Explaining the Black-White Disparity in Preterm Birth: A Consensus Statement From a Multi-Disciplinary Scientific Work Group Convened by the March of Dimes

In 2017-2019, the March of Dimes convened a workgroup with biomedical, clinical, and epidemiologic expertise to review knowledge of the causes of the persistent Black-White disparity in preterm birth (PTB). Multiple databases were searched to identify hypothesized causes examined in peer-reviewed literature, 33 hypothesized causes were reviewed for whether they plausibly affect PTB and either occur more/less frequently and/or have a larger/smaller effect size among Black women vs. White women. While definitive proof is lacking for most potential causes, most are biologically plausible. No single downstream or midstream factor explains the disparity or its social patterning, however, many likely play limited roles, e.g., while genetic factors likely contribute to PTB, they explain at most a small fraction of the disparity. Research links most hypothesized midstream causes, including socioeconomic factors and stress, with the disparity through their influence on the hypothesized downstream factors. Socioeconomic factors alone cannot explain the disparity's social patterning. Chronic stress could affect PTB through neuroendocrine and immune mechanisms leading to inflammation and immune dysfunction, stress could alter a woman's microbiota, immune response to infection, chronic disease risks, and behaviors, and trigger epigenetic changes influencing PTB risk. As an upstream factor, racism in multiple forms has repeatedly been linked with the plausible midstream/downstream factors, including socioeconomic disadvantage, stress, and toxic exposures. Racism is the only factor identified that directly or indirectly could explain the racial disparities in the plausible midstream/downstream causes and the observed social patterning. Historical and contemporary systemic racism can explain the racial disparities in socioeconomic opportunities that differentially expose African Americans to lifelong financial stress and associated health-harming conditions. Segregation places Black women in stressful surroundings and exposes them to environmental hazards. Race-based discriminatory treatment is a pervasive stressor for Black women of all socioeconomic levels, considering both incidents and the constant vigilance needed to prepare oneself for potential incidents. Racism is a highly plausible, major upstream contributor to the Black-White disparity in PTB through multiple pathways and biological mechanisms. While much is unknown, existing knowledge and core values (equity, justice) support addressing racism in efforts to eliminate the racial disparity in PTB.

Underascertainment of child abuse mortality in the United States

CONTEXT

Mortality figures in the United States are believed to underestimate the incidence of fatal child abuse.

OBJECTIVES

To describe the true incidence of fatal child abuse, determine the proportion of child abuse deaths missed by the vital records system, and provide estimates of the extent of abuse homicides in young children.

DESIGN AND SETTING

Retrospective descriptive study of child abuse homicides that occurred over a 10-year period in North Carolina from 1985-1994.

CASES

The Medical Examiner Information System was searched for all cases of children younger than 11 years classified with International Classification of Diseases, Ninth Revision codes E960 to E969 as the underlying cause of death and homicide as the manner of death. A total of 273 cases were identified in the search and 259 cases were reviewed after exclusion of fetal deaths and deaths of children who were not residents of North Carolina.

MAIN OUTCOME MEASURE

Child abuse homicide.

RESULTS

Of the 259 homicides, 220 (84.9%) were due to child abuse, 22 (8.5%) were not related to abuse, and the status of 17 (6.6%) could not be determined. The rate of child abuse homicide increased from 1.5 per 100000 person-years in 1985 to 2.8 in 1994. Of all 259 child homicides, the state vital records system underrecorded the coding of those due to battering or abuse by 58.7%. Black children were killed at 3 times the rate of white children (4.3 per 100000 vs 1.3 per 100000). Males made up 65.5% (133/203) of the known probable assailants. Biological parents accounted for 63% of the perpetrators of fatal child abuse. From 1985 through 1996, 9467 homicides among US children younger than 11 years were estimated to be due to abuse rather than the 2973 reported. The ICD-9 cause of death coding underascertained abuse homicides by an estimated 61.6%.

CONCLUSIONS

Using medical examiner data, we found that significant underascertainment of child abuse homicides in vital records systems persists despite greater societal attention to abuse fatalities. Improved recording of such incidences should be a priority so that prevention strategies can be appropriately targeted and outcomes monitored, especially in light of the increasing rates.

Racial and Ethnic Inequities in Postpartum Pain Evaluation and Management

OBJECTIVE

To evaluate whether the frequency of pain assessment and treatment differed by patient race and ethnicity for women after cesarean birth.

