Showing papers in "Maternal and Child Health Journal in 2001"

Stress and Preterm Birth: Neuroendocrine, Immune/Inflammatory, and Vascular Mechanisms

Abstract: A growing literature suggests that maternal psychological and social stress is a significant and independent risk factor for a range of adverse reproductive outcomes including preterm birth. Several issues remain to be addressed about stress and vulnerability to stress during pregnancy. Of these, perhaps one of the most important questions relates to biologic plausibility. Parturition, the process that results in birth, is a biological phenomenon. Very little empirical research to date, however, has examined the role of biological processes, if any, as mediators of the relationship between stress and preterm birth. In this paper we discuss the maternal, placental, and fetal neuroendocrine, immune/inflammatory, and vascular processes that may bridge the experience of social adversity before and during pregnancy and the biological outcome of preterm birth.

Maternal stress is associated with bacterial vaginosis in human pregnancy.

Abstract: Objectives: Maternal infection, particularly bacterial vaginosis (BV) in pregnancy, is one of the leading causes of adverse perinatal outcomes. The determinants of individual differences in susceptibility, or vulnerability, to maternal infections are poorly understood. This study examines whether chronic maternal stress predisposes women to infection during pregnancy, and if so, whether the effects of chronic stress on infection are independent of other established risk factors. Methods: We conducted a cross-sectional, clinical prevalence study of chronic maternal stress and BV status in a sample of 454 pregnant women at 14.3 ± 0.3 weeks gestation (±SEM). BV was diagnosed by Gram-stain of vaginal fluid samples; chronic maternal stress was assessed using the Cohen Perceived Stress Scale. Other established risk factors for BV, including maternal age, race/ethnicity, marital status, SES, and behaviors related to feminine hygiene, sexual practices, and substance use, were measured using a structured interview. Results: Of the 454 women enrolled in this study, 224 (49%) were BV positive (Nugent score 7–10), 64 (14%) had intermediate vaginal flora (Nugent score 4–6), and 166 (37%) were BV negative (Nugent score 0–3). BV+ women had significantly higher chronic stress levels than BV− women (24.6 ± 0.5 vs. 22.2 ± 0.6 units (±SEM), respectively; t = 3.19; p < .01). Maternal sociodemographic variables (African-American race/ethnicity) and behavioral characteristics (vaginal douching, number of lifetime sexual partners, and use of illicit drugs) also were significantly associated with the presence of BV. After controlling for the effects of these variables, using a multivariable logistic regression model, chronic maternal stress remained a significant and independent predictor of BV status. Women in the moderate-stress group (third quartile) and high-stress (fourth quartile) group were 2.3 times (95% CI = 1.2–4.3) and 2.2 times (95% CI = 1.1–4.2) more likely to be BV+ than women in the low-stress group (bottom quartile). Conclusions: High levels of chronic stress during pregnancy are associated with bacterial vaginosis. The effect of chronic maternal stress is independent of the effects of other established sociodemographic and behavioral risk factors for BV.

Predictors of pregnancy-associated change in physical activity in a rural white population.

Abstract: Objective: The objective of this study was to examine the relationship of sociodemographic and psychosocial characteristics and exercise prior to pregnancy to change in physical activity (PA) during pregnancy. Methods: This study was part of the Bassett Mothers' Health Project (BMHP), a prospective cohort study of women who enrolled for prenatal care in the Bassett Healthcare system between November 7, 1994, and November 15, 1996. Six hundred twenty-two women met the eligibility criteria and were enrolled in the study. Sociodemographic and psychosocial characteristics and exercise behavior were assessed prenatally using the medical record and an anonymous mailed questionnaire. Staged linear regression analysis was used to predict change in physical activity with the psychosocial and sociodemographic characteristics as the independent variables and prepregnancy exercise frequency as a control variable. Results: Women who were older, more educated, and had higher household incomes were more likely to exercise prior to pregnancy (p < .05). Change in PA after becoming pregnant was associated with prepregnancy exercise frequency (p < .001). Women who exercised frequently moderated their activity, while sedentary women maintained or increased their PA after becoming pregnant. Exercise self-efficacy (the belief in one's ability to exercise regularly) and body mass index (BMI) were positive predictors of change in PA (p < .05), while prepregnancy exercise frequency remained significant as a control variable. Conclusion: Interventions that aim to help women maintain or increase their PA during the perinatal period should be designed to increase exercise self-efficacy.

Examining the burdens of gendered racism: implications for pregnancy outcomes among college-educated African American women.

