Changes in Breastfeeding and Related Maternity Care Practices After Hurricanes Irma and Maria in Puerto Rico

Background: Breastfeeding is recommended globally for most infants, especially during and after natural disasters when risk of adverse outcomes increases because of unsanitary conditions and lack of potable water. Materials and Methods: Using 2017-2019 data from Puerto Rico's Pregnancy Risk Assessment Monitoring System for 2,448 respondents with a recent live birth, we classified respondents into 4 hurricane exposure time periods based on infant birth month and year relative to when Hurricanes Irma and Maria occurred: (1) prehurricane; (2) acute hurricane; (3) posthurricane, early recovery; and (4) posthurricane, long-term recovery. We examined the association between maternity care practices during delivery hospitalization and exclusive breastfeeding at 3 months overall and stratified by time period. We also examined the associations between each maternity care practice and exclusive breastfeeding separately by time period. Results: Exclusive breastfeeding at 3 months was higher during the acute hurricane time period (adjusted prevalence ratio [aPR]: 1.43, 95% confidence interval: 1.09-1.87) than the prehurricane time period. Supportive maternity care practices were positively associated with exclusively breastfeeding, and practices that are risk factors for discontinuing breastfeeding were negatively associated with exclusive breastfeeding. Breastfeeding in the first hour (aPR range: 1.51-1.92) and rooming-in (aPR range: 1.50-2.58) were positively associated with exclusive breastfeeding across all time periods, except the prehurricane time period. Receipt of a gift pack with formula was negatively associated with exclusive breastfeeding (aPR range: 0.22-0.54) across all time periods. Conclusions: Maternity care practices during delivery hospitalization may influence breastfeeding behaviors and can improve breastfeeding during and after natural disasters. Strategies to maintain and improve these practices can be further supported during and after natural disasters.

Breastfeeding by Disability Status in the United States: Pregnancy Risk Assessment Monitoring System, 2018-2020

Objectives. To describe breastfeeding initiation and breastfeeding at 1, 2, and 3 months, and information sources on breastfeeding among women with a recent live birth by disability status. Methods. We analyzed October 2018 to December 2020 data from the Pregnancy Risk Assessment Monitoring System for 24 sites in the United States that included the Washington Group Short Set of Questions on Disability (seeing, hearing, walking or climbing stairs, remembering or concentrating, self-care, communicating). We defined disability as reporting "a lot of difficulty" or "cannot do this at all" on any of these questions. Results. Among 39 673 respondents, 6.0% reported disability. In adjusted analyses, breastfeeding was lower among respondents with disability at 2 (62.6% vs 66.6%; adjusted prevalence ratio [APR] = 0.94; 95% confidence interval [CI] = 0.89, 0.99) and 3 months (54.7% vs 59.6%; APR = 0.92; 95% CI = 0.86, 0.98) than those without disability. Respondents with disability were less likely to receive information from health care providers or support professionals (89.3% vs 92.3%), but as likely from breastfeeding or lactation specialists (78.1% vs 75.3%). Conclusions. Strategies to ensure women with disability, receive breastfeeding support, including breastfeeding information, could improve breastfeeding outcomes. (Am J Public Health. 2024;114(1):108-117. https://doi.org/10.2105/AJPH.2023.307438).

Pandemic-related stressors and mental health among women with a live birth in 2020

