartum mothers; and (5) the risk of postpartum mothers, which could cause death. The SMAP CARE provides some features to educate postpartum mothers, for example (a) changes in the physiological aspects of postpartum mothers, (b) breast milk, (c) newborn care, (d) signs of danger in newborns, (e) problems with babies, (f) problems with postpartum mothers, and (g) signs of danger in postpartum mothers.

CONCLUSIONS

The application developed in this research, SMAP CARE, helps to facilitate mentoring for postpartum mothers and can be extended to community health centers in Indonesia.

App-Based Ecological Momentary Assessment to Enhance Clinical Care for Postpartum Depression: Pilot Acceptability Study

Background

Wearable tracking devices and mobile health technology are increasingly used in an effort to enhance clinical care and the delivery of personalized medical treatment. Postpartum depression is the most frequently diagnosed complication of childbirth; however, significant gaps in screening and treatment remain.

Objective

This study aims to investigate the clinical utility, predictive ability, and acceptability of using ecological momentary assessment to collect daily mood, sleep, and activity data through the use of an Apple Watch and mobile app among women with postpartum depression.

Methods

This was a pilot study consisting of 3 in-person research visits over the course of a 6-week enrollment period. Questionnaires to assess depression, anxiety, and maternal functioning were periodically collected, along with daily self-reported symptoms and passively collected physiological data via an Apple Watch. Feedback was collected from study participants and the study clinician to determine the utility and acceptability of daily tracking. Logistic regression was used to determine whether mood scores in the 2 weeks before a visit predicted scores at follow-up. Compliance with daily assessments was also measured.

Results

Of the 26 women enrolled, 23 (88%) completed the 6-week study period. On average, the participants completed 67% (34.4/51.5 days) of all active daily assessments and 74% (38/51.5 days) of all passive measures. Furthermore, all 23 participants completed the 3 required visits with the research team. Predictive correlations were found between self-reported mood and Edinburgh Postnatal Depression Scale score at follow-up, self-reported anxiety and EDPS, and sleep quality and Edinburgh Postnatal Depression Scale.

Conclusions

Using ecological momentary assessment to track daily symptoms of postpartum depression using a wearable device was largely endorsed as acceptable and clinically useful by participants and the study clinician and could be an innovative solution to increase care access during the COVID-19 pandemic.

A Technology-Based Pregnancy Health and Wellness Intervention (Two Happy Hearts): Case Study

BACKGROUND

The physical and emotional well-being of women is critical for healthy pregnancy and birth outcomes. The Two Happy Hearts intervention is a personalized mind-body program coached by community health workers that includes monitoring and reflecting on personal health, as well as practicing stress management strategies such as mindful breathing and movement.

OBJECTIVE

The aims of this study are to (1) test the daily use of a wearable device to objectively measure physical and emotional well-being along with subjective assessments during pregnancy, and (2) explore the user's engagement with the Two Happy Hearts intervention prototype, as well as understand their experiences with various intervention components.

METHODS

A case study with a mixed design was used. We recruited a 29-year-old woman at 33 weeks of gestation with a singleton pregnancy. She had no medical complications or physical restrictions, and she was enrolled in the Medi-Cal public health insurance plan. The participant engaged in the Two Happy Hearts intervention prototype from her third trimester until delivery. The Oura smart ring was used to continuously monitor objective physical and emotional states, such as resting heart rate, resting heart rate variability, sleep, and physical activity. In addition, the participant self-reported her physical and emotional health using the Two Happy Hearts mobile app-based 24-hour recall surveys (sleep quality and level of physical activity) and ecological momentary assessment (positive and negative emotions), as well as the Perceived Stress Scale, Center for Epidemiologic Studies Depression Scale, and State-Trait Anxiety Inventory. Engagement with the Two Happy Hearts intervention was recorded via both the smart ring and phone app, and user experiences were collected via Research Electronic Data Capture satisfaction surveys. Objective data from the Oura ring and subjective data on physical and emotional health were described. Regression plots and Pearson correlations between the objective and subjective data were presented, and content analysis was performed for the qualitative data.

