Improving Racial and Ethnic Equity in Clinical Trials Enrolling Pregnant and Lactating Individuals.

Racial and ethnic marginalized populations have historically been poorly represented, underrecruited, and underprioritized across clinical trials enrolling pregnant and lactating individuals. The objectives of this review are to describe the current state of racial and ethnic representation in clinical trials enrolling pregnant and lactating individuals and to propose evidence-based tangible solutions to achieving equity in these clinical trials. Despite efforts from federal and local organizations, only marginal progress has been made toward achieving equity in clinical research. This continued limited inclusion and transparency in pregnancy trials exacerbates health disparities, limits the generalizability of research findings, and may heighten the maternal child health crisis in the United States. Racial and ethnic underrepresented communities are willing to participate in research; however, they face unique barriers to access and participation. Multifaceted approaches are required to facilitate the participation of marginalized individuals in clinical trials including partnering with the local community to understand their priorities, needs, and assets; establishing accessible recruitment strategies; creating flexible protocols; supporting participants for their time; and increasing culturally congruent and/or culturally sensitive research staff. This article also highlights exemplars in pregnancy research.

MCH Leadership Training Program: An Innovative Application of an Implementation Science Framework.

INTRODUCTION: MCH training programs in schools of public health provide specialized training to develop culturally competent and skilled MCH leaders who will play key roles in public health infrastructure. Previous literature has reported on the effectiveness of MCH training programs (e.g., number of trainees, improvement in knowledge/skills); less attention has been devoted to understanding factors influencing program implementation during times of rapid change, while considering internal and external contexts (e.g., global pandemic, social unrest, uncertainty of funding, mental health issues, and other crises). PURPOSE: This article describes a graduate-level MCH leadership training program and illustrates how an implementation science framework can inform the identification of determinants and lessons learned during one year of implementation of a multi-year program. ASSESSMENT: Findings reveal how CFIR can be applicable to a MCH training program and highlight how constructs across domains can interact and represent determinants that serve as both a barrier and facilitator. Key lessons learned included the value of accountability, flexibility, learner-centeredness, and partnerships. CONCLUSION: Findings may apply to other programs and settings and could advance innovative training efforts that necessitate attention to the multi-level stakeholder needs (e.g., student, program, institution, community, and local/regional/national levels). Applying CFIR could be useful when interpreting process and outcome evaluation data and transferring findings and lessons learned to other organizations and settings. Integrating implementation science specifically into MCH training programs could contribute to the rigor, adaptability, and dissemination efforts that are critical when learning and sharing best practices to expand leadership capacity efforts that aim to eliminate MCH disparities across systems.

Tobacco-related health inequalities among Black Americans: A narrative review of structural and historical influences.

We conducted a narrative literature review to examine contributing factors of disparities in tobacco usage and outcomes affecting Black Americans. We propose potential solutions that can be used to effectively address these disparities. We identified historical factors; socioeconomic factors; targeted marketing/advertising; the influence of racism/discrimination; neighborhood socioeconomic disadvantage; and mass incarceration. We call for more thorough examinations of these factors as a key element of tobacco-focused research and interventions to eliminate the disproportionate burdens faced by Black Americans. We advocate for greater emphases on the impacts of personal and structural racism on tobacco usage and outcomes affecting Black Americans.

Women's Perspectives on Factors Influencing Florida Pregnancy Risk Assessment Monitoring System (PRAMS) Response.

OBJECTIVES: To inform updates to the Pregnancy Risk Assessment Monitoring System (PRAMS) design and processes, African American/Black and Hispanic/Latina women in Florida provided feedback on their awareness and perceptions of the PRAMS survey, and preferences for survey distribution, completion, design and content. METHODS: Focus groups were conducted in English and Spanish with 29 women in two large metropolitan counties. Participants completed a brief survey, reviewed the PRAMS questionnaire and recruitment materials, engaged in discussion, and gave feedback directly onto cover design posters. RESULTS: Participants reported limited awareness of PRAMS. Preferences for survey distribution and completion varied by participant lifestyle. Interest in topics covered by PRAMS was as a motivator for completion, while distrust and confidentiality concerns were deterrents. Participants were least comfortable answering questions about income, illegal drug use, and pregnancy loss/infant death. Changes to the length of the survey, distribution methods, and incentives/rewards for completion were recommended. CONCLUSIONS FOR PRACTICE: Results highlight the need to increase PRAMS awareness, build trust, and consider the design, length and modality for questionnaire completion as possible avenues to improve PRAMS response rates.

