Group prenatal care for pregnant women with opioid use disorder: Preliminary evidence for acceptability and benefits compared with individual prenatal care.

INTRODUCTION: The effectiveness of group prenatal care (G-PNC) compared with individual prenatal care (I-PNC) for women with opioid use disorder (OUD) is unknown. The objectives of this study were to (1) assess the acceptability of co-locating G-PNC at an opioid treatment program and (2) describe the maternal and infant characteristics and outcomes of pregnant women in treatment for OUD who participated in G-PNC and those who did not. METHODS: This was a retrospective cohort study of 71 women (G-PNC n = 15; I-PNC n = 56) who were receiving treatment for OUD from one center and who delivered in 2019. Acceptability was determined by assessing the representativeness of the G-PNC cohorts, examining attendance at sessions, and using responses to a survey completed by G-PNC participants. The receipt of health services and healthcare use, behaviors, and infant health between those who participated in G-PNC and those who received I-PNC were described. RESULTS: G-PNC was successfully implemented among women with varying backgrounds (e.g., racial, ethnic, marital status) who self-selected into the group. All G-PNC participants reported that they were satisfied to very satisfied with the program. Increased rates of breastfeeding initiation, breastfeeding at hospital discharge, receipt of the Tdap vaccine, and postpartum visit attendance at 1-2 weeks and 4-8 weeks were observed in the G-PNC group compared with the I-PNC group. Fewer G-PNC reported postpartum depression symptomatology. CONCLUSION: Findings suggest that co-located G-PNC at an opioid treatment program is an acceptable model for pregnant women in treatment for OUD and may result in improved outcomes.

Group Well Child Care for Mothers with Opioid Use Disorder: Framework for Implementation.

OBJECTIVE: For parents with opioid use disorder (OUD) and their children, group well child care (WCC) is an under-studied intervention that may reduce stigma, increase quality of care, and improve clinical outcomes. We explored barriers and facilitators to this intervention using an implementation science framework. METHODS: A qualitative study was conducted from October 2020-March 2021 as part of the planning phase of a cluster-randomized trial of group WCC. Parent participants were recruited from one urban, university-affiliated OUD treatment center to participate in semi-structured telephone interviews. Eligible parents had a child under two years old and were English speaking. Clinician participants were recruited from a nearby pediatric primary care practice. Inductive thematic analysis of interview responses was led by two investigators using open coding procedures. RESULTS: Thirty-one parents and thirteen pediatric clinicians participated in the interviews. Most parents (68%) reported that they would be likely or very likely to bring their child to the OUD treatment center for WCC. Six themes emerged describing perceived implementation barriers, including intervention difficulty, complexity, and potential negative outcomes such as loss of privacy. Six themes emerged as implementation facilitators: (1) focus on parental OUD and recovery, (2) peer support, (3) accessibility and coordination of care, (4) clinician skill and expertise in parental OUD, (5) increased time for patient care, and (6) continuity of care. CONCLUSIONS FOR PRACTICE: Parents and clinicians expressed multiple perceived benefits of this intervention. Identified barriers and facilitators will inform implementation and evaluation of group WCC within one OUD treatment program.

Comprehensive and compassionate responses for opioid use disorder among pregnant and parenting women.

Pregnant and parenting women with opioid use disorder face multiple challenges to recovery. Trauma histories, poverty, stigma and discrimination, and lack of access to treatment intersect to marginalise this population. It is important that pregnant and parenting women with opioid use disorder receive comprehensive care to improve their health, the health of their child(ren), and prevent the intergenerational transmission of opioid and other substance use disorders. For nearly 50 years the Maternal Addiction Treatment, Education, and Research program has provided an evolving and expanding range of comprehensive services for treating opioid and other substance use disorders in this population. In this review the rationale for, and processes by which, key components of a comprehensive approach are discussed. These components include patient navigation for access to care, low-barrier medications for opioid use disorder, effective trauma-responsive therapy, prenatal and well-child healthcare, and other support services that make it possible for pregnant and parenting women to engage in treatment and improve the health of the entire family. Additionally, a method for supporting staff to build resilience and reduce fatigue and burnout is discussed. These components comprise an effective model of care for pregnant and parenting women with opioid and other substance use disorders.

Mindfulness in Pregnancy: A Brief Intervention for Women at Risk.