METHODS

We performed a retrospective cohort study of all women who underwent cesarean birth resulting in a liveborn neonate at a single institution between July 1, 2014, and June 30, 2016. Pain scores documented and medications administered after delivery were grouped into 0-24 and 25-48 hours postpartum time periods. Number of pain scores recorded, whether any pain score was 7 of 10 or greater, and analgesic medication administered were calculated. Models were adjusted for propensity scores incorporating maternal age, body mass index, gestational age, nulliparity, primary compared with repeat cesarean delivery, classical hysterotomy, and admission to the neonatal intensive care unit.

RESULTS

A total of 1,987 women were identified, and 1,701 met inclusion criteria. There were 30,984 pain scores documented. Severe pain (7/10 or greater) was more common among black (28%) and Hispanic (22%) women than among women who identified as white (20%) or Asian (15%). In the first 24 hours after cesarean birth, non-Hispanic white women had more documented pain assessments (adjusted mean 10.2) than, black, Asian, and Hispanic women (adjusted mean 8.4-9.5; P<.05). Results at 25-48 hours were similar, compared with non-Hispanic white women (adjusted mean 8.3). Black, Asian, and Hispanic women and women who were identified as other all received less narcotic medication at 0-24 hours postpartum (adjusted mean 5.1-7.5 oxycodone tablet equivalents; P<.001-.05), as well as at 25-28 hours postpartum.

CONCLUSION

Racial and ethnic inequities in the experience, assessment and treatment of postpartum pain were identified. A limitation of our study is that we were unable to assess the role of patient beliefs about expression of pain, patient preferences with regards to pain medication, and beliefs and potential biases among health care providers.

Catalyzing a Reproductive Health and Social Justice Movement

Objectives The maternal and child health (MCH) community, partnering with women and their families, has the potential to play a critical role in advancing a new multi-sector social movement focused on creating a women’s reproductive and economic justice agenda. Since the turn of the twenty-first century, the MCH field has been planting seeds for change. The time has come for this work to bear fruit as many states are facing stagnant or slow progress in reducing infant mortality, increasing maternal death rates, and growing health inequities. Methods This paper synthesizes three current, interrelated approaches to addressing MCH challenges—life course theory, preconception health, and social justice/reproductive equity. Conclusion Based on these core constructs, the authors offer four directions for advancing efforts to improve MCH outcomes. The first is to ensure access to quality health care for all. The second is to facilitate change through critical conversations about challenging issues such as poverty, racism, sexism, and immigration; the relevance of evidence-based practice in disenfranchised communities; and how we might be perpetuating inequities in our institutions. The third is to develop collaborative spaces in which leaders across diverse sectors can see their roles in creating equitable neighborhood conditions that ensure optimal reproductive choices and outcomes for women and their families. Last, the authors suggest that leaders engage the MCH workforce and its consumers in dialogue and action about local and national policies that address the social determinants of health and how these policies influence reproductive and early childhood outcomes.

A national action plan for promoting preconception health and health care in the United States (2012-2014)

Preconception health and health care (PCHHC) has gained increasing popularity as a key prevention strategy for improving outcomes for women and infants, both domestically and internationally. The Action Plan for the National Initiative on Preconception Health and Health Care: A Report of the PCHHC Steering Committee (2012-2014) provides a model that states, communities, public, and private organizations can use to help guide strategic planning for promoting preconception care projects. Since 2005, a national public-private PCHHC initiative has worked to create and implement recommendations on this topic. Leadership and funding from the Centers for Disease Control and Prevention combined with the commitment of maternal and child health leaders across the country brought together key partners from the public and private sector to provide expertise and technical assistance to develop an updated national action plan for the PCHHC Initiative. Key activities for this process included the identification of goals, objectives, strategies, actions, and anticipated timelines for the five workgroups that were established as part of the original PCHHC Initiative. These are further described in the action plan. To assist other groups doing similar work, this article discusses the approach members of the PCHHC Initiative took to convene local, state, and national leaders to enhance the implementation of preconception care nationally through accomplishments, lessons learned, and projections for future directions.