Sociodemographic and socioeconomic correlates of learning disability in preterm children in the United States.

BACKGROUND: In 2019, 1 in every 10 infants born in the United States was preterm. Prematurity has life-threatening consequences and causes a range of developmental disabilities, of which learning disability is a prevalent complication. Despite the availability of special services for children living with learning disability, gaps still exist in terms of access due to socioeconomic factors. The aim of this study is to evaluate socioeconomic and sociodemographic correlates of learning disability in preterm children. METHODS: This cross-sectional study used data from the 2016-2018 National Survey of Children's Health. Weighted multivariable analyses were conducted to ascertain the association of sociodemographic and socioeconomic factors on learning disability among preterm children. The main outcome variable was the presence of learning disability. RESULTS: Among 9555 preterm children in our study population, 1167 (12%) had learning disability. Learning disability was significantly associated with health insurance, food situation, and poverty level after adjustment for other variables. Children currently insured had lower odds of having learning disability compared to those without health insurance (OR = 0.79, 95% C.I. = 0.70-0.91). Also, children living in households that cannot afford nutritious meals are more likely to have learning disability compared to those that can afford nutritious meals at home (OR = 1.55, 95% C.I. = 1.22-1.97). CONCLUSION: These findings highlight the need for intervention efforts to target these children living with a learning disability to achieve the 2004 Individuals with Disabilities Education Act of promoting educational equality and empowerment of children living with a learning disability.

An Overview of an Undergraduate Diversity MCH Pipeline Training Program: USF's Train-A-Bull.

PURPOSE: To describe an undergraduate pipeline training program (PTP) designed to guide underrepresented minorities (URM) trainees into MCH-related health professions, ultimately contributing to a diverse maternal and child health (MCH) workforce that can improve health outcomes for all women/mothers, children, and their families, including fathers and children with special healthcare needs. DESCRIPTION: Three cohorts with 35 total undergraduate trainees were recruited to participated in the 2 years USF MCH PTP program where they were mentored, trained, guided, and supported by program faculty/staff. Students were recruited early in their education track, and the program was individually tailored based on trainees' educational discovery stages. Key program components included seminars, summer institutes, public health courses, mentorship, internship, experiential learning opportunities, and professional networking opportunities. ASSESSMENT: The majority of the undergraduate participants were diverse URMs including Hispanic/Latino (37.1%), Black/African American (31.4%), Asian (20%), and American Indian/Alaskan Native (5.7%) trainees. Out of all the cohorts, 51.4% were first-generation college students and 74.3% had economic hardships (i.e., PELL Grant, FAFSA). Resulting from the program, all cohorts increased in educational discovery stages, one-third enrolled in health-related graduate studies and half joined the MCH workforce. CONCLUSION: Recruitment in pipeline programs should be intentional and meet students where they are in their education discovery stage. The use of educational discovery stages within a pipeline program are useful in both tailoring curriculum to individuals' needs and assessment of progression in career decision-making. Mentoring from program staff remains an important component for pipeline programs.

Impact of Doula-Led Lactation Education on Breastfeeding Outcomes in Low-Income, Minoritized Mothers.

Prenatal education may improve breastfeeding outcomes among low-income women. Our objective was to assess breastfeeding intentions and knowledge among women participating in doula-facilitated prenatal education classes from August 2016 to October 2017. Breastfeeding knowledge and infant feeding intentions were assessed before and after the classes. Breastfeeding rates were assessed at birth, 2-4 weeks postpartum, and 6-8 weeks postpartum. Paired t-tests tests were conducted. A total of 121 racially diverse, low-income women were enrolled. Intentions to breastfeed increased pre- to post-intervention (p = 0.007). Breastfeeding knowledge scores increased pre- to post-intervention (p <.001); specifically, among women who were exclusively breastfeeding or breastfeeding while supplementing with formula at birth (p < .001 and p = 0.046, respectively). Doula-facilitated breastfeeding education may help improve breastfeeding outcomes for low-income women.

Multilevel factors associated with length of stay for neonatal abstinence syndrome in Florida's NICUs: 2010-2015.

