Maternal and Child Health Pipeline Training Programs: A Description of Training Across 6 Funded Programs.

PURPOSE: The HRSA-funded maternal and child health pipeline training programs (MCHPTPs) are a response to the critical need to diversify the MCH workforce, as a strategy to reduce health disparities in MCH populations. These MCHPTPs support students from undergraduate to graduate education and ultimately into the MCH workforce. DESCRIPTION: The models and components of training across the six MCHPTPs funded in 2016-2021 are summarized, to examine the design and delivery of undergraduate pipeline training and the insights gained across programs. ASSESSMENT: Strategies that emerged across training programs were organized into three themes: recruitment, support for student persistence (in education), and pipeline-to-workforce intentionality. Support for student persistence included financial support, mentoring, creating opportunity for students to develop a sense of belonging, and the use of research as a tool to promote learning and competitiveness for graduate education. Finally, the link to Maternal and Child Health Bureau (MCHB) long-term training and other MCHB opportunities for professional development contributed significant nuance to the pipeline-to-workforce objectives of these programs. CONCLUSIONS: The MCHPTPs not only increase the diversity of the MCH workforce, they also actively prepare the next generation of MCH leaders. The intentional connection of undergraduates to the infrastructure and continuum of MCH training, underscores the comprehensive impact of this funding.

Racial Differences in DNA-Methylation of CpG Sites Within Preterm-Promoting Genes and Gene Variants.

Objective To evaluate the role DNA methylation may play in genes associated with preterm birth for higher rates of preterm births in African-American women. Methods Fetal cord blood samples from births collected at delivery and maternal demographic and medical information were used in a cross-sectional study to examine fetal DNA methylation of genes implicated in preterm birth among black and non-black infants. Allele-specific DNA methylation analysis was performed using a methylation bead array. Targeted maximum likelihood estimation was applied to examine the relationship between race and fetal DNA methylation of candidate preterm birth genes. Receiver-operating characteristic analyses were then conducted to validate the CpG site methylation marker within the two racial groups. Bootstrapping, a method of validation and replication, was employed. Results 42 CpG sites were screened within 20 candidate gene variants reported consistently in the literature as being associated with preterm birth. Of these, three CpG sites on TNFAIP8 and PON1 genes (corresponding to: cg23917399; cg07086380; and cg07404485, respectively) were significantly differentially methylated between black and non-black individuals. The three CpG sites showed lower methylation status among infants of black women. Bootstrapping validated and replicated results. Conclusion for Practice Our study identified significant differences in levels of methylation on specific genes between black and non-black individuals. Understanding the genetic/epigenetic mechanisms that lead to preterm birth may lead to enhanced prevention strategies to reduce morbidity and mortality by eventually providing a means to identify individuals with a genetic predisposition to preterm labor.

Preterm birth in the first pregnancy and risk of neonatal death in the second pregnancy: a propensity score-weighted matching approach.

The study purpose was to assess the relationship between various grades of preterm birth (moderate preterm: 33-36 weeks; severe preterm: 27-32 weeks; extreme preterm: ≤ 26 weeks) in the first pregnancy and neonatal mortality (death within 28 days of birth; early: 0-7 days; late: 8-28 days) in the second pregnancy. Using the Missouri maternally-linked dataset (1989-2005), a population-based, retrospective cohort analysis with propensity score-weighted matching was conducted on mothers with two consecutive singleton live births (n = 310,653 women). Women with a prior preterm birth were more likely to subsequently experience neonatal death. The odds increased in a dose-dependent pattern with ascending severity of the preterm event in the first pregnancy (moderate preterm: AOR = 1.32; 95% CI: 1.10-1.60; severe preterm: AOR = 2.62; 95% CI: 2.01-3.41; extreme preterm: AOR = 5.84; 95% CI: 4.28-7.97; p value for trend < 0.001). However, the pathway for the relationship between prior preterm birth and subsequent neonatal mortality may be the recurrence of preterm birth.

Maternal hepatitis B and hepatitis C infection and neonatal neurological outcomes.