The objective of this analysis was to assess the associations between pandemic-related stressors and feeling more anxious/depressed, among women with a live birth. We analyzed data from the Pregnancy Risk Assessment Monitoring System (PRAMS) COVID-19 maternal experiences supplement, implemented in 29 U.S. jurisdictions from October 2020-June 2021, among women with a live birth during April-December 2020. We examined stressors by type (economic, housing, childcare, food insecurity, partner, COVID-19 illness) and score (number of stressor types experienced [none, 1-2, 3-4, or 5-6]). Outcomes were feeling 1) more anxious and 2) more depressed than usual due to the pandemic. We calculated adjusted prevalence ratios estimating associations between stressors and outcomes. Among 12,525 respondents, half reported feeling more anxious and 28% more depressed than usual. The prevalence of stressor types was 50% economic, 41% childcare, 18% partner, 17% food insecurity, 12% housing, and 10% COVID-19 illness. Respondents who experienced partner stressors (anxious aPR: 1.81, 95% CI: 1.73-1.90; depressed aPR: 3.01, 95% CI: 2.78-3.25) and food insecurity (anxious aPR: 1.79, 95% CI: 1.71-1.88; depressed aPR: 2.32, 95% CI: 2.13-2.53) had the largest associations with feeling more anxious and depressed than usual. As stressor scores increased, so did the aPRs for feeling more anxious and more depressed due to the pandemic. COVID-19 stressors, not COVID-19 illness, were found to be significantly associated with feeling more anxious and depressed. Pregnant and postpartum women might benefit from access to supports and services to address pandemic-related stressors/social-determinants and feelings of anxiety and depression.

Timing of Postpartum Depressive Symptoms

Introduction

Postpartum depression is a serious public health problem that can adversely impact mother-child interactions. Few studies have examined depressive symptoms in the later (9-10 months) postpartum period.

Methods

We analyzed data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS) linked with data from a telephone follow-up survey administered to PRAMS respondents 9 to 10 months postpartum in 7 states (N = 1,954). We estimated the prevalence of postpartum depressive symptoms (PDS) at 9 to 10 months overall and by sociodemographic characteristics, prior depression (before or during pregnancy), PDS at 2 to 6 months, and other mental health characteristics. We used unadjusted prevalence ratios (PRs) to examine associations between those characteristics and PDS at 9 to 10 months. We also examined prevalence and associations with PDS at both time periods.

Results

Prevalence of PDS at 9 to 10 months was 7.2%. Of those with PDS at 9 to 10 months, 57.4% had not reported depressive symptoms at 2 to 6 months. Prevalence of PDS at 9 to 10 months was associated with having Medicaid insurance postpartum (PR = 2.34; P = .001), prior depression (PR = 4.03; P <.001), and current postpartum anxiety (PR = 3.58; P <.001). Prevalence of PDS at both time periods was 3.1%. Of those with PDS at both time periods, 68.5% had prior depression.

Conclusion

Nearly 3 in 5 women with PDS at 9 to 10 months did not report PDS at 2 to 6 months. Screening for depression throughout the first postpartum year can identify women who are not symptomatic early in the postpartum period but later develop symptoms.

Pregnant Women's Experiences During and After Hurricanes Irma and Maria, Pregnancy Risk Assessment Monitoring System, Puerto Rico, 2018

OBJECTIVE

Exposure to natural disasters during and after pregnancy may increase adverse mental health outcomes. Hurricanes Irma and Maria struck Puerto Rico in September 2017. Our objectives were to understand hurricane-related experiences, maternal health concerns, and the impact of hurricane experiences on postpartum depressive symptoms (PDS).

METHODS

We used data from the 2018 Pregnancy Risk Assessment Monitoring System to describe differences in maternal hurricane experiences among women who were pregnant during and after the 2017 hurricanes. We assessed maternal concerns and PDS. We estimated adjusted prevalence ratios (aPRs) and 95% CIs for the associations between hurricane experiences and PDS.

RESULTS

The most frequently reported hurricane experiences were losing power for ≥1 week (97%) and feeling unsafe due to lack of order/security (70%). Almost 30% of women who were pregnant during the hurricanes reported missing prenatal care. PDS were reported by 13% of women. Most hurricane experiences were associated with an increased prevalence of PDS. Feeling unsafe (aPR = 2.4; 95% CI, 1.2-4.9) and having difficulty getting food (aPR = 2.1; 95% CI, 1.1-4.1) had the strongest associations.