OBJECTIVE: To investigate potential factors influencing initial length of hospital stay (LOS) for infants with neonatal abstinence syndrome (NAS) in Florida. METHODS: The study population included 2984 term, singleton live births in 33 Florida hospitals. We used hierarchical linear modeling to evaluate the association of community, hospital, and individual factors with LOS. RESULTS: The average LOS of infants diagnosed with NAS varied significantly across hospitals. Individual-level factors associated with increased LOS for NAS included event year (P < 0.001), gestational age at birth (P < 0.001), maternal age (P = 0.002), maternal race and ethnicity (P < 0.001), maternal education (P = 0.032), and prenatal care adequacy (P < 0.001). Average annual hospital NAS volume (P = 0.022) was a significant hospital factor. CONCLUSION: NAS varies widely across hospitals in Florida. In addition to focusing on treatment regimens, to reduce LOS, public health and quality improvement initiatives should identify and adopt strategies that can minimize the prevalence and impact of these contributing factors.

Review of Prediabetes and Hypertensive Disorders of Pregnancy.

Obesity and diabetes increase hypertensive disorders of pregnancy (HDP) risk, thus preventive interventions are heavily studied. How pregestational prediabetes and related interventions impact HDP risk is less characterized. Therefore, we searched and reviewed the literature to assess the impact on HDP risk of prediabetes and varied interventions. We identified 297 citations related to pregnancy, prediabetes, and early pregnancy interventions. We also reviewed the references and citations of included articles. We included five studies assessing HDP outcomes in women with first trimester hemoglobin A1c in the prediabetes range (5.7-6.4%). One prospective observational study demonstrated first trimester hemoglobin A1c (5.9-6.4%) is associated with increased HDP risk, while another prospective observational study and one retrospective observational study had similar trends without statistical significance. A small and underpowered randomized controlled trial demonstrated initiating gestational diabetes mellitus treatment (i.e., diet, monitoring, ± insulin) in response to first trimester hemoglobin A1c (5.7-6.4%) did not statistically reduce HDP compared with standard care. One retrospective observational study suggested metformin, when started early, may reduce HDP risk in patients with prediabetes. Pregestational prediabetes appears to increase HDP risk. Interventions (i.e., metformin, diet/glucose monitoring, and/or exercise) to reduce HDP risk require additional study with long-term follow-up.

Effectiveness of a 24/7 Dad® Curriculum in Improving Father Involvement: Profiles of Engagement.

BACKGROUND OR OBJECTIVES: Father involvement is a key component in maintaining healthy families and communities. This study presents quantitative results of the first five years of a comprehensive fatherhood training program offered by REACHUP, Inc. in Florida, United States. METHODS: The program utilized the 24/7 Dad ® curriculum for the fatherhood training program. Key program outcome was differences in pre and post-test scores on self-awareness, fathering skills, parenting skills, relationship skills, and self-care. Demographic and pretest-posttest data collected between 2013 and 2017 were analyzed using chi-square test for categorical variables, McNemar's test for differences in proportions pre- and post-intervention, paired sample t-test to compare means in pretest and posttest scores and analysis of variance (ANOVA) to test the difference between means across years and demographic characteristics. RESULTS: Attendance in the program increased yearly, nearly doubling from 55 participants in 2013 to 97 in 2017. The mean pretest score was 8.90 (±4.04) and the mean posttest score was 16.42 (±4.54) out of 22 total points, representing a highly significant positive effect of the program on self-awareness, fathering skills, parenting skills, relationship skills and self-care which will enable men to establish long-lasting positive relationships with their children. There were significant differences by demographic characteristics. Younger participants tended to score lower on the pretest but made the most knowledge gains following the training as indicated by the difference in pre- and posttest scores (<0.001). CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Increasing yearly attendance indicates the notion of male involvement is gaining momentum. An important lesson learned over the five-year period is that not all males who participated in the program were biological fathers of infants, young children or adolescents. Many participants were grandfathers, uncles and family friends, indicating that the benefits of a male involvement program can extend beyond the boundaries of biological fatherhood.

Evaluation of an Evidence-based and Community-responsive Fatherhood Training Program: Providers' Perspective.