To examine the associations between maternal hepatitis B (HBV) and hepatitis C (HCV) infection status and selected infant neurological outcomes diagnosed at birth, we conducted a population-based, retrospective cohort study on singleton live births in Florida from 1998 to 2009. Primary exposures included maternal HBV and HCV monoinfection. The neurological outcomes included brachial plexus injury, cephalhematoma, foetal distress, feeding difficulties, intraventricular h aemorrhage and neonatal seizures. Multivariable logistic regression models were used to generate odds ratios (OR) and 95% confidence intervals (CI) that were adjusted for socio-demographic characteristics, risky behaviours, pregnancy complications and pre-existing medical conditions, and timing of delivery. The risk of an adverse neurological outcome was higher in infants born to mothers with hepatitis viral infection (7.2% for HCV, 5.0% for HBV), compared with infants of hepatitis virus-free mothers (4.2%). After adjusting for potential confounders, women with HBV were twice as likely to have infants who suffered from brachial plexus injury (OR = 2.04, 95% CI = 1.15-3.60), while those with HCV had an elevated odds of having an infant with feeding difficulties (OR: 1.32, 95% CI = 1.06-1.64) and a borderline increased likelihood for neonatal seizures (OR = 1.74, 95% CI = 0.98-3.10). Additionally, HCV+ mothers had a 22% increased odds of having an infant with some type of adverse neurological outcome (OR: 1.22, 95% CI = 1.03-1.44). Our findings add to current understanding of the association between maternal HBV/HCV infections and infant neurological outcomes. Further research evaluating the role of maternal HBV and HCV infections (including viraemia, treatment) on pregnancy outcomes is warranted.

Perception of infertility and acceptability of assisted reproduction technology in northern Nigeria.

BACKGROUND: Infertility is a stigmatized reproductive morbidity with severe psycho-social consequences, especially in developing countries. There has been little exploration of the public view of infertility and acceptance of assisted reproduction in these countries, including Nigeria. OBJECTIVE: To determine the public perception of infertility, its causes and factors associated with acceptability of Assisted Reproductive Technologies (ART) in Kano, Northern Nigeria. METHOD: Using interviewer administered questionnaires, a cross-section of 600 adults were interviewed about perceived definition, causes and acceptance of ART. RESULT: Majority of the respondents (n = 577, 99.3%) perceived infertility as a disease. Only 18.1% (n = 105) of the respondents would consider a couple infertile after one year of marriage. Causes of infertility mentioned by participants included paranormal events (n = 535, 92.1%), suprapubic pain (n = 321, 55.2%), induced abortion (n = 187, 32.2%) and sexually transmitted infections (n = 177, 30.5%). A minority of respondents (n = 161,27.7%) of participants mentioned blocked tubes and 24.6% (n = 143) irregular menstrual cycles. Although 36.1% of respondents were aware of ART; only 7.6% were willing to accept it. Being male [adjusted odds ratio (AOR) (95% CI)] 2.1 (1.55.72), childless [AOR (95% CI)] 2.2 (1.35.95), highly educated [AOR (95% CI)] 3.2 (1.326.72) and non-Muslim [AOR (95% CI)] 2.3 (1.23.76) were significant predictors of acceptance ofART. CONCLUSION: Infertility was correctly perceived as a disease, but there were misconceptions about its causes. The low acceptance of ART was influenced by socio-demographic factors. There is a need for sustained targeted information, education and communication regarding new reproductive technologies for fertility management.

Environmental justice burden and Black-White disparities in spontaneous preterm birth in Harris County, Texas.