RESULTS

Decreased resting heart rate was significantly correlated with increased heart rate variability (r=-0.92, P<.001). We found significant associations between self-reported responses and Oura ring measures: (1) positive emotions and heart rate variability (r=0.54, P<.001), (2) sleep quality and sleep score (r=0.52, P<.001), and (3) physical activity and step count (r=0.77, P<.001). In addition, deep sleep appeared to increase as light and rapid eye movement sleep decreased. The psychological measures of stress, depression, and anxiety appeared to decrease from baseline to post intervention. Furthermore, the participant had a high completion rate of the components of the Two Happy Hearts intervention prototype and shared several positive experiences, such as an increased self-efficacy and a normal delivery.

CONCLUSIONS

The Two Happy Hearts intervention prototype shows promise for potential use by underserved pregnant women.

Trends in Stress Throughout Pregnancy and Postpartum Period During the COVID-19 Pandemic: Longitudinal Study Using Ecological Momentary Assessment and Data From the Postpartum Mothers Mobile Study

BACKGROUND

Stress is associated with adverse birth and postpartum health outcomes. Few studies have longitudinally explored racial differences in maternal stress in a birthing population in the United States during the ongoing COVID-19 pandemic.

OBJECTIVE

This study aimed to do the following: (1) assess changes in reported stress before, during, and after initial emergency declarations (eg, stay-at-home orders) were in place due to the COVID-19 pandemic, and (2) assess Black-White differences in reported stress in a pregnant and postpartum population from Southwestern Pennsylvania.

METHODS

We leveraged data from the ongoing Postpartum Mothers Mobile Study (PMOMS), which surveys participants in real time throughout the pregnancy and postpartum periods via ecological momentary assessment (EMA) and smartphone technology. We analyzed data from a subset of PMOMS participants (n=85) who were either Black or White, and who submitted EMA responses regarding stress between November 1, 2019, and August 31, 2020, the time frame of this study. We divided data into four phases based on significant events during the COVID-19 pandemic: "pre" phase (baseline), "early" phase (first case of COVID-19 reported in United States), "during" phase (stay-at-home orders), and "post" phase (stay-at-home orders eased). We assessed mean stress levels at each phase using linear mixed-effects models and post hoc contrasts based on the models.

RESULTS

Overall mean stress (0=not at all to 4=a lot) during the pre phase was 0.8 for Black and White participants (range for Black participants: 0-3.9; range for White participants: 0-2.8). There was an increase of 0.3 points (t5649=5.2, P<.001) in the during phase as compared with the pre phase, and an increase of 0.2 points (t5649=3.1, P=.002) in the post phase compared with the pre phase (n=85). No difference was found between Black and White participants in the change in mean stress from the pre phase to the during phase (overall change predicted for the regression coefficient=-0.02, P=.87). There was a significant difference between Black and White participants in the change in mean stress from the during phase to the post phase (overall change predicted for the regression coefficient=0.4, P<.001).

CONCLUSIONS

There was an overall increase in mean stress levels in this subset of pregnant and postpartum participants during the same time as the emergency declarations/stay-at-home orders in the United States. Compared to baseline, mean stress levels remained elevated when stay-at-home orders eased. We found no significant difference in the mean stress levels by race. Given that stress is associated with adverse birth outcomes and postpartum health, stress induced by the ongoing COVID-19 pandemic may have adverse implications for birthing populations in the United States.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/13569.