BACKGROUND AND OBJECTIVES: Studies on male involvement and pregnancy outcomes have often not incorporated the providers' perspectives, which are potentially critical to understanding program context, evolution, perceived impact, and sustainability. We sought to evaluate the 24/7 Dad® program from the viewpoint of the program providers. METHODS: We conducted purposive sampling of 24/7 Dad program facilitators and administrators who were involved in recruitment, training, and follow up of program participants within a federal Healthy Start program (REACHUP) in Tampa, Florida, USA. Using a snowballing approach, we recruited six key informants who had administered the program for at least four years. We elicited and evaluated factors impacting the performance of the father involvement program using content analysis. RESULTS: Under program participation and perceived impact, most providers thought that the program had created a safe space previously unavailable for men in the community. The most useful recruitment strategy was building partnerships with other organizations. The key informants noted an important evolutionary trend in the father involvement program over time as well as the nature of linkages to partner organizations within the area. Threats to program sustainability included the continued reluctance and scepticism to invest funds to address male issues, sub-optimal retention of participants who were living transient lives as well as geographical/transportation barriers. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: The involvement of fathers during pregnancy has significant implications for healthy babies. Our study results provide a clarion call to augment capacity and infuse more resources to improve paternal involvement in order to attain the United Nations Sustainable Goal (2015-2030) of ensuring healthy lives and the promotion of well-being for all at all ages.

Protective Factors Using the Life Course Perspective in Maternal and Child Health.

The life course perspective (LCP), a valuable theoretical framework for investigating racial disparities in birth outcomes, examines the cumulative exposure of risk and protective factors throughout the life span. Although risk and protective exposures are equally vital to health, most studies have focused solely on the risk factor exposures faced by vulnerable populations. In clear contrast to the traditional public health approach, which emphasizes a deficit model, strengths-based approaches focus on protective factors and fostering resilience. These approaches view communities as valuable assets that have the capacity to fully engage themselves and their residents to achieve optimal health. Participatory action research methods are well suited to apply a strengths-based approach to understand health disparities. Our study aimed to explore maternal and child health protective factors from community residents' perspective. A group of researchers, including active members in the community with a long history of grassroots development work, conducted ten community-based participatory focus groups with community residents in Tampa, FL, using the LCP framework. A total of 78 residents participated in ten focus groups. Perceived protective factors during pregnancy included self-esteem, spirituality, pregnancy support, good nutrition, prenatal care, and community resources. Protective factors for non-pregnant women were self-esteem, spirituality, social support, health literacy, community support and community resources, and societal factors. For children and adolescents, relevant protective factors were self-esteem, positive role models, nutrition and physical activity, and community support. The identified factors are community assets or strengths that mitigate or eliminate maternal and child health risks in families and communities residing in low-income neighborhoods, which must be considered in developing effective maternal and child health interventions.

The CI Index (CII): A New Instrument to Evaluate and Foster Collaborative Partnership in Public Health.

BACKGROUND OR OBJECTIVES: Collective Impact (CI) is the sum of collaborative actions through coalition building to examine and address issues that threaten public health. We sought to develop an instrument to measure CI across diverse health-related organizations. METHODS: The study was performed in 5 phases initiated with a comprehensive literature review through the generation of candidate items using a deductive instrument development approach. A matrix was then created to map assembled items onto related CI domains. An one-hundred and nine (n=109) item questionnaire covering multiple items per domain was administered to 200 health-related organizations selected randomly throughout the United States. Survey data were evaluated using Principal Component Analysis and Kaiser criterion or eigenvalue-greater-than-one rule was the factor retention method utilized. RESULTS: Based on Kaiser's eigenvalue criteria and communality estimates, the number of items across the five domains of CI was reduced from 109 to 20, with 4 items populating each subdomain. All communality estimates in the final instrument had values > 0.6, which was sufficiently adequate as per Kaiser's criterion. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: This pilot study demonstrates CI represents a multi-factorial concept with domains that are multi-dimensional capturing diverse aspects of a construct. We developed the first measure of CI for public health practice. The index bears potential utility for assessing and monitoring areas of strengths and weaknesses within collaborative partnerships across the spectrum of population health.

Community-based fortified dietary intervention improved health outcomes among low-income African-American women.