Introduction: Given limited evidence of previous studies, we evaluated the role of environmental justice (EJ) burden (i.e., a neighborhood characterized by both increased environmental burden and socioeconomic deprivation) in Black-White disparities in spontaneous preterm birth (sPTB) in Harris County, Texas and compared results that evaluated neighborhood-level socioeconomic deprivation alone. Methods: We conducted a retrospective analysis using PeriBank, a database and biospecimen repository of gravidae giving birth at two hospitals in the Texas Medical Center. We included 3,703 non-Hispanic Black and 5,475 non-Hispanic white gravidae who were U.S.-born, delivered from August 2011-December 2020, and resided in Harris County, TX. We used data from the U.S. EPA EJScreen to characterize the EJ burden of participant's zip code of residence from fine particulate matter (PM2.5), ozone, and proximity to National Priorities List (NPL) sites and calculated zip-code level Area Deprivation Index (ADI). We assessed the contribution of neighborhood-level variables to the Black-White disparity in sPTB by evaluating attenuation of the odds ratio (OR) representing the effect of race in multivariable logistic regression models, controlling for individual-level characteristics. We also conducted race-stratified analyses between each neighborhood variable and sPTB. Exposure indices were treated as continuous variables; in stratified models, ORs and 95% Confidence Intervals (CIs) are presented per 10-unit increase in the neighborhood variable. Results: Accounting for individual-level variables, Black gravidae had 79% higher odds of sPTB than white gravidae (OR = 1.79, 95%CI = 1.32, 2.44); the disparity was moderately attenuated when accounting for EJ burden or ADI (ORs ranged from 1.58 to 1.69). Though we observed no association between any of the EJ burden indices and sPTB among white gravidae, we found increased risks among Black gravidae, with ORs of similar magnitude for each EJ variable. For example, Black gravidae experienced 17% increased odds of sPTB associated with a 10-unit increase in the EJ burden index for PM2.5 (OR = 1.17, 95%CI = 0.97, 1.40). No racial differences were observed in the association of ADI with sPTB. Discussion: Though we observed limited evidence of the contribution of living in EJ neighborhoods to the Black-White disparity in sPTB, our study suggests living in an EJ neighborhood may differentially impact Black and white gravidae.

The association between female genital mutilation and intimate partner violence.

OBJECTIVE: To determine whether female genital mutilation (FGM) is a risk factor for intimate partner violence (IPV) and its subtypes (physical, sexual and emotional). DESIGN: Population-based cross-sectional study. SETTING: The study used the 2006 Demographic and Health Survey (DHS) conducted in Mali. POPULATION: A total of 7875 women aged 15-49 years who responded to the domestic violence and female circumcision modules in the 2006 administration of the DHS in Mali. METHODS: Multivariable logistic regression was used to compute adjusted odds ratios (aOR) and 95% confidence intervals (CI) to measure risk for IPV. MAIN OUTCOME MEASURES: The outcomes of interest were IPV and its subtypes. RESULTS: Women with FGM were at heightened odds of IPV (aOR 2.71, 95% CI 2.17-3.38) and IPV subtypes: physical (aOR 2.85, 95% CI 2.22-3.66), sexual (aOR 3.24, 95% CI 1.80-5.82), and emotional (aOR 2.28, 95% CI 1.68-3.11). The odds of IPV increased with ascending FGM severity (P for trend <0.0001). The most elevated odds were observed among women with severe FGM, who were nearly nine times as likely to experience more than one IPV subtype (aOR 8.81, 95% CI 5.87-13.24). CONCLUSIONS: Study findings underscore the need for multi-tiered strategies, incorporating policy and education, to reduce FGM and IPV, potentially improving the holistic health and wellbeing of Malian women.

Pregnancy in the workplace.

BACKGROUND: Women constitute a large percentage of the workforce in industrialized countries. As a result, addressing pregnancy-related health issues in the workplace is important in order to formulate appropriate strategies to promote and protect maternal and infant health. AIMS: To explore issues affecting pregnant women in the workplace. METHODS: A systematic literature review was conducted using Boolean combinations of the terms 'pregnant women', 'workplace' and 'employment' for publications from January 1990 to November 2010. Studies that explicitly explored pregnancy in the workplace within the UK, USA, Canada or the European Union were included. RESULTS: Pregnancy discrimination was found to be prevalent and represented a large portion of claims brought against employers by women. The relationship between environmental risks and exposures at work with foetal outcomes was inconclusive. In general, standard working conditions presented little hazard to infant health; however, pregnancy could significantly impact a mother's psychosocial well-being in the workplace. CONCLUSIONS: Core recommendations to improve maternal and infant health outcomes and improve workplace conditions for women include: (i) shifting organizational culture to support women in pregnancy; (ii) conducting early screening of occupational risk during the preconception period and (iii) monitoring manual labour conditions, including workplace environment and job duties.

Does maternal obesity cause preeclampsia? A systematic review of the evidence.