Abstract: Objectives: As investigators increasingly identify racism as a risk factor for poor health outcomes (with implications for adverse birth outcomes), research efforts must explore individual experiences with and responses to racism. In this study, our aim was to determine how African American college-educated women experience racism that is linked to their identities and roles as African American women (gendered racism). Methods: Four hundred seventy-four (474) African American women collaborated in an iterative research process that included focus groups, interviews, and the administration of a pilot stress instrument developed from the qualitative data. Analysis of the qualitative and quantitative data from the responses of a subsample of 167 college-educated women was conducted to determine how the women experienced racism as a stressor. Results: The responses of the women and the results from correlational analysis revealed that a felt sense of obligations for protecting children from racism and the racism that African American women encountered in the workplace were significant stressors. Strong associations were found between pilot scale items where the women acknowledged concerns for their abilities to provide for their children’s needs and to the women’s specific experiences with racism in the workplace (r D 0:408, p < :001). Conclusions: We hypothesize that the stressors of gendered racism that precede and accompany pregnancy may be risk factors for adverse birth outcomes.

Hopelessness and violence among inner-city youths.

Abstract: Objectives: Ethnographic literature on inner-city life argues that adolescents react to their uncertain (and objectively bleak) future by abandoning hope; this, in turn, leads them to engage in risk behaviors, including violence, with considerable frequency. This study empirically measures the pervasiveness of hopelessness and uncertainty about the future among inner-city adolescents and documents the link between hopelessness, uncertainty, and risk behavior. Methods: We surveyed a sample of 583 adolescents (aged 9–19) living in public housing in Huntsville, AL; this constitutes 80% of the eligible population. Each participant in the survey received $10. Their responses yielded empirical distributions for hopelessness, uncertainty about the future, and four violent behaviors. Using OLS regression, we examined the effect of hopelessness on these violent behaviors. Results: Hopelessness about the future was relatively rare, affecting only 20–30% of the respondents. However, it was a strong predictor of fighting and carrying a knife for females, and of carrying a knife, carrying a gun, and pulling a knife or gun on someone else for males. Uncertainty about the future was more prevalent, but unrelated to the violent behaviors. Conclusions: These results suggest that the conclusions of the ethnographic literature are only partially valid: While hopelessness is, in fact, strongly related to risk behavior, it is not nearly so prevalent as is generally assumed.

Prenatal care utilization among non-Hispanic Whites, African Americans, and Mexican Americans.

Abstract: Objectives: The general objective of this study is to explain differentials in prenatal care (PNC) utilization in a nationally representative sample of non-Hispanic White (Anglo), African American, and Mexican American women. Method: The analysis is based on the National Maternal and Infant Health Survey. Multivariate, multinomial logistic regression models were employed to adjust for demographic, socioeconomic, medical risk, and program participation factors, as well as for perceived barriers. Both race/ethnic-specific models and models with race/ethnicity as a covariate were estimated. Results: Inadequate PNC use was much less common among Anglos (10.4%) as compared to African Americans and Mexican Americans (22.1% and 25.0%, respectively). In fully adjusted models, the odds ratio (OR) of African Americans receiving inadequate PNC was 1.46, while the risk for Mexican Americans was greater (OR = 1.93). Perception of obstacles to PNC access doubled the odds of receiving inadequate care, but this psychosocial variable had little impact on race/ethnic differentials. Race/ethnic-specific models uncovered potentially important racial/ethnic variations associated with perception of barriers, marital status, and program participation. Conclusions: Although the same risk factors sometimes have different effects across race/ethnic groups, and while certain findings indicate a beneficial impact of health outreach efforts and program participation, our findings support the conclusion that PNC utilization continues to be stratified along race/ethnic lines.

The prevalence of socioeconomic and behavioral characteristics and their impact on very low birth weight in black and white infants in Georgia.

Abstract: Objectives: We examined possible reasons for the disparity in the rate of very low birth weight (VLBW) delivery (<1500 g) in the United States between black women and white women. Methods: Using data from a population-based, case–control study of very low birth weight infants, we compared the prevalence of sociodemographic and behavioral characteristics between black and white mothers of normal birth weight infants; the difference in these characteristics between case and control mothers; and, using logistic regression, calculated odds ratios for VLBW for black versus white infants, adjusting for these characteristics. Results: Although black women were disadvantaged on every variable examined, they did not report more behavioral risk factors. Among white women, several traditional risk factors were associated with VLBW, while among black women, only marital status, cigarette smoking, and vitamin nonuse were associated with VLBW delivery. Controlling for the socioeconomic and behavioral factors reduced the odds ratio for VLBW delivery among black mothers from 3.7 to 3.3. Conclusions: Racial disparity in socioeconomic status may be greater than our current ability to adjust for it in epidemiologic studies. The fact that traditional risk factors were not associated with VLBW delivery in black women may be due to the very high prevalence of these risk factors among black women or to different or additional risks or stresses experienced by black women.