Knowledge about the impact of age on fertility: a brief review

Delayed childbearing is currently a major challenge in reproductive medicine as increased age has an important impact on successful conception, both in natural and in assisted reproduction. There is a lack of knowledge about the impact of age on fertility, even in highly educated populations. A number of initiatives have been taken to increase fertility awareness. Health care providers have been encouraged to talk with patients about their reproductive life plan (RLP) for almost a decade based on recommendations from the Centres for Disease Control and Prevention. This concept has been explored successfully in Swedish contraception counselling. A growing number of online interventions aim to raise fertility awareness. These websites or interactive tools provide relevant information for individuals and couples as they consider whether they want children, when they should have them, and how many they may wish to have. These interventions are important, because research depicts that knowledge helps people in their decision-making process. With new fertility preservations such as egg freezing now available, additional education is needed to be sure that women and couples are well informed about the cost and low success rates of this intervention.

Rationale, design, and methodology for the optimizing outcomes in women with gestational diabetes mellitus and their infants study

BACKGROUND

Women who are diagnosed with gestational diabetes mellitus (GDM) are at increased risk for developing prediabetes and type 2 diabetes mellitus (T2DM). To date, there have been few interdisciplinary interventions that target predominantly ethnic minority low-income women diagnosed with GDM. This paper describes the rationale, design and methodology of a 2-year, randomized, controlled study being conducted in North Carolina.

METHODS/DESIGN

Using a two-group, repeated measures, experimental design, we will test a 14- week intensive intervention on the benefits of breastfeeding, understanding gestational diabetes and risk of progression to prediabetes and T2DM, nutrition and exercise education, coping skills training, physical activity (Phase I), educational and motivational text messaging and 3 months of continued monthly contact (Phase II). A total of 100 African American, non-Hispanic white, and bilingual Hispanic women between 22-36 weeks of pregnancy who are diagnosed with GDM and their infants will be randomized to either the experimental group or the wait-listed control group. The first aim of the study is to determine the feasibility of the intervention. The second aim of study is to test the effects of the intervention on maternal outcomes from baseline (22-36 weeks pregnant) to 10 months postpartum. Primary maternal outcomes will include fasting blood glucose and weight (BMI) from baseline to 10 months postpartum. Secondary maternal outcomes will include clinical, adiposity, health behaviors and self-efficacy outcomes from baseline to 10 months postpartum. The third aim of the study is to quantify the effects of the intervention on infant feeding and growth. Infant outcomes will include weight status and breastfeeding from birth through 10 months of age. Data analysis will include general linear mixed-effects models. Safety endpoints include adverse event reporting.

DISCUSSION

Findings from this trial may lead to an effective intervention to assist women diagnosed with GDM to improve maternal glucose homeostasis and weight as well as stabilize infant growth trajectory, reducing the burden of metabolic disease across two generations.

TRIAL REGISTRATION

NCT01809431.

Postpartum Health and Wellness: A Call for Quality Woman-Centered Care

Introduction The first 3 months after giving birth can be a challenging time for many women. The Postpartum Health and Wellness special issue explores this period, one that is often overlooked and under-researched. Methods This issue is designed to bring greater focus to the need for woman-centered care during the postpartum period. Articles in this issue focus on four key areas: (1) the postpartum visit and access to care, (2) the content of postpartum care and postpartum health concerns, (3) interconception care including contraception, and (4) policy, systems, and measurement. Results The submissions highlight deficits in the provision of comprehensive care and services during a critical period in women's lives. The research highlighted in this issue supports the recommendation that Maternal and Child Health leaders collaborate to create woman-centered postpartum services that are part of a coordinated system of care. Conclusion In order to achieve optimal health care in the postpartum period it is becoming more apparent that increased flexibility of services, cross-training of providers, a "no wrong door" approach, new insurance and work-place policy strategies, improved communication, and effective coordinated support within a system that values all women and families is required.

Preconception Health Indicators for Public Health Surveillance

OBJECTIVES

In response to an expressed need for more focused measurement of preconception health (PCH), we identify a condensed set of PCH indicators for state and national surveillance.

METHODS

We used a systematic process to evaluate, prioritize, and select 10 PCH indicators that maternal and child health programs can use for surveillance. For each indicator, we assessed prevalence, whether it was addressed by professional recommendations, Healthy People 2020 objectives, or Centers for Disease Control and Prevention winnable battles, measurement simplicity, data completeness, and stakeholders' input.

RESULTS

Fifty PCH indicators were evaluated and prioritized. The condensed set includes indicators that rely on data from the Pregnancy Risk Assessment Monitoring System (n = 4) and the Behavioral Risk Factor Surveillance System (n = 6). The content encompasses heavy alcohol consumption, depression, diabetes, folic acid intake, hypertension, normal weight, recommended physical activity, current smoking, unwanted pregnancy, and use of contraception.