AIM: The aim of this paper was to assess whether maternal obesity causes preeclampsia. METHODS: A systematic literature review of the previous two decades (1992-2011) was conducted. The exposure was maternal obesity while the outcome of interest was preeclampsia. RESULTS: Our review revealed consistent findings showing strong association between obesity and preeclampsia. Multiple biomarkers that potentially explain the mechanistic pathway in this relationship were identified, including leptin and adiponectin, matrix metalloproteinase (MMP), C-reactive protein (CRP), and sex hormone-binding globulin (SHBG). A causative biologic linkage remains, however, elusive. CONCLUSION: Epidemiologic evidence exists linking maternal obesity and preeclampsia. However, the exact causal pathway remains poorly defined. Given the minimal understanding of the nature of this relationship, research studies that utilize prospective designs and expand on the previous examination of biomarkers are recommended to determine potential causative pathways.

Infant mortality and subsequent risk of stillbirth: a retrospective cohort study.

OBJECTIVE: To examine the association between infant mortality in a first pregnancy and risk for stillbirth in a second pregnancy. DESIGN: Population-based, retrospective cohort study. SETTING: Maternally linked cohort data files for the state of Missouri. POPULATION: Women who had two singleton pregnancies in Missouri during the period 1989-2005 (n = 320 350). METHODS: Women whose first pregnancy resulted in infant death were compared with those whose infant from the first pregnancy survived the first year of life. The Kaplan-Meier product limit estimator was employed to compare probabilities for stillbirth in the second pregnancy between both groups of women. Adjusted hazard ratios (AHRs) and 95% confidence intervals (95% CIs) were generated to assess the association between infant mortality in the first pregnancy and stillbirth in the second pregnancy. MAIN OUTCOME MEASURES: Exposure was defined as infant mortality in the first pregnancy, and the outcome was defined as stillbirth in the second pregnancy. RESULTS: Women with prior infant deaths were about three times as likely to experience stillbirth in their subsequent pregnancy (AHR 2.91; 95% CI 2.02-4.18). White women with a previous infant death were nearly twice as likely to experience a subsequent stillbirth, compared with white women with a surviving infant (AHR 1.96; 95% CI 1.13-3.39). Black women with a previous infant death were more than four times as likely to experience subsequent stillbirth, compared with black women with a surviving infant (AHR 4.28; 95% CI 2.61-6.99). CONCLUSIONS: Previous infant mortality results in an elevated risk for subsequent stillbirth, with the most profound increase observed among black women. Interconception care should consider prior childbearing experiences to avert subsequent fetal loss.

Interpregnancy BMI change and risk of primary caesarean delivery.

We conducted a retrospective study using Missouri maternally linked cohort files (1989-2005). We examined the association between interpregnancy body mass index (BMI) change and risk of primary caesarean delivery. BMI was classified as normal (18.5-24.9 kg/m(2)) or obese (≥30.0 kg/m(2)). Interpregnancy BMI change was defined using the following categories: normal-normal, normal-obese, obese-normal and obese-obese. Logistic regression models were used to generate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the risk of primary caesarean delivery in the second pregnancy. Elevated risks for caesarean delivery in the second pregnancy were noted for normal weight mothers becoming obese (OR = 1.41, 95% CI 1.26-1.57) and obese mothers maintaining their obese status across both pregnancies (OR = 1.75, 95% CI 1.65-1.87). Women with a reduction in BMI (obese-normal) had a risk level for primary caesarean section that was comparable with that of women with normal BMI status in both pregnancies.

Repeat caesarean delivery as a risk factor for abnormal blood loss, blood transfusion and perinatal mortality.

We reviewed 450 cases of caesarean delivery (January-December 2009) at the University of Ilorin Teaching Hospital in Nigeria. We analysed the association between caesarean delivery status (primary or previous) and the following outcomes: abnormal blood-loss, blood transfusion and perinatal mortality. Although significant differences were observed between primary and previous caesarean delivery groups in regards to maternal age, urgency of the caesarean delivery, booking status, and cadre of birth attendant staff, no association was noted between caesarean delivery status and any of the three outcomes. Further analyses identified parity as an important predictor for blood transfusion and abnormal blood loss. In addition, we found a dose?response relationship between parity and abnormal blood loss (< 0.05). Also, mothers with an emergency caesarean delivery of the index pregnancy were more than twice as likely to have a blood transfusion as compared with those with an elective caesarean delivery.