Protective Factors Associated with American Indian Adolescents' Safer Sexual Patterns

Abstract: Objectives: This paper presents findings from a research partnership with rural American Indian communities to identify protective factors associated with their adolescents' health-related behaviors including 1) delay of sexual debut; 2) not having had intercourse in the past 3 months; 3) birth control use among sexually active adolescents in the past 3 months; 4) condom use in the past 3 months. Our goal was to identify salient characteristics of students and their perceptions of family, school, and friends which could be incorporated or supported in future program planning for adolescents. Methods: A written survey was administered to 484 Indian students in Grades 6–12 from five rural schools. The survey measured several potential protective factors identified by Problem Behavior Theory, along with self-efficacy and cultural interest and knowledge. Logistic regression assessed the relationship of the protective factors and positive sexual behaviors. Results: Factors significantly associated with abstention from intercourse and/or consistent use of birth control included perceived lower health-risk behavior of friends, higher perceived parental support, higher perceived parental knowledge and monitoring of the adolescent's activities and friends, a higher value on scholastic achievement, higher reported academic performance, and higher self-efficacy for safer sexual behaviors. Conclusions: This research suggests that Indian adolescents have several protective factors indigenous to their communities which are modifiable. Building on the unique cultural heritage of Indian communities, many of these factors may be addressed through community planned prevention programs.

Ecological Analysis of Teen Birth Rates: Association with Community Income and Income Inequality

Abstract: Objectives: To examine whether per capita income and income inequality are independently associated with teen birth rate in populous U.S. counties. Methods: This study used 1990 U.S. Census data and National Center for Health Statistics birth data. Income inequality was measured with the 90:10 ratio, a ratio of percent of cumulative income held by the richest and poorest population deciles. Linear regression and analysis of variance were used to assess associations between county-level average income, income inequality, and teen birth rates among counties with population greater than 100,000. Results: Among teens aged 15–17, income inequality and per capita income were independently associated with birth rate; the mean birth rate was 54 per 1,000 in counties with low income and high income inequality, and 19 per 1,000 in counties with high income and low inequality. Among older teens (aged 18–19) only per capita income was significantly associated with birth rate. Conclusions: Although teen childbearing is the result of individual behaviors, these findings suggest that community-level factors such as income and income inequality may contribute significantly to differences in teen birth rates.

Qualitative methodologies and community participation in examining reproductive experiences: the Harlem Birth Right Project.

Abstract: Objectives: Racial disparities in health present a challenge to public health because of the complexity of interacting social forces. The Harlem Birth Right Project sought to improve understanding of these forces by using qualitative and community participatory methods. In this paper we 1) describe the process of qualitative inquiry and community involvement, 2) evaluate the impact of community participation, and 3) present a brief summary of the findings on social context as it relates to pregnancy outcomes of women in Harlem. Methods: We operationalized the qualitative method by combining participant observation, longitudinal case studies, and focus groups. An ethnographic survey was used to verify and triangulate findings across methods of data collection. We involved the community in the design, implementation, and analysis by collaborating with community-based organizations, setting up a community advisory board, and the use of dialogue groups and community meetings. Results: The use of qualitative methods and community partnership uncovered important aspects of the social context of women's lives that may not have emerged through traditional epidemiologic research. We found that pregnancy may serve as a catalyst to increase perception of the magnitude of preexisting social stressors. Several stressors and chronic strains associated with structural forces were identified. For example, the high percentage of households headed by women is seen as one consequence of larger structural forces. While social support networks serve as an important coping mechanism to buffer against the stress caused by these structural forces, the types of support women seek differs by social strata, and some strategies were identified as being substantially more effective than others. Conclusions: Qualitative and community participatory research can be successfully conducted to support public health goals and can derive important new information on the social context of women's lives.

Eliminating disparities in perinatal outcomes--lessons learned.

Abstract: The disparity between blacks and whites in perinatal health ranges from a 2.3-fold excess risk among black women for preterm delivery and infant mortality to a 4-fold excess risk among black women for maternal mortality. To stimulate concerted public health action to address such racial and ethnic disparities in health, the national Healthy People objectives call for elimination of all health disparities by the year 2010. Eliminating health disparities requires a greater understanding of the factors that contribute to their development. This commentary summarizes the state of the science of reducing such disparities and proposes a framework for using the results of qualitative studies on the social context of pregnancy to understand, study, and address disparities in infant mortality and preterm delivery. Understanding the social context of African American women's lives can lead to an improved understanding of the etiology of preterm birth, and can help identify promising new interventions to reduce racial and ethnic disparities in preterm delivery.