INTRODUCTION: The U.S. has the highest rate of preterm birth (PTB), of all developed countries, especially among African American women. Social determinants of health and inequalities in health outcomes are understudied areas. The intersectionality of race and socioeconomic status has been shown to contribute to chronic stress, stress has been shown to be associated with PTB, yet the mechanisms that affect pregnancy outcomes have not been explicit. Mindfulness-based Interventions that address stress reduction during pregnancy may improve quality of life during pregnancy, perhaps enhancing resilience, and be on the pathway to reducing the risk of negative pregnancy outcomes such as PTB. METHODS: We over-enrolled African American women and those covered by Medicaid to reach women at higher risk for PTB and included women in substance use treatment. Participants were enrolled in a 6-week mindfulness in pregnancy (MIP) intervention at the obstetric clinic. Sociodemographic characteristics and psychosocial assessments were obtained at three time points. RESULTS: We enrolled 35 women who self-identified as: non-white, Medicaid recipients, aged 25-35 years, with high school or less education. We found reductions in perceived stress, pregnancy specific stress, trait anxiety and depression and increases in mindfulness that sustained post-intervention at 2 and 7 months. DISCUSSION: Social determinants and stress in particular have been associated with negative birth outcomes. This paper describes a brief intervention and results of MIP tailored to women who have significantly more stress due to race, poverty, homelessness, substance use treatment and other comorbid health risks including PTB.

Breastfeeding Intention, Knowledge, and Attitude of Pregnant Women in Treatment for Opioid Use Disorder.

OBJECTIVE: The objective of this study was to describe breastfeeding intention, knowledge, and attitude, and sources of infant feeding information during the prenatal period among a cohort of pregnant women in treatment for opioid use disorder (OUD). STUDY DESIGN: Pregnant women who were receiving treatment for OUD and in the third trimester completed a questionnaire that measured demographic characteristics, infant feeding intentions, breastfeeding beliefs and attitudes, and sources of breastfeeding information. Frequency counts and percentages and means and standard deviations were used to describe data. RESULTS: Sixty-five women completed the survey. Three-fourths reported some intention to breastfeeding. While attitudes around breastfeeding were generally positive, less than half of respondents knew the recommendations and infant health benefits of breastfeeding. CONCLUSION: Prenatal programs for women in treatment for OUD should consider addressing patient-reported concerns and gaps in knowledge regarding the benefits of and recommendation for breastfeeding. KEY POINTS: · Breastfeeding has unique benefits for mother-infant dyads affected by maternal OUD.. · Breastfeeding decisions are influenced by maternal psychosocial factors (e.g., knowledge and attitudes), however, such factors have not been previously assessed in women in treatment for OUD.. · Results indicate that attitudes around breastfeeding are positive but knowledge gaps exist..

What aspects of their child's primary care do mothers value? A qualitative analysis of perspectives of women in treatment for opioid use disorder.

BACKGROUND: Preventive paediatric healthcare is essential for infant and child health. Current research, however, suggests that the delivery of routine well child care (WCC) for children affected by maternal opioid use disorder (OUD) could be improved. How mothers perceive interactions with healthcare providers may help identify ways to modify the experience of WCC, which could ultimately improve healthcare utilization, patient satisfaction and clinical outcomes. The objective of this qualitative study was to assess perceptions of WCC among mothers in treatment for OUD. METHODS: Four focus group sessions of 4-8 participants each (N = 22) were conducted. All study participants were receiving comprehensive behavioural and physical health support and care plus pharmacotherapy for OUD from a single outpatient treatment centre. Focus groups were semi-structured, with a standardized set of open-ended questions and follow-up prompts to engage participants in a fluid discussion. Participants were asked to identify and discuss important aspects of their youngest child's WCC and what they liked and disliked about their child's WCC. Grounded theory analysis was used to identify themes. RESULTS: Several aspects of WCC were identified as important to the mothers. Main themes identified included (1) mother-provider relationship, (2) communication with healthcare team and (3) support for mother's OUD treatment. Participants discussed their desire to be heard and understood and wanted the entire healthcare team and clinic staff to see them as mothers first and foremost, not merely as individuals with OUD. CONCLUSION: Future attempts to refine care may consider healthcare models that highlight open communication and personalized care and offer strong support and ongoing encouragement for the mother's OUD treatment and recovery process.

Perceptions of Pediatric Primary Care Among Mothers in Treatment for Opioid Use Disorder.