Poor dietary exposure disproportionately affects African-Americans and contributes to the persistence of disparities in health outcomes. In this study, we hypothesized that fortified dietary intervention (FDI) will improve measured dietary and related health outcomes and will be acceptable among low-income African-American women living in Tampa, FL. These objectives were tested using a prospective experimental study using pretest and posttest design with a control group, using a community-based participatory research approach. The intervention (FDI) was designed by the community through structural modification of a preexisting, diet-based program by the addition of a physical and mental health component. Paired sample t tests were used to examine preintervention and postintervention changes in study outcomes. A total of 49 women participated in the study, 26 in the FDI group and 23 controls. Two weeks postintervention, there were significant improvements in waist circumference and health-related quality of life related to physical health (P< .0001), physical fitness subscores (P= .002), and nutritional subscores (P= .001) in the FDI group. Among overweight/obese women, improvement in health-related quality of life related to physical health, a significant decrease in depressive score, and a reduction in waist circumference were noted. In the control group, a decrease in waist circumference was observed. Implementation of the FDI through a community-based participatory research approach is feasible and effective among low-income African-American women in general and overweight/obese women in particular. Social reengineering of a nutritional intervention coupled with community-based approach will enhance health outcomes of low-income women.

Transformative Use of an Improved All-Payer Hospital Discharge Data Infrastructure for Community-Based Participatory Research: A Sustainability Pathway.

OBJECTIVE: To describe the use of a clinically enhanced maternal and child health (MCH) database to strengthen community-engaged research activities, and to support the sustainability of data infrastructure initiatives. DATA SOURCES/STUDY SETTING: Population-based, longitudinal database covering over 2.3 million mother-infant dyads during a 12-year period (1998-2009) in Florida. SETTING: A community-based participatory research (CBPR) project in a socioeconomically disadvantaged community in central Tampa, Florida. STUDY DESIGN: Case study of the use of an enhanced state database for supporting CBPR activities. PRINCIPAL FINDINGS: A federal data infrastructure award resulted in the creation of an MCH database in which over 92 percent of all birth certificate records for infants born between 1998 and 2009 were linked to maternal and infant hospital encounter-level data. The population-based, longitudinal database was used to supplement data collected from focus groups and community surveys with epidemiological and health care cost data on important MCH disparity issues in the target community. Data were used to facilitate a community-driven, decision-making process in which the most important priorities for intervention were identified. CONCLUSIONS: Integrating statewide all-payer, hospital-based databases into CBPR can empower underserved communities with a reliable source of health data, and it can promote the sustainability of newly developed data systems.

Socio-ecological Model as a Framework for Overcoming Barriers and Challenges in Randomized Control Trials in Minority and Underserved Communities.

BACKGROUND: Numerous barriers and challenges can hinder the successful enrollment and retention of study participants in clinical trials targeting minority populations. To conduct quality research, it is important to investigate these challenges, determine appropriate strategies that are evidence-based and continue seeking methods of improvement. METHODS: In this paper, we report such experiences in a registered clinical trial in an underserved minority population in the Southern part of United States. This research study is a randomized double-blind controlled clinical trial that tests the efficacy of higher-strength as compared to low-strength/standard of care folic acid to prevent fetal body and brain size reduction in pregnant women who smoke. A unique approach in this socio-behavioral, genetic-epigenetic clinical trial is that we have adopted the socio-ecological model as a functional platform to effectively achieve and maintain high participant recruitment and retention rates. RESULTS: We highlight the barriers we have encountered in our trial and describe how we have successfully applied the socio-ecological model to overcome these obstacles. CONCLUSIONS AND GLOBAL HEALTH IMPLICATIONS: Our positive experience will be of utility to other researchers globally. Our fi ndings have far-reaching implications as the socio-ecological model approach is adaptable to developed and developing regions and has the potential to increase recruitment and retention of hard-to-reach populations who are typically under-represented in clinical trials.

Impact of maternal thyroperoxidase status on fetal body and brain size.

The obstetric consequences of abnormal thyroid function during pregnancy have been established. Less understood is the influence of maternal thyroid autoantibodies on infant outcomes. The objective of this study was to examine the influence of maternal thyroperoxidase (TPO) status on fetal/infant brain and body growth. Six-hundred thirty-one (631) euthyroid pregnant women were recruited from prenatal clinics in Tampa Bay, Florida, and the surrounding area between November 2007 and December 2010. TPO status was determined during pregnancy and fetal/infant brain and body growth variables were assessed at delivery. Regression analysis revealed maternal that TPO positivity was significantly associated with smaller head circumference, reduced brain weight, and lower brain-to-body ratio among infants born to TPO+ white, non-Hispanic mothers only, distinguishing race/ethnicity as an effect modifier in the relationship. No significant differences were noted in body growth measurements among infants born to TPO positive mothers of any racial/ethnic group. Currently, TPO antibody status is not assessed as part of the standard prenatal care laboratory work-up, but findings from this study suggest that fetal brain growth may be impaired by TPO positivity among certain populations; therefore autoantibody screening among high-risk subgroups may be useful for clinicians to determine whether prenatal thyroid treatment is warranted.