CONCLUSIONS

Having a condensed set of PCH indicators can facilitate surveillance of reproductive-aged women's health status that supports monitoring, comparisons, and benchmarking at the state and national levels.

Postpartum Health Services Requested by Mothers with Newborns Receiving Intensive Care

Objectives Our pilot study aimed to build knowledge of the postpartum health needs of mothers with infants in a newborn intensive care unit (NICU). Methods Between May 2008 and December 2009, a Certified Nurse Midwife was available during workday hours to provide health care services to mothers visiting their infants in the NICU at a large tertiary care center. Results A total of 424 health service encounters were recorded. Maternal requests for services covered a wide variety of needs, with primary care being the most common. Key health concerns included blood pressure monitoring, colds, coughs, sore throats, insomnia and migraines. Mothers also expressed a need for mental health assessment and support, obstetric care, treatment for sexually transmitted infections, tobacco cessation, breastfeeding assistance, postpartum visits, and provision of contraception. Conclusions Our study suggests that mothers with babies in the NICU have a host of health needs. We also found that women were receptive to receiving health services in a critical care pediatric setting. Intensive care nurseries could feasibly partner with in-patient mother-baby units and/or on-site obstetric clinics to increase access to health care for the mothers of the high-risk newborns in their units. Modifications should be made within health care systems that serve high-risk infants to better address the many needs of the mother/baby dyad in the postpartum period.

Using the Reproductive Life Plan in contraceptive counselling

Having children or not is one of the most important decisions that a person will make in his or her lifetime. The Reproductive Life Plan (RLP) is a protocol that aims to encourage both women and men to reflect on their reproductive intentions and to find strategies for successful family planning, for example to have the wanted number of children and to avoid unwanted pregnancies as well as ill-health that may threaten reproduction. The RLP was developed in an American context for promotion of reproductive health in a life cycle perspective. Few studies have systematically evaluated the effectiveness of using an RLP protocol in clinical practice. This article describes the application of using the RLP protocol in contraceptive counselling in Sweden.

17-Hydroxyprogesterone caproate (17OHP-C) coverage among eligible women delivering at 2 North Carolina hospitals in 2012 and 2013: A retrospective cohort study

BACKGROUND

Although a weekly injection of 17-hydroxyprogestone caproate is recommended for preventing recurrent preterm birth, clinical experience in North Carolina suggested that many eligible patients were not receiving the intervention.

OBJECTIVE

Our study sought to assess how well practices delivering at 2 major hospitals were doing in providing access to 17-hydroxyprogesterone caproate treatment for eligible patients.

STUDY DESIGN

This retrospective cohort analysis studied all deliveries occurring between January 1, 2012, and December 31, 2013, at 2 large hospitals in North Carolina. Women were included if they had a singleton pregnancy and history of a prior spontaneous preterm birth. We extracted demographic, payer, and medical information on each pregnancy, including whether women had been offered, accepted, and received 17-hydroxyprogesterone caproate. Our outcome of 17-hydroxyprogesterone caproate coverage was defined as documentation of ≥1 injection of the drug.

RESULTS

Over the 2-year study period, 1216 women with history of a prior preterm birth delivered at the 2 study hospitals, of which 627 were eligible for 17-hydroxyprogesterone caproate eligible after medical record review. Only 296 of the 627 eligible women (47%; 95% confidence interval, 43-51%) received ≥1 dose of the drug. In multivariable analysis, hospital of delivery, later presentation for prenatal care, fewer prenatal visits, later gestation of prior preterm birth, and having had a term delivery immediately before the index pregnancy were all associated with failed coverage. Among those women who were "covered," the median number of 17-hydroxyprogesterone caproate injections was 9 (interquartile range, 4-15), with 84 of 296 charts (28%) not having complete information on the number of doses.

CONCLUSION

Even under our liberal definition of coverage, less than half of eligible women received 17-hydroxyprogesterone caproate in this sample. Low overall use suggests that there is opportunity for improvement. Quality improvement strategies, including population-based measurement of 17-hydroxyprogesterone caproate coverage, are needed to fully implement this evidence-based intervention to decrease preterm birth.