Pregnancy Discovery and Acceptance Among Low-Income Primiparous Women: A Multicultural Exploration

Abstract: As part of a larger study exploring psychosocial factors that influence self-care and use of health care services during pregnancy, we investigated the process of pregnancy discovery and acceptance among a culturally diverse group of women who had given birth to their first child in the year preceding data collection. Methods: Eighty-seven low-income women from four cultural groups (African American, Mexican, Puerto Rican, and white) participated in eight focus groups held in their communities. The focus groups were ethnically homogenous and stratified by early and late entry into prenatal care. A social influence model guided the development of focus group questions, and the study followed a participatory action research model, with community members involved in all phases of the research. Results: Issues that emerged from the focus groups as possible influences on timing of pregnancy recognition include the role of pregnancy signs and symptoms and pregnancy risk perception in the discovery process, the role of social network members in labeling and affirming the pregnancy, concerns about disclosure, “planning” status of the pregnancy, and perceived availability of choices for resolving an unintended pregnancy. Conclusions: The pregnancy discovery process is complex, and when protracted, can potentially result in delayed initiation of both prenatal care and healthful pregnancy behaviors. Enhancing our understanding of pregnancy discovery and acceptance has clear implications for primary and secondary prevention. Future research is needed to further explain the trajectory of pregnancy discovery and acceptance and its influence on health behaviors and pregnancy outcome.

The protective influence of parents and peers in violence avoidance among African-American youth.

Abstract: Objectives: This study attempted to provide further insight into the roles of parents and peers as they influence youth involvement with violence. Specifically, this paper considers whether parents who are close to their children have children who affiliate with prosocial friends who may in turn serve as a buffer against violence. This study also considers how parent and peer influences may change as youth transition to adolescence. Methods: A cross-sectional health behavior survey was administered to 384 low-income, African-American youth aged 10‐15 from three Chicago area schools. Structural equation models (SEM) were developed to assess the impact of youth reported prosocial friends and parental closeness on violence involvement. The overall model was tested to examine equivalence across preadolescent and adolescent age-groupings. Results: Results from the overall model indicated that parental closeness did not have a direct influence on youth violence involvement, but having a close parent‐ child relationship improved the youth’s ability to select prosocial friends, which was directly related to decreased involvement with violence. Differences in the model by age-grouping suggested the presence of prosocial friends was a stronger factor for adolescent violence avoidance when compared to preadolescents. Conclusions: Parents can make a difference in the way in which their children choose their friends and therefore get involved with violence by maintaining a closely bonded relationship throughout preadolescence and adolescence. The importance of this closely bonded relationship has even greater effects for decreasing violence involvement for adolescents than preadolescents.

Why do women douche? Results from a qualitative study.

Abstract: Objectives: To explore women's attitudes and practices related to douching. Methods: We conducted focus groups between July and December 1999 with 34 black and 27 white women enrolled in a managed care plan in Memphis, Tennessee. Participants were at least 18 years of age and had douched at some time in their lives. Five groups were held with black women and five with white women. Results: The focus groups identified 13 themes that fell in four broad categories: general perceptions about feminine hygiene, douching behavior, factors perpetuating douching, and health information. Each of these categories is briefly discussed with supporting evidence. Conclusions: First, women have deeply-rooted beliefs about the critical role of douching in making them feel clean. Second, douching generally starts at a young age and is reinforced by family, friends, and the media. Third, douching is a very difficult behavior to change; any efforts to influence this behavior must consider women's beliefs and the media marketing efforts that promote douching. Finally, simplistic interventions that only provide risk information about douching are not likely to result in behavior change.

Gender attitudes and health risk behaviors in urban African American and Latino early adolescents.

Abstract: Objectives: This study examines the association of beliefs about gender differences (frequently termed gender attitudes or attitudes about women in other research) and of beliefs specifically about masculinity to health risk behaviors in minority, urban, early adolescents, in light of the “gender conventionality” hypothesis. Methods: Data from a self-administered questionnaire assessing gender attitudes and violence-related, substance use, and heterosexual health risk behaviors administered to 587 African American and Latino early adolescents are analyzed. Results: With sociodemographic and family variables controlled, in males violence-related behaviors and substance use are associated with traditional beliefs about masculinity, and heterosexual activity is associated with traditional beliefs about gender differences. In females, being sexually active is positively associated with traditional beliefs about masculinity. Conclusions: Interventions to reduce health risk behaviors in minority, urban, early adolescents may be more effective if they include greater attention to ways in which gender-related attitudes may play a role in health risk taking.

Violent behaviors in early adolescent minority youth: results from a "middle school youth risk behavior survey".