Maternal mortality in Niger: a retrospective study in a high risk maternity.

OBJECTIVE: This study analyzes maternal deaths in a tertiary maternity in Niamey, Niger. METHODS: This is a retrospective study covering the period of one year, from January 1 to December 31 2007. The setting for this study was the Maternity Issaka Gazobi, a tertiary maternity referral centre in the city of Niamey, Niger. Data encompasses all hospital maternal deaths attributable to obstetric causes. The data were abstracted from emergency room, delivery rooms and hospitalization units' patient files. RESULTS: During the study period a total of 4,582 live births were registered with a total count of 121 maternal deaths, yielding a maternal mortality ratio of 2,640/100,000 live births. The mean age of deceased mothers was 26 years with a range of 15 to 43 years, and 46% of them were 15-24 years old. The most common risk factors for maternal death were primiparity (33%), haemorrhage (30%) and anaemia (22%). Most of the maternal deaths occurred post-partum (70%), 24 died peripartum, 6 died from miscarriage or abortion in association with excessive bleeding or septic complications, and one died from etopic pregnancy. Among most deaths, the burden of morbidity was important, with 57.9% of patients admitted in a state of shock from eclampsia or acute cerebral malaria. CONCLUSIONS: The high rate of mortality in this hospital testifies to the high morbidity of the patients, with anemia as an important risk factor. Maternal mortality in Niger remains high due to socio-economic factors, lack of access to quality care, and insufficient number of qualified health personnel.

Super-obesity and risk for early and late pre-eclampsia.

OBJECTIVE: To examine the association between obesity subtypes and risk of early and late pre-eclampsia. DESIGN: Population-based retrospective study. SETTING: State of Missouri maternally linked birth cohort files. POPULATION: All singleton live births in the state of Missouri from 1989 to 2005. METHODS: The body mass index (BMI) was used to classify women as normal weight (BMI = 18.5-24.9 kg/m(2)), class I obesity (BMI = 30-34.9 kg/m(2)), class II obesity (BMI = 35-39.9 kg/m(2)), class III obesity (BMI = 40-49.9 kg/m(2)) or super-obesity (BMI > or = 50 kg/m(2)). Adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association between obesity and the risk of pre-eclampsia were obtained from logistic regression models with adjustment for intracluster correlation. RESULTS: The rate of pre-eclampsia increased with increasing BMI, with super-obese women having the highest incidence (13.4%). Compared with normal weight women, obese women (BMI > or = 30 kg/m(2)) had a higher risk for pre-eclampsia (OR = 2.59, 95% CI = 2.87-3.01). This risk remained approximately the same for late-onset pre-eclampsia (pre-eclampsia occurring at 34 weeks or more of gestation) and was slightly reduced for early-onset pre-eclampsia (pre-eclampsia occurring at 34 weeks or less of gestation). Within each BMI category, the risk of pre-eclampsia increased with the rate of weight gain. Compared with normal weight mothers with moderate weight gain, super-obese women with a high rate of weight gain had the greatest risk for pre-eclampsia (OR = 7.52, 95% CI = 2.70-21.0). CONCLUSION: BMI and rate of weight gain are synergistic risk factors that amplify the burden of pre-eclampsia among super-obese women.

The HIV/AIDS epidemic in Nigeria: progress, problems and prospects.

Nigeria is Africa's most populous country, and is home to the third largest number of persons living with HIV/ AIDS in the world. Poverty, stigma, discrimination, and a poorly coordinated health system constitute major barriers to HIV treatment and prevention efforts. The purpose of this paper is to review the current status of the HIV/AIDS epidemic in Nigeria, analyze the challenges facing provision of HIV/AIDS services, examine the prospects of attaining universal access to HIV prevention, treatment, care and support, and advance recommendations for developing quality, sustainable and efficient HIV/AIDS services in Nigeria. HIV programs in Nigeria must emphasize sustainability of current foreign-donor driven treatment and prevention initiatives by engaging all segments of the society and enhancing community leadership and ownership of the programs.