Advancing preconception health in the United States: strategies for change

In January 2015, the US Preconception Health and Health Care Initiative (PCHHC) established a new national vision that all women and men of reproductive age will achieve optimal health and wellness, fostering a healthy life course for them and any children they may have. Achieving this vision presents both challenges and opportunities. This manuscript describes the reasons why the US needs to prioritize preconception health as well as its efforts historically to advance change. The authors share lessons from past work and current strategies in the US to reach this ambitious goal.

What Makes an Intervention a Life Course Intervention?

OBJECTIVES

To develop an initial list of characteristics of life course interventions to inform the emerging discipline of life course intervention research.

METHODS

The Life Course Intervention Research Network, a collaborative national network of >75 researchers, service providers, community representatives, and thought leaders, considered the principles, characteristics, and utility of life course interventions. After an in-person launch meeting in 2019, the steering committee collaboratively and iteratively developed a list of life course intervention characteristics, incorporating a modified Delphi review process.

RESULTS

The Life Course Intervention Research Network identified 12 characteristics of life course interventions. These interventions (1) are aimed at optimizing health trajectories; (2) are developmentally focused, (3) longitudinally focused, and (4) strategically timed; and are (5) designed to address multiple levels of the ecosystem where children are born, live, learn, and grow and (6) vertically, horizontally, and longitudinally integrated to produce a seamless, forward-leaning, health optimizing system. Interventions are designed to (7) support emerging health development capabilities; are (8) collaboratively codesigned by transdisciplinary research teams, including stakeholders; and incorporate (9) family-centered, (10) strengths-based, and (11) antiracist approaches with (12) a focus on health equity.

CONCLUSIONS

The intention for this list of characteristics of life course interventions is to provide a starting point for wider discussion and to guide research development. Incorporation of these characteristics into intervention designs may improve emerging health trajectories and move critical developmental processes and pathways back on track, even optimizing them to prevent or reduce adverse outcomes.

Health Needs of Mothers of Infants in a Neonatal Intensive Care Unit : A Mixed-Methods Study

BACKGROUND

Mothers with babies in the neonatal intensive care unit (NICU) face a host of challenges following childbirth. Limited information is available on these mothers' postpartum health needs and access to services.

OBJECTIVE

To identify health needs of NICU mothers, access to services, and potential service improvements.

DESIGN

A mixed-methods study including a retrospective cohort study, in-depth interviews, and focus groups.

SETTING

Large, Level IV, regional referral, university-affiliated hospital in the United States.

PARTICIPANTS

Mothers of live-born infants born from 1 July 2014 to 30 June 2016 (n = 6849). Interviews included 50 NICU mothers and 59 stakeholders who provide services to these mothers or their infants.

MEASUREMENTS

Severe maternal morbidity, chronic health conditions, health care encounters from discharge through 12 weeks postpartum, maternal health needs, care access, and system improvements.

RESULTS

Compared with mothers of well babies, NICU mothers had more chronic diseases, experienced more perinatal complications, and utilized more acute care postpartum. Qualitative analyses revealed the desire to be at the baby's bedside as a driver of maternal health-seeking behaviors, with women not seeking or delaying medical care so as to stay by their infant. Stakeholders acknowledged the unique needs of NICU mothers and cited system challenges, lack of clarity about provider roles, and reimbursement policies as barriers to meeting needs.

LIMITATIONS

The study was conducted within a single health care system, which may limit generalizability. Qualitative analyses did not explore the influence of fathers, other children in the home, or length of NICU stay.

CONCLUSION

Universal screening and convenient access to maternal health services for NICU mothers should be explored to reduce adverse maternal health outcomes.

PRIMARY FUNDING SOURCE

Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services.

Addressing Unmet Maternal Health Needs at a Pediatric Specialty Infant Care Clinic

OBJECTIVE

The objective of this intervention was to evaluate the feasibility of screening mothers of medically fragile infants in the domains of 1) depression, 2) tobacco exposure, and 3) family planning at a post-neonatal intensive care unit (NICU) developmental pediatric visit. Additionally, we sought to estimate the percentage who met criteria for further evaluation in the three domains assessed.

METHODS

A cross-sectional questionnaire was administered to 100 caregivers of medically fragile infants at a specialty, post-NICU clinic visit. Participants' responses in three domains were evaluated and appropriate referrals were provided. Analysis was then restricted to the 87 biological mothers who completed the screening. Study staff contacted the mothers 2 months later to determine whether services had been accessed and to assess overall satisfaction with the screening within the pediatric visit. Qualitative interviews were conducted with pediatric clinic staff.