Abstract: Objectives: To describe the prevalence and characteristics of violence and violence-related behaviors among six populations of U.S. minority adolescents in grades 6–8. Methods: Six thousand four hundred non-White adolescents were recruited from six sites that were part of a collaborative project. Surveys were administered either during the school day or at community facilities. All students at each site were asked 10 questions about recent violence-related behaviors (including use of threats, fighting, weapon carrying, and weapon use). Prevalence of each violence-related behavior was reported within and across sites, and stratified by race/ethnicity, gender, age, and other characteristics expected to influence the behaviors. Results: Sixty-six percent (66%) of the middle school students sampled reported being involved in some type of recent fighting and/or weapon-related behaviors. Sixty-one percent (61%) indicated some form of fighting behavior in the past 3 months (threatening to beat someone up, physical fighting, and/or being hurt in a fight). Thirty percent (30%) of participating youth reported one or more weapon-related behaviors (threatening to use a weapon, carrying a weapon, using a weapon, and/or being cut, stabbed or shot at). Reported gun carrying among males varied depending upon site, but was as high as 20%. Grade in school was positively associated with reported violent behaviors. Adolescents who reported living full-time with a parent or parent figure, and those who reported religious observance or beliefs, were less likely to report violence involvement. All violence-related behaviors were more common among male than female adolescents. Conclusions: Violence prevention efforts should begin in elementary school and continue throughout adolescence. Programs should be prepared to provide services or referrals to victims of violence, implement programs tailored toward females as well as males, and build partnerships with churches and other community organizations in which youth are involved.

Foreword: The Social Context of Pregnancy for African American Women: Implications for the Study and Prevention of Adverse Perinatal Outcomes

Abstract: This special issue of the Maternal and Child Health Journal largely results from a 1999 conference sponsored by the Centers for Disease Control and Prevention (CDC) titled “The Social Context of Pregnancy Among African American Women: Implications for Preterm Delivery Prevention.” During this conference, results of qualitative and quantitative research were presented to identify potential new explanatory risk factors for adverse pregnancy outcomes and to better understand how known factors interact among women in the real world. Knowledge of the social context of African American women’s lives, in particular, along with improved understanding of the etiology of preterm birth can generate new perspectives for future research and new interventions to reduce racial and ethnic disparities in preterm delivery. While other publications have contributed to our understanding of medical and biologic factors influencing pregnancy outcome, this issue focuses on furthering our understanding of the social factors influencing pregnancy outcome. Preterm delivery (PTD) is the birth of an infant before completing 37 weeks of gestation. Singleton PTDs to non-Hispanic black women in the United States declined between 1990 and 1997 in 24 states, and the national rate for black women fell by 9.8% from 178.5 per 1000 live births in 1990 to 160.9 in 1997 (1). Despite this improvement, racial disparities persist: PTD is still twice as common among black women compared with white women.

Closing the gap, opening the process: why study social contributors to preterm delivery among black women.

Abstract: In the United States, the excess rates of infant mortality, VLBW, and preterm delivery among African American families relative to white families are known as “the gap.” A group of researchers in the Division of Reproductive Health at the Centers for Disease Control and Prevention proposed that the study of causes of the gap in preterm delivery and the potential interventions to eliminate this disparity required a multidisciplinary approach to elucidate the biologic pathways, stressors, and social environment associated with preterm birth. They encouraged studies that examined the social and political impact of being an African American woman in the United States, racism, and the combined effects of gender, racism, and relative social position, as potential unmeasured etiologic factors that contribute to the gap. The studies conducted represent the expertise of anthropologists, sociologists, medical researchers, and epidemiologists who study both individual and social causes and then also provide a theoretical interpretation by those who lived the experience, (e.g., the study participants) rather than just the researchers' interpretation of the causes of and prevention strategies for the gap.

Stressful life events and physical abuse among pregnant women in North Carolina.

Abstract: Objectives: This study estimates the prevalence of stressful life events and physical abuse among North Carolina women prior to infant delivery, and examines potential associations between abuse and the other stressors. Methods: Data were from the North Carolina Pregnancy Risk Assessment Monitoring System, a statewide representative survey of over 2,600 postpartum women. The survey assessed women's sociodemographic characteristics and their experiences of physical abuse and 13 other stressful life events before delivery. The prevalences of each life event and abuse were estimated. Logistic regression modeled the probability of women having high levels of stressful life events in relation to physical abuse and sociodemographics. Results: Most women were married, white, high school graduates, aged 20 or older. The most common stressful life events were residential moves, increased arguing with husbands/partners, family member hospitalizations, financial hardship, and deaths of loved ones. Fourteen percent of women had high levels of stressful events (5 or more), and almost 9% were physically abused. Abuse was positively associated with increased arguing with husbands/partners, physical fighting, having someone close with an alcohol/drug problem, becoming separated/divorced, and financial hardship. Logistic regression analysis showed that a high level of stressful life events was significantly more likely among women abused both before and during pregnancy (OR = 11.94) and among women abused before but not during pregnancy (OR = 14.19). Conclusions: The high frequency of multiple stressful events and abuse in women's lives suggests that women's care providers should ask their patients about these issues, and offer appropriate referral/interventions to those in need.