Geographically-explicit Ecological Momentary Assessment (GEMA) Architecture and Components: Lessons Learned from PMOMS

Geographically explicit Ecological Momentary Assessment (GEMA), an extension of Ecological Momentary Assessment (EMA), allows to record time-stamped geographic location information for behavioral data in the every-day environments of study participants. Considering that GEMA studies are continually gaining the attention of researchers and currently there is no single approach in collecting GEMA data, in this paper, we propose and present a GEMA architecture that can be used to conduct any GEMA study based on our experience developing and maintaining the Postpartum Mothers Mobile Study (PMOMS). Our GEMA client-server architecture can be customized to meet the specific requirements of each GEMA study. Key features of our proposed GEMA architecture include: utilization of widely used smartphones to make GEMA studies practical; alleviation of the burden of activities on participants by designing clients (mobile applications) that are very lightweight and servers that are heavyweight in terms of functionality; utilization of at least one positioning sensor to determine EMA contexts marked with locations; and communication through the Internet. We believe that our proposed GEMA architecture, with the illustrated foundation for GEMA studies in our exemplar study (PMOMS), will help researchers from any field conduct GEMA studies efficiently and effectively.

Ecological momentary assessment of stress, racism and other forms of discrimination during pregnancy using smartphone technology

BACKGROUND

In the United States, there are considerable racial inequities in adverse perinatal outcomes. Exposure to racism, sexism, and other forms of oppression may help explain these inequities.

OBJECTIVES

To describe the application of real-time data collection using ecological momentary assessment (EMA) and smartphone technology to assess exposure to stress, racism, sexism, microaggressions, and other forms of oppression.

METHODS

The Postpartum Mothers Mobile Study (PMOMS) is an ongoing longitudinal cohort study that began recruitment in December 2017. Participants delivering at a hospital in Pittsburgh, PA are recruited by 29 weeks' gestation. Using smartphones and smart scales, participants complete daily surveys related to psychosocial, behavioural, and contextual factors and weigh themselves weekly for approximately 15 months. We provide a preliminary descriptive analysis of EMA self-reported measures of stress, racism, sexism, and microaggressions; and non-EMA measures of stress and major discrimination.

RESULTS

The sample (n = 230) is 63.5% White, 24.8% Black/African American, and 7% Hispanic origin. The most commonly reported item from the Major Discrimination Scale is being unfairly fired (18.1% of the sample). Of those, 31.7% and 17.1% attribute unfair firing to their gender and race, respectively. From the random EMA measures, on average, participants report experiences of racism and sexism at least once daily, in an average 12-hour day over the 4-week period. Black participants indicate about two experiences per day of racism, and White participants indicate more than 1 per day of sexism. Mean stress levels from the EMA measures were similar to the stress measures collected at baseline.

CONCLUSIONS

The methods applied in PMOMS provide real-time data regarding how participants' daily experiences of stress and discrimination influence their lives. Future work will include understanding if and how these EMA measures may relate to already established measures of racism, sexism, and stress; and ultimately understanding associations with perinatal inequities.

Pharmacotherapeutic strategies for the treatment of anorexia nervosa - too much for one drug?

INTRODUCTION

Anorexia nervosa is a severe psychiatric illness and no medication has been approved for its treatment. This lack of biological treatments requires the development of new directions for pharmacological research.

AREAS COVERED

There is modest but emerging evidence that dopamine D2 and serotonin 1A and 2A receptor agonistic and antagonist medication might be beneficial for weight gain, although the underlying mechanisms are uncertain. Improving quality of life including treating comorbid conditions is an additional important outcome measure, but this has not been well researched. Biological and psychological risk factors together with neurobiological alterations during the illness maintain the disorder 's pathophysiology. Neuroscience research can be used to understand those interactions and advance the research agenda. The authors discuss the above as well as give perspectives on future research.

EXPERT OPINION

If a multidisciplinary approach that includes evidence-based psychotherapy shows unsatisfactory success in weight normalization and cognitive-emotional recovery, then more experimental treatments that are safe and have indicated treatment effectiveness should be tried to augment treatment. Identification and treatment of comorbid conditions to improve quality of life of the patient should also be part of the treatment regimen, even if the effect on weight gain is uncertain.