RESULTS

Screening questionnaires were completed by 87 biological mothers. Twenty-two mothers (25%) met referral criteria. Pediatric clinic staff and providers were comfortable administering the screening instrument, and there was minimal disruption to clinic flow.

CONCLUSIONS

Mothers of medically fragile infants are likely to have unmet health care needs that can be identified at a specialty pediatric clinic visit. A screening and referral intervention can be implemented with minimal interruption in pediatric clinic flow and is acceptable to mothers and pediatric providers.

A design thinking approach to primary ovarian insufficiency

Most clinicians are not prepared to provide integrated personal care to address all the clinical needs of women with primary ovarian insufficiency. Design thinking is an engineering methodology used to develop and evaluate novel concepts for systems operation. Here we articulate the need for a seamlessly integrated mobile health system to support genomic research as well as patient care. We also review the pathophysiology and management of primary ovarian insufficiency. Molecular understanding regarding the pathogenesis is essential to developing strategies for prevention, earlier diagnosis, and appropriate management of the disorder. The syndrome is a chronic disorder characterized by oligo/amenorrhea and hypergonadotropic hypogonadism before age 40 years. There may be significant morbidity due to: 1) depression and anxiety related to the loss of reproductive hormones and infertility; 2) associated autoimmune adrenal insufficiency or hypothyroidism; and 3) reduced bone mineral density and increased risk of cardiovascular disease related to estrogen deficiency. Approximately 5% to 10% of women with primary ovarian insufficiency conceive and have a child. Women who develop primary ovarian insufficiency related to a premutation in FMR1 are at risk of having a child with fragile X syndrome, the most common cause of inherited intellectual disability. In most cases of spontaneous primary ovarian insufficiency no environmental exposure or genetic mechanism can be identified. As a rare disease, the diagnosis of primary ovarian insufficiency presents special challenges. Connecting patients and community health providers in real time with investigators who have the requisite knowledge and expertise would help solve this dilemma.

Cardiovascular Health of Mothers in the United States: National Health and Nutrition Examination Survey 2007-2014

Background: Pregnancy and childrearing can impact women's health and alter chronic disease trajectories in later life, including cardiovascular disease. The purpose of this study was to assess measures of women's cardiovascular health by time since last live birth. Materials and Methods: Data were from 4,021 nonpregnant U.S. women, 20-44 years of age, participating in the 2007-2014 National Health and Nutrition Examination Survey (NHANES). Cardiovascular health was assessed using physical measures, laboratory measures, self-reported behaviors, medical conditions, and selected psychosocial factors by time since last live birth. Results: Women reported their last live birth within the past 12 months ("mothers of infants"; 7.4%), >12 months, but <3 years ago ("mothers of toddlers"; 10.0%), or ≥3 years ago ("mothers of older children"; 45.2%); 37.3% were nulliparous. Compared with nulliparous women, mothers of older children had a higher prevalence of selected cardiovascular risk factors, including unhealthy diet (75.6% vs. 68.8%) and smoking (28.1% vs. 21.9%), after adjustment for sociodemographics (including age). Mothers of toddlers had a higher prevalence of unhealthy diet (78.0% vs. 68.8%). Mothers also had poorer metabolic health as indicated by a higher prevalence of low HDL cholesterol among mothers of toddlers and older children (44.2% and 40.4%, respectively, vs. 33.6%), and a higher prevalence of high waist circumference among mothers of infants (65.6% vs. 53.8%). Some mothers also had a higher prevalence of other cardiovascular risk factors, including low physical activity and poor sleep. Conclusion: Prior pregnancy and childrearing may be associated with selected cardiovascular risk factors among nonpregnant reproductive-aged U.S. women.

Building a Life Course Intervention Research Framework

OBJECTIVES

To report on first steps toward building a Life Course Intervention Research Framework (LCIRF) to guide researchers studying interventions to improve lifelong health.

METHODS

The Life Course Intervention Research Network, a collaborative national network of >75 researchers, service providers, community representatives and thought leaders, participated in an iterative review process. Building on the revised Medical Research Council Guidance for Developing and Evaluating Complex Interventions, they identified 12 additional key models with features for inclusion in the LCIRF, then incorporated the 12 characteristics identified by the Life Course Intervention Research Network as actionable features of Life Course Interventions to produce the new LCIRF.