The impact of national health insurance on the utilization of health care services by pregnant women: the case in Taiwan.

Abstract: Objectives: Substantially increased funding for health care services occurred in Taiwan after the implementation of a national health insurance plan in 1995. This study attempts to examine the impact of this national health insurance plan on the utilization of prenatal and intrapartum care services. Methods: Nationally representative surveys of all pregnant women in Taiwan in 1989 (1,662 participants) and in 1996 (3,626 participants) were included in the analysis. We first compared the distribution of birth characteristics between the two surveys. We then calculated the rate of utilization of various prenatal and intrapartum care services in the two surveys in the overall sample and in subsamples, stratified by maternal education, age, and parity. Results: The utilization of most prenatal and intrapartum care services, especially the complicated laboratory tests, increased in 1996 compared to 1989. For example, the proportion of women who received amniocentesis increased from 1.62% in 1989 to 5.60% in 1996 and German measles testing increased from 5.96% to 27.11%. By contrast, the proportion of women who received consultation services was stable over time, or for family planning, consultation declined from 33.21% to 27.00%. These changes in utilization over time were consistently observed across different maternal education, age, and parity groups. Conclusions: The utilization of prenatal and intrapartum care services, especially for the more expensive services, has substantially increased in Taiwan since the implementation of the national health insurance. For countries considering similar national health insurance plan, it may be helpful to consider cost-containing measures before the implementation of such a plan.

Minority health risk behaviors: an introduction to research on sexually transmitted diseases, violence, pregnancy prevention and substance use.

Abstract: Aims: The goal of this article is to introduce the Research on Sexually Transmitted Diseases, Violence, and Pregnancy Prevention Project (RSVPP), which represents one response of the National Institutes of Health to reduce health disparities in racial and ethnic populations. Methods: As part of this effort, seven independent projects were funded to design, implement, and evaluate community-based intervention strategies aimed at reducing risk behaviors among minority youth. The interventions and research designs varied across the sites; however, all sites included a common set of questions in their questionnaires. This study focuses on the lessons learned about community-based research across all sites. Results: Sites learned many lessons regarding community-based research, including: the value of building trust, the dynamic nature of communities, the intensive time and resources necessary for success, dissimilarities between researcher and community goals, the value of clear communication, the importance of recognizing the contribution of community members and expressing gratitude for their efforts; the difficulty of disseminating findings regarding sensitive topics, and the need for continuation of interventions. Conclusion: Community involvement posed challenges, but enhanced the quality of the implementation and the evaluation of the interventions. This special issue includes findings from the RSVPP sites.

The theory of planned behavior as a model of intentions for fighting among African American and Latino adolescents.

Abstract: Objectives: To test the theory of planned behavior as a model for predicting and understanding behavioral intentions for fighting among inner-city adolescents and to determine whether its predictive power differs as a function of ethnicity (African American versus Latino). Methods: Participants were 956 (511 females, 445 males) African American (n = 702) and Latino (n = 254) adolescents (mean age = 12.72 years; SD = 1.12) recruited from sixth, seventh, and eighth grade classes in public middle schools serving two inner-city communities in New Jersey who completed self-administered, confidential questionnaires. Results: Consistent with the theory of planned behavior, hierarchical multiple regression analyses revealed that attitudes, subjective norms, and perceived behavioral control predicted intentions for fighting. Although the theory of planned behavior accounted for substantial variance in intentions to fight in both ethnic groups, it accounted for greater variance among Latinos than among African Americans. The strength of the relations of subjective norms and perceived behavioral control to intentions was similar in the two groups, but the relation of attitudes to intentions to fight was significantly stronger among Latinos. Conclusions: The findings strongly suggest that the theory of planned behavior provides a potentially useful conceptual framework for guiding the creation of interventions for African American and Latino adolescents that are designed to reduce violent behavior and the tragedies that such behavior leaves in its wake.

Racial and ethnic disparities in the discordance between women's assessment of the timing of their prenatal care entry and the first trimester standard

Abstract: Objective: The purpose of this study was to investigate whether the discordance between women's assessment of the adequacy of the timing of their prenatal care entry and the standard of first trimester initiation was associated with maternal race or ethnicity. Methods: A population-based surveillance system, the California Pregnancy Risk Assessment Monitoring System, provided data on a stratified random sample of 4,987 women. The women delivered live-born infants from 1994–95 in three perinatal regions. Respondents completed an in-hospital, self-administered questionnaire. Weighted data were analyzed with multiple logistic regression. Results: Twenty-two percent of the women in the sample initiated prenatal care after the first trimester of pregnancy (n = 1,097). Among the women with untimely care, 57% (n = 591) were satisfied with the time of care initiation. Discordance between the women's perception of the adequacy of the time of care initiation and the public health standard of first trimester initiation was associated with maternal ethnicity. After controlling for potential confounders, Mexican-born women with untimely care were more likely to report being satisfied with the time of initiation than were white non-Latina women with untimely care (OR = 4.03, CI = 2.46, 6.59). Conclusions: The design of public health interventions to increase the timeliness of prenatal care initiation will require a greater understanding of pregnant women's own perceptions of their needs for prenatal care, and the differences in perceptions across ethnic groups.