Extreme obesity and risk of placental abruption.

BACKGROUND: Data on extreme obesity and placental abruption are scarce. This study aimed to determine the association between pre-pregnancy weight and placental abruption and whether pregnancy weight gain impacts this risk. METHODS: We used the Missouri maternally linked cohort files (years 1989-1997). Analyses were restricted to singleton live births (n = 461 729). Maternal body mass index (BMI) was classified as normal (18.5-24.9) (referent group), obese [Class 1 (30.0-34.9), Class 2 (35.0-39.9) and extreme or Class 3 (> or =40)]. Pregnancy weight gain categories included: < or =0.22 kg/week (low), 0.23-0.68 kg/week (moderate) and > or =0.69 kg/week (high). Adjusted odds ratios generated from generalized estimating equations for logistic regression models were used to approximate relative risks. RESULTS; Obese women were less likely to have placental abruption than normal weight women (adjusted odds ratio = 0.8, 95% confidence interval 0.7-0.9). The risk was similar regardless of severity of obesity. However, analyses stratified by weight gain during pregnancy indicated that reduced risk was limited to obese women with low or moderate weight gain during pregnancy, although the analyses by subclass of obesity were only statistically significant for women with moderate weight gain. Among women with moderate weight gain, the risk of placental abruption decreased with increasing BMI in a dose-dependent pattern (P < 0.01). CONCLUSIONS: Obesity is associated with reduced risk for placental abruption when the weight gain during pregnancy is moderate. These findings underscore the need for further research on the role of nutritional status during pregnancy as a protective factor against placental abruption so that preventive strategies may be appropriately developed.

Characteristics associated with reported sputum culture conversion in the era of re-emergent Mycobacterium tuberculosis in the State of North Carolina, 1993-1998.

OBJECTIVE: To determine predictors of sputum culture conversion among patients undergoing treatment for pulmonary tuberculosis. DESIGN: Cohort study based on data collected through the expanded tuberculosis control program in the State of North Carolina, USA. Survival analysis using Kaplan-Meier product-limit estimator and Cox proportional hazards models was employed to compute estimates for time to sputum conversion and rate ratios, respectively. RESULTS: Sputum conversion was reported in 1144 of 1735 cases (66%). Documented conversion rose significantly from 52.9% at baseline to a peak of 95.1% by the end of the study, representing a 5.1% annual increase in the proportion of patients with reported conversion (P = 0.007). Patients co-infected with the human immunodeficiency virus (HIV) had a 46% lower rate of sputum conversion than non-HIV-infected TB patients (adjusted hazard ratio [HR] 0.54, 95%CI 0.44-0.67). Other significant predictors of reported conversion rates included directly observed therapy (DOT) (P = 0.02), the number of drugs used in the therapy regimen (P = 0.001), and non-injectable drug use (P = 0.012). CONCLUSION: The rate of reported sputum culture conversion in TB patients was low, consistent with an earlier population-based report. The symbiotic relationship between HIV and mycobacterial infection might be a factor that compromised response to therapy in coinfected individuals.

Eagle-Barrett syndrome: occurrence and outcomes.

OBJECTIVE: To examine the occurence and outcomes of African babies born with features of Eagle-Barret syndrome at a tertiary health centre. DESIGN: Case series. SETTING: University Teaching Hospital, Yaounde, Cameroon. SUBJECTS: Patients were identified through a retrospective review of obstetric records of mothers admitted at the centre within the period 1984 to 1996 inclusive. A total of eleven cases were identified over a period of thirteen years. RESULTS: The most prominent associated defects consisted of clubfoot, pulmonary hypoplasia, Potter's facies, imperforate anus and arthrogryposis. None of our patients survived the perinatal period. CONCLUSION: Our study indicates the need for the establishment of a prenatal and cytogenetic infrastructure in Cameroon to enhance early detection of congenital malformation and chromosomal aberrations. In the meantime, early detection of foetuses with Eagle-Barret syndrome using ultrasound could facilitate timely institutions of antenatal management options and lead to favourable birth outcomes of affected babies.