RESULTS

The LCIRF sets out a detailed step-wise approach to intervention development: (1) conceptualization and planning, (2) design, (3) implementation, (4) evaluation, and (5) spreading and scaling of interventions. Each step is infused with life course intervention characteristics including a focus on (1) collaborative codesign (2) health optimization, (3) supporting emerging health development capabilities (4) strategic timing, (5) multilevel approaches, and (6) health equity. Key features include a detailed transdisciplinary knowledge synthesis to inform intervention development; formation of strong partnerships with family, community, and youth representatives in intervention codesign; a means of testing the impact of each intervention on biobehavioral processes underlying emerging health trajectories; and close attention to intervention context.

CONCLUSIONS

This first iteration of the LCIRF has been largely expert driven. Next steps will involve widespread partner engagement in framework refinement and further development. Implementation will require changes to the way intervention studies are organized and funded.

Assessing Preconception Wellness in the Clinical Setting Using Electronic Health Data

Background: One key strategy to reduce maternal morbidity and mortality involves optimizing prepregnancy health. Although nine core indicators of preconception wellness (PCW) have been proposed by clinical experts, few studies have attempted to assess the preconception health status of a population using these indicators. Methods: We conducted a retrospective chart review study of patients who received prenatal or primary care, identified by pregnancy-related ICD-10 codes, at either of two health systems in geographically and socioeconomically different areas of North Carolina between October 1, 2015, and September 30, 2018. Our primary study aim was to determine the feasibility of measuring the proposed PCW indicators through retrospective review of prenatal electronic health records at these two institutions. Results: Data were collected from 15,384 patients at Site 1 and 6,983 patients at Site 2. The indicators most likely to be documented and to meet the preconception health goal at each site were avoidance of teratogenic medications (98.8% and 98.3% at Sites 1 and 2, respectively) and entry to care in the first trimester (64.5% and 73.5% at Sites 1 and 2, respectively), whereas our measures of folic acid use, depression screening, and discussion of family planning were documented less than 20% of the time at both sites. Conclusions: Differences in measuring and documenting PCW indicators across the two health systems in our study presented barriers to monitoring and optimizing PCW. Efforts to address health and wellness before pregnancy will likely require health systems and payors to standardize, incorporate, and promote preconception health indicators that can be consistently measured and analyzed across health systems.

Engaging Families in Life Course Intervention Research: An Essential Step in Advancing Equity

Life course intervention research requires a thorough understanding of complex factors that interact to affect health over time. Partnerships with families and communities are critical to understanding these interconnections and identifying effective interventions. Here, family and community engagement are presented, aligned with the 5 phases of the life course intervention research framework: planning, design, implementation, evaluation, and translation. During planning, the researcher considers their own starting position and what they need to learn from families and the community. The design phase produces a plan for family engagement that is layered, iterative, and includes qualitative methods that will inform life course modeling and the research process. The implementation phase includes administrative actions such as creating opportunities for contributions and providing compensation to family and community partners. The evaluation phase requires measurement of the quality of partnerships with families and community and includes making adjustments as indicated to improve these partnerships. This phase also calls for reflection on the impact these partnerships had on the intervention, including if they made a difference for those being served. During translation, the researcher works with all partners, including families and communities, about follow up steps toward project continuation, replication, or completion. The researcher also works collaboratively in determining how the study results are shared. A holistic approach to health over the life course that is designed and executed in partnership with families and their community can generate research findings with broad practical applicability and strong translational potential.

Perinatal morbidity and health utilization among mothers of medically fragile infants

OBJECTIVE

To determine the burden of perinatal morbidity among mothers of medically fragile infants.

STUDY DESIGN

We conducted a retrospective cohort study of 6849 mothers who delivered liveborn infants at a quaternary care hospital during a two-year period. We compared mothers of well babies with mothers of infants admitted to the Neonatal Intensive Care Unit (NICU), and we used logistic regression to model predictors of postpartum acute care utilization among NICU mothers.

RESULTS

Rates of obstetric morbidity were highest for mothers of infants staying ≥72 h in the NICU; 54.2% underwent cesarean birth, 7.5% experienced severe maternal morbidity, and 6.6% required a blood transfusion. Factors independently associated with postpartum acute care use included gestational age <28 weeks, ever smoking, non-Hispanic Black race, temperature >38 °C and receiving psychiatric medication during the birth hospitalization.

CONCLUSION

Focused support for mothers of NICU infants has the potential to reduce maternal morbidity and improve health.