State welfare reform policies and maternal and child health services: a national study.

Abstract: Objectives: Welfare reform (Personal Responsibility and Work Opportunity Reconciliation Act of 1996) resulted in dramatic policy changes, including health-related requirements and the administrative separation of cash assistance from Medicaid. We were interested in determining if changes in welfare and health policies had had an impact on state MCH services and programs. Methods: We conducted a survey in fall 1999 of state MCH Title V directors. Trained interviewers administered the telephone survey over a 3-month period. MCH directors from all 50 states, Washington, DC, and Puerto Rico participated (n = 52; response rate = 100%). Results: Among the most noteworthy findings is that similar proportions of respondents reported that welfare policy changes had either helped (46%) or hindered (42%) the agency's work, with most of the positive impact attributed to increased funding. MCH data linkages with welfare and other social programs were low. Despite welfare reform's emphasis on work, limited services and exemptions were available for mothers with CSHCN. Almost no efforts have been undertaken to specifically address the needs of substance abusers in the context of new welfare policies. Conclusions: Few MCH agencies have developed programs to address the special needs of women receiving TANF who either have health problems themselves or have children with health problems. Recommendations including increased MCH and family planning funding and improved coordination between TANF and MCH to facilitate linkages and services are put forth in light of reauthorization of PRWORA.

Children's access to dental care in Connecticut's Medicaid managed care program.

Abstract: Objective: To describe dental care utilization and access problems in Connecticut's Medicaid managed care program, using quantitative and qualitative research methods. Methods: Using Medicaid managed care enrollment and encounter data from Connecticut, utilization rates for preventive care and treatment services are determined for 87,181 children who were continuously enrolled in Medicaid managed care for 1 year in 1996–97. Sociodemographic and enrollment factors associated with utilization are identified using bivariate and multivariate methods. Dental providers and practices where children received services are described. Qualitative methods are used to characterize problems experienced by families seeking dental care during the study period. Results: Only 30.5% of children continuously enrolled in Medicaid managed care for 1 year received any preventive dental services; 17.8% received any treatment services. Children who received preventive care were eight times more likely to have received treatment services. Utilization was higher among (a) younger children, (b) children who lived in Hartford and in other counties served by public dental clinics, and (c) children enrolled in health plans that did not subcontract for administration of dental services. Just 5% of providers, primarily those in public dental clinics, performed 50% of the services. Families whose children needed care encountered significant administrative and logistical problems when trying to find willing providers and obtain appointments. Conclusions: Access to dental care is a problem for children in Connecticut's Medicaid managed care program. Several features of managed care have negatively affected access. Public dental clinics served many children across the state and contributed to higher utilization of preventive care and treatment services among children living in Hartford.

The MCH Certificate Program: a new path to graduate education in public health.

Abstract: Objective: The purpose of the MCH Certificate Program was threefold: to develop a new educational initiative in response to national and local demands for increased MCH workforce capacity, to eliminate key financial and nonfinancial barriers to advanced MCH academic preparation, and to improve rates of recruitment and retention of students from minority communities, thus enhancing the quality of MCH services available to the region. Methods: An MCH Certificate Program, designed for clinicians (e.g., nurses, occupational therapists and nutritionists) and public health practitioners as a bridge to graduate programs in public health, combined a competency based curriculum with skills workshops, leadership seminars, mentoring, small group activities, and an interactive teaching format. Results: Students from the first two cohorts (n = 45) report an expansion of core public health knowledge (issues, policies, and strategies), enhanced self-confidence, and efficacy. Half have experienced job changes that represent increased responsibility, leadership, and professional advancement. A third are enrolled in or have completed a formal program of graduate study in MCH. Conclusions: This innovative MCH Certificate Program, now in its fourth year, is a new approach to increasing workforce capacity and a successful model of instruction for adult learners. It has the potential for adaptation to a variety of educational settings and MCH populations, and helps to expand the continuum of MCH training experiences in schools of public health.

Risk-adjusted primary cesarean delivery rates for managed care plans in New York State, 1998.