CONCLUSIONS

Most women who were pregnant during or after hurricanes Irma and Maria struck Puerto Rico reported negative hurricane experiences, and most experiences were associated with an increased prevalence of PDS. Understanding the experiences of pregnant women during and after disasters and identifying risks for adverse mental health outcomes after pregnancy are important to inform emergency preparedness and prenatal and postpartum care.

The Postpartum Period: An Opportunity for Alcohol Screening and Counseling to Reduce Adverse Health Impacts

OBJECTIVES

The postpartum period presents an opportunity to engage in discussions about alcohol consumption and related health harms. This study examined the prevalence of alcohol consumption among a sample of postpartum persons with a recent live birth and screening and brief intervention (alcohol SBI) or counseling by their providers.

METHODS

We analyzed 2019 data from a telephone survey conducted 9 to 10 months postpartum among individuals who responded to the standard Pregnancy Risk Assessment Monitoring System survey in 6 states. Weighted prevalence estimates were calculated for alcohol consumption and alcohol SBI after birth through up to 10 months postpartum.

RESULTS

Among 1790 respondents, 53.1% reported consuming alcohol postpartum. Among those who drank postpartum, 70.8% reported being asked about alcohol use by a healthcare provider. Slightly more than half of respondents who drank postpartum and were trying to get pregnant (52.4%) or were not using birth control at the time of the survey (59.8%) reported being asked about alcohol use. Approximately 25% of respondents who drank alcohol postpartum were advised about risky alcohol levels by a healthcare provider. Small proportions of individuals who drank alcohol postpartum and were pregnant or trying to get pregnant at the time of the survey were advised to reduce or stop drinking alcohol (10.6% and 2.3%, respectively).

CONCLUSIONS

These findings suggest missed opportunities to promote health and prevent adverse alcohol-related health outcomes during the postpartum period through evidence-based tools such as alcohol SBI.

Fathers, Breastfeeding, and Infant Sleep Practices: Findings From a State-Representative Survey

OBJECTIVES

To assess infant breastfeeding initiation and any breastfeeding at 8 weeks and safe sleep practices (back sleep position, approved sleep surface, and no soft objects or loose bedding ["soft bedding"]) by select paternal characteristics among a state-representative sample of fathers with new infants.

METHODS

Pregnancy Risk Assessment Monitoring System (PRAMS) for Dads, a novel population-based cross-sectional study, surveyed fathers in Georgia 2-6 months after their infant's birth. Fathers were eligible if the infant's mother was sampled for maternal PRAMS from October 2018 to July 2019.

RESULTS

Of 250 respondents, 86.1% reported their infants ever breastfed and 63.4% reported breastfeeding at 8 weeks. Initiation and breastfeeding at 8 weeks were more likely to be reported by fathers who reported wanting their infant's mother to breastfeed than those who did not want her to breastfeed or had no opinion (adjusted prevalence ratio [aPR] = 1.39; 95% confidence interval [CI], 1.15-1.68; aPR = 2.33; 95% CI, 1.59-3.42, respectively) and fathers who were college graduates than those with ≤high school diploma (aPR = 1.25; 95% CI, 1.06-1.46; aPR = 1.44; 95% CI, 1.08-1.91, respectively). Although about four-fifths (81.1%) of fathers reported usually placing their infants to sleep on their back, fewer fathers report avoiding soft bedding (44.1%) or using an approved sleep surface (31.9%). Non-Hispanic Black fathers were less likely to report back sleep position (aPR = 0.70; 95% CI, 0.54-0.90) and no soft bedding (aPR = 0.52; 95% CI, 0.30-0.89) than non-Hispanic white fathers.

CONCLUSIONS

Fathers reported suboptimal infant breastfeeding rates and safe sleep practices overall and by paternal characteristics, suggesting opportunities to include fathers in promotion of breastfeeding and infant safe sleep.