Low-level exposure to air pollution and risk of adverse birth outcomes in Hillsborough County, Florida.

OBJECTIVE: In this retrospective cohort (1998 to 2007), 145,445 singleton live births in Hillsborough, Florida, were analyzed to elucidate the relationship between fetal morbidity and prenatal exposure to six criteria air pollutants. METHODS: This study was based on three linked databases: Florida Hospital Discharge, vital statistics records, and air pollution meteorological data from the Environmental Protection Agency. The primary outcomes of interest were low birth weight, preterm births, and small for gestational age. This study used structural equation modeling and trimester groupings to evaluate the relationship between air pollution and birth outcomes of pregnant residents. RESULTS: The latent variables of structural equation modeling yielded a significant B value of 0.35, indicating that exposure to the criteria pollutants in pregnancy may have a significant relationship to fetal morbidity. CONCLUSION: Exposure to criteria air pollutants in pregnancy is associated with fetal morbidity outcomes.

Exposure to environmental tobacco smoke and risk of antenatal depression: application of latent variable modeling.

This study sought to determine the impact of passive smoking on the risk for depressive symptoms during pregnancy. In this prospective study, 236 pregnant women were recruited at less than 20 weeks of gestation from a university-affiliated obstetric clinic from November 2009 through July 2011. Tobacco use/exposure was measured using questionnaire and confirmed by salivary cotinine analysis. The Edinburgh Perinatal Depression Scale (EPDS) was employed to capture perinatal depressive symptomatology. Traditionally, a cutoff of 13 is utilized to indicate depressive symptoms in the perinatal population. However, this approach is vulnerable to measurement errors that are inherent in assessing depression using cutoff points. Therefore, in this analysis, we apply a flexible approach (latent variable modeling) that accounts for measurement errors thereby reducing bias in the estimates of association. Significant differences were observed in the mean EPDS scores across non-smokers (mean ± SD = 4.8 ± 4.8), passive smokers (5.3 ± 5.5) and active smokers (7.4 ± 6.1) [p value = 0.02]. For each itemized response of the EPDS, passive smokers demonstrated an increased risk for depressive symptoms with the greatest risk exhibited by items 8 and 9 of the questionnaire (feeling sad or miserable and feeling unhappy [and]crying, respectively). In addition, for each item of the EPDS, a dose-response pattern was revealed with non-smokers having the least risk of depressive symptoms during pregnancy and active smokers having the greatest risk. Women who are exposed to secondhand smoke are at elevated risk for depressive symptoms during pregnancy.

Association between tobacco use in pregnancy and placenta-associated syndromes: a population-based study.

INTRODUCTION: Cigarette smoking is an established risk factor for adverse perinatal outcomes. The purpose of this study is to examine the association between maternal smoking in pregnancy and the occurrence of placental-associated syndromes (PAS). METHODS: We analyzed data from a population-based retrospective cohort of singleton deliveries that occurred in the state of Missouri from 1989 through 2005 (N = 1,224,133). The main outcome was PAS, a composite outcome defined as the occurrence of placental abruption, placenta previa, preeclampsia, small for gestational age, preterm or stillbirth. We used logistic regression models to generate adjusted odd ratios and their 95 percent confidence intervals. Non-smoking gravidas served as the referent category. RESULTS: The overall prevalence of prenatal smoking was 19.6%. Cigarette smoking in pregnancy was associated with the composite outcome of placental syndromes (odds ratio, 95% confidence interval = 1.59, 1.57-1.60). This association showed a dose-response relationship, with the risk of PAS increasing with increased quantity of cigarettes smoked. Similar results were observed between smoking in pregnancy and independent risks for abruption, previa, SGA, stillbirth, and preterm delivery. CONCLUSION: Maternal smoking in pregnancy is a risk factor for the development of placenta-associated syndrome. Smoking cessation interventions in pregnancy should continue to be encouraged in all maternity care settings.