Abstract: Objective: To demonstrate the effect of risk adjustment methodologies compared to crude rates in evaluating the rate of primary cesarean deliveries in managed care plans, after accounting for known demographic and clinical factors. Risk adjustment allows for a more accurate comparison of primary cesarean delivery rates among plans, eliminating potential confounding factors that could influence rates. Methods: Data was collected from managed care plans as part of their 1998 Quality Assurance Reporting Requirements (QARR). Medicaid and commercial populations were matched to New York State Department of Health Vital Statistics birth file to produce a crude measure of cesarean deliveries per plan. Logistic regression models were then used to adjust for maternal education, age, race/ethnicity, obstetrical history, preexisting comorbid conditions, obstetrical conditions, and pregnancy-related conditions to produce adjusted rates. Results: For Medicaid, the crude analysis showed four plans that were significantly lower than the statewide Medicaid managed care rate of 9.5 per 100 live births. One plan was significantly higher. The risk-adjusted results showed one plan being significantly lower than the statewide average and none being higher. For the commercial population, seven plans were significantly lower than the average of 16.3 and four plans were higher. After risk-adjusting, three plans were significantly lower and three plans were significantly higher than the statewide average. Conclusions: Risk-adjustment of primary cesarean delivery rates allows for a more accurate comparison among managed care plans. It is hoped that the generation and publication of more accurate rates will facilitate the acceptance and use of this information by clinicians in managed care plans to focus on improving health outcomes.

Maternal perceptions of pediatric providers for children with chronic illnesses.

Abstract: Objective: To identify maternal perceptions of general and subspecialty pediatric providers of children with selected chronic illnesses. Method: Cross-sectional analyses of survey data. Sample was recruited from eight specialty and four general pediatric practices in an urban setting. Interviews were conducted with mothers of 159 children with one of four chronic illnesses: sickle cell anemia, cystic fibrosis, diabetes, and moderate/severe asthma. About 56% of the participants were white; 40% were African-American; 11% were receiving public assistance. The main outcome measures were maternal reports of which pediatric providers: are visited in the past year, are seen most frequently, have been seen over the longest period of time, relied on most, and know their family best. Rates of dissatisfaction with these providers are also reported. Results: Overall, more mothers reported that they relied on their general pediatric providers, saw them more frequently, and had longer relationships with them than their subspecialty pediatric providers. However, mothers were more satisfied with the care they received from their subspecialty providers than from their primary care providers. Conclusions: Our findings illustrate the complexity of maternal perceptions of the different roles that general and subspecialty pediatric providers play in the care of children with chronic illness.

A preterm birth prevention project in Nova Scotia, Canada.

Abstract: Objective: The Halifax County Preterm Birth Prevention Project was designed to evaluate the effectiveness of a population-based preterm birth (PTB) prevention program in Nova Scotia from January 1995 through June 1997 (n = 10,326). Methods: Preterm birth rates, adjusted for risk status and maternal age, were evaluated over time in Halifax County and compared to non-Halifax County parturients in Nova Scotia. Physician participation was evaluated by means of a mailed survey. Results: There was no appreciable change in the overall (<37 weeks) or early (<34 weeks) PTB rates within or outside Halifax County during the intervention period compared to the preintervention period. Although not significant, the very (<30 weeks) PTB rate in Halifax County decreased by 40% from 0.53 to 0.32%, while outside Halifax County it remained stable (0.43–0.42%). There was a statistically significant decrease in early and very PTB associated with spontaneous labour, as well as an apparent shift in the timing of delivery from very preterm to preterm (≥30 weeks). Participation among responding physicians was greater for high-risk than low-risk women, but full compliance with project recommendations was low. Conclusion: The overall ineffectiveness of the Halifax County Preterm Birth Prevention Project may reflect the reluctance of practitioners to fully incorporate the recommended prevention strategies into their practice. However, such interventions may reduce the risk of spontaneous early preterm birth.

"The Embarrassment of Riches;" an historical theme for a children's health agenda in 21st century America.

Abstract: How can the United States use its immense wealth to create an agenda for children in the 21st century? The field of maternal and child health must strengthen and broaden the social strategies needed to overcome the changing demography and diminished political place of children in society, globally. Four approaches are proposed: First, adopting a life-course orientation emphasizes the continuities of the early part of life with the conditions, developmental tasks, and health problems of the rest of the life cycle; it makes maternal and child health relevant to health and well being across the entire life span. Second, shifting to a focus on the multiple determinants of population health will overcome the limitations of a medical model that is narrowly concerned with etiological risk factors for disease and medical interventions; in particular, poverty among children must be addressed on a global scale. Third, promoting social justice for children demands an open political discussion of the moral and ethical foundations of child health. Finally, preventing health problems across the life span requires a new set of population level, univeral intervention strategies. These fundamental principles are proposed to stimulate a discussion of how to make our field more influential in the 21st century.