Association of Mental Health Conditions, Recent Stressful Life Events, and Adverse Childhood Experiences with Postpartum Substance Use - Seven States, 2019-2020

Most pregnancy-related deaths due to mental health conditions, which include overdose and poisoning related to substance use disorder, occur during the late (43-365-day) postpartum period (1). Adverse childhood experiences and stressful life events are associated with increased substance use during pregnancy (2,3). Pregnancy Risk Assessment Monitoring System (PRAMS) respondents in seven states with high opioid overdose mortality rates were recontacted 9-10 months after giving birth in 2019 and asked about postpartum prescription opioid misuse,* tobacco use, unhealthy alcohol use,† and use of other substances.§ Substance and polysubstance use prevalence estimates were calculated, stratified by mental health and social adversity indicators. Overall, 25.6% of respondents reported postpartum substance use, and 5.9% reported polysubstance use. The following conditions were associated with higher substance and polysubstance use prevalence in postpartum women: depressive symptoms, depression, anxiety, adverse childhood experiences, and stressful life events. Substance use prevalence was higher among women who experienced six or more stressful life events during the year preceding the birth (67.1%) or four adverse childhood experiences related to household dysfunction (57.9%). One in five respondents who experienced six or more stressful life events in the year before giving birth and 26.3% of women with four adverse childhood experiences reported postpartum polysubstance use. Clinical and community- and systems-level interventions to improve postpartum health can include screening and treatment for depression, anxiety, and substance use disorders during the postpartum period. Evidence-based strategies can prevent adverse childhood experiences and mitigate the immediate and long-term harms.¶.

Polysubstance use during pregnancy: The importance of screening, patient education, and integrating a harm reduction perspective

BACKGROUND

Substance use during pregnancy is associated with poor health outcomes. This study assessed substance use, polysubstance use, and use of select prescription medications during pregnancy.

METHODS

We analyzed 2019 data from the Pregnancy Risk Assessment Monitoring System in 25 United States jurisdictions that included questions on prescription medications, tobacco, and illicit substance use during pregnancy. Alcohol and electronic cigarette use were assessed during the last three months of pregnancy, and all other substances and medications were assessed throughout pregnancy. Weighted prevalence estimates and 95% confidence intervals (CIs) were calculated.

RESULTS

Nearly one-fifth of respondents who reported use of any substance reported use of at least one other substance during pregnancy. Cigarettes (8.1%; 95% CI 7.6-8.7%) and alcohol (7.4%; 95% CI 6.7-8.1%) were the most frequently reported substances, followed by cannabis (4.3%; 95% CI 3.9-4.7%). Substance use was higher among individuals who reported having depression or using antidepressants during pregnancy compared with those who did not report depression or antidepressant use. Illicit drug use prevalence was low (0.5%, 95% CI 0.4-0.7%); however, respondents reporting heroin use also frequently reported use of illicit stimulants (amphetamines: 51.7%, 95% CI 32.1-71.3% or cocaine: 26.5%, 95% CI 11.9-41.1%). Although prenatal clinician screening for alcohol and cigarette use was approximately 95%, fewer respondents (82.1%) reported being screened for cannabis or illicit substance use during pregnancy.

CONCLUSIONS

One in five individuals who reported use of any substance during pregnancy engaged in polysubstance use, highlighting the importance of comprehensive screening and evidence-based interventions including harm reduction.

Infant Receipt of Health Care Services during the 2016-2017 Zika Virus Outbreak in Puerto Rico

OBJECTIVE

To assess the receipt of health care services among live-born infants of women with and without evidence of Zika virus (ZIKV) infection while pregnant during the 2016-2017 ZIKV outbreak in Puerto Rico.

METHODS

We used data from the Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response study telephone surveys to examine maternal reports of the receipt of health care services by infants born in Puerto Rico from August through December 2016 and November through December 2017. Evidence of ZIKV infection was ascertained from the infant's birth certificate or was self-reported in the survey.

RESULTS

Fourteen percent of women in 2016 and 9% in 2017 had evidence of ZIKV infection during pregnancy. Most infants of women with evidence of ZIKV received the recommended health care services in 2016 and 2017, respectively, including a hearing test (91% vs. 92%), developmental assessment (90% vs. 92%), and an eye exam (74% vs. 70%); fewer received a head scan (45% vs. 36%) and evaluation for physical therapy (17% vs. 10%). From 2016 to 2017, the proportion of infants having a personal doctor increased for all infants; for infants of women without evidence of ZIKV infection, receiving hearing, developmental, and eye assessments increased.

CONCLUSION

Most infants of women with evidence of ZIKV infection during pregnancy received the recommended hearing and developmental assessments during the ZIKV outbreak. Experiences with increasing service capacity during the ZIKV outbreak can be evaluated to inform the response to future emergencies that affect maternal and child health.

Rapid Population-Based Surveillance of Prenatal and Postpartum Experiences During Public Health Emergencies, Puerto Rico, 2016‒2018

The Pregnancy Risk Assessment Monitoring System-Zika Postpartum Emergency Response study, implemented in Puerto Rico during the Zika virus outbreak (2016-2017) and after Hurricanes Irma and María (2017-2018), collected pregnancy-related data using postpartum hospital-based surveys and telephone follow-up surveys. Response rates of 75% or more were observed across five study surveys. The study informed programs, increased the Puerto Rico Department of Health's capacity to conduct maternal‒infant health surveillance, and demonstrated the effectiveness of this methodology for collecting data during public health emergencies. (Am J Public Health. 2022;112(4):574-578. https://doi.org/10.2105/AJPH.2021.306687).

Pregnancy Risk Assessment Monitoring System for Dads: A piloted randomized trial of public health surveillance of recent fathers' behaviors before and after infant birth

BACKGROUND

Becoming a father impacts men's health and wellbeing, while also contributing to the health and wellbeing of mothers and children. There is no large-scale, public health surveillance system aimed at understanding the health and behaviors of men transitioning into fatherhood. The purpose of this study was to describe piloted randomized approaches of a state-based surveillance system examining paternal behaviors before and after their infant's birth to better understand the health needs of men and their families during the transition to parenthood.

METHODS

During October 2018-July 2019, 857 fathers in Georgia were sampled 2-6 months after their infant's birth from birth certificates files and surveyed via mail, online or telephone, in English or Spanish, using two randomized approaches: Indirect-to-Dads and Direct-to-Dads. Survey topics included mental and physical health, healthcare, substance use, and contraceptive use.

FINDINGS

Weighted response rates (Indirect-to-Dads, 33%; Direct-to-Dads, 31%) and population demographics did not differ by approach. Respondents completed the survey by mail (58%), online (28%) or telephone (14%). Among 266 fathers completing the survey, 55% had a primary care physician, and 49% attended a healthcare visit for themselves during their infant's mother's pregnancy or since their infant's birth. Most fathers were overweight or had obesity (70%) while fewer reported smoking cigarettes (19%), binge drinking (13%) or depressive symptoms (10%) since their infant's birth.

CONCLUSIONS

This study tests a novel approach for obtaining population-based estimates of fathers' perinatal health behaviors, with comparable response rates from two pragmatic approaches. The pilot study results quantify a number of public health needs related to fathers' health and healthcare access.

Preventing Vector-Borne Transmission of Zika Virus Infection During Pregnancy, Puerto Rico, USA, 2016-20171

We examined pregnant women’s use of personal protective measures to prevent mosquito bites during the 2016–2017 Zika outbreak in Puerto Rico. Healthcare provider counseling on recommended measures was associated with increased use of insect repellent among pregnant women but not with wearing protective clothing.

Preventing Sexual Transmission of Zika Virus Infection during Pregnancy, Puerto Rico, USA, 20161

We examined condom use throughout pregnancy during the Zika outbreak in Puerto Rico during 2016. Overall, <25% of women reported consistent condom use during pregnancy. However, healthcare provider counseling was associated with a 3-fold increase in consistent use, reinforcing the value of provider counseling in Zika prevention efforts.