To assess receipt of anticipatory guidance and family-centered care during well-child care (WCC) for children of mothers with opioid use disorder (OUD). Cross-sectional survey of 157 mothers receiving treatment for OUD who had a child < 3 years old and received primary care. Survey items evaluated (1) receipt of anticipatory guidance on 15 topics during WCC for the participant's child and (2) whether WCC was family-centered. The percentage of participants who reported guidance for each topic and the distribution of responses on family-centered items were calculated. A Pearson correlation was conducted to evaluate the association between the total number of topics for which anticipatory guidance was received and the family centeredness summary score. Receipt of anticipatory guidance varied by topic, ranging from 59% for guidance on childcare to 98% for guidance on safe sleep. Less than two-thirds of mothers reported that their child's provider "always" knew their child's medical history (56%), listened carefully (58%), clearly explained things (61%), and respected the mother (62%). Less than half reported that the provider spent enough time with them, and less than one-third reported that they were asked for their viewpoints. Anticipatory guidance and family-centeredness scores were positively correlated (r = 0.22, P = 0.006). Mothers with OUD report gaps in anticipatory guidance on important WCC topics, and limited family-centered care for their children. Further research may focus on refinements to the delivery of care for this population.

The Relationship between Body Mass Index in Pregnancy and Adverse Maternal, Perinatal, and Neonatal Outcomes in Rural India and Pakistan.

OBJECTIVE: The objective of this study was to describe the relationship between early pregnancy body mass index (BMI) and maternal, perinatal, and neonatal outcomes in rural India and Pakistan. STUDY DESIGN: In a prospective, population-based pregnancy registry implemented in communities in Thatta, Pakistan and Nagpur and Belagavi, India, we obtained women's BMI prior to 12 weeks' gestation (categorized as underweight, normal, overweight, and obese following World Health Organization criteria). Outcomes were assessed 42 days postpartum. RESULTS: The proportion of women with an adverse maternal outcome increased with increasing maternal BMI. Less than one-third of nonoverweight/nonobese women, 47.2% of overweight women, and 56.0% of obese women experienced an adverse maternal outcome. After controlling for site, maternal age and parity, risks of hypertensive disease/severe preeclampsia/eclampsia, cesarean/assisted delivery, and antibiotic use were higher among women with higher BMIs. Overweight women also had significantly higher risk of perinatal and early neonatal mortality compared with underweight/normal BMI women. Overweight women had a significantly higher perinatal mortality rate. CONCLUSION: High BMI in early pregnancy was associated with increased risk of adverse maternal, perinatal, and neonatal outcomes in rural India and Pakistan. These findings present an opportunity to inform efforts for women to optimize weight prior to conception to improve pregnancy outcomes.

Reducing Stress Among Mothers in Drug Treatment: A Description of a Mindfulness Based Parenting Intervention.

Background Parenting women with substance use disorder could potentially benefit from interventions designed to decrease stress and improve overall psychosocial health. In this study we assessed whether a mindfulness based parenting (MBP) intervention could be successful in decreasing general and parenting stress in a population of women who are in treatment for substance use disorder and who have infants or young children. Methods MBP participants (N = 59) attended a two-hour session once a week for 12 weeks. Within-group differences on stress outcome measures administered prior to the beginning of the MBP intervention and following the intervention period were investigated using mixed-effects linear regression models accounting for correlations arising from the repeated-measures. Scales assessed for pre-post change included the Perceived Stress Scale-10 (PSS) and the Parenting Stress Index-Short Form (PSI). Results General stress, as measured by the PSS, decreased significantly from baseline to post-intervention. Women with the highest baseline general stress level experienced the greatest change in total stress score. A significant change also occurred across the Parental Distress PSI subscale. Conclusions Findings from this innovative interventional study suggest that the addition of MBP within treatment programs for parenting women with substance use disorder is an effective strategy for reducing stress within this at risk population.

Decreasing prevalence of no known major risk factors for cardiovascular disease among Mississippi adults, Mississippi Behavioral Risk Factor Surveillance System, 2001 and 2009.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in Mississippi. However, the prevalence of no known CVD risk factors among Mississippi adults and the change of prevalence in the past 9 years have not been described. We assess changes in prevalence of no known CVD risk factors during 2001 and 2009. METHODS: Prevalence of high blood pressure, high cholesterol, diabetes, physical inactivity, smoking, and obesity were investigated. Survey respondents who reported having none of these factors were defined as having no known CVD risk factors. Differences in prevalence and 95% confidence intervals were determined using t-test analysis. RESULTS: Overall, age-standardized prevalence of having no known CVD risk factors significantly decreased from 17.3% in 2001 to 14.5% in 2009 (p = 0.0091). The age-standardized prevalence of no known CVD risk factors were significantly lower in 2009 than in 2001 among blacks (8.9% vs. 13.2%, p = 0.008); males (13.5% vs. 17.9%, p = 0.0073); individuals with a college degree (25.2%, vs. 30.8%, p = 0.0483); and those with an annual household income of $20,000-$34,999 (11.6% vs. 16.9%, p = 0.0147); and $35,000-$49,999 (15.2% vs. 23.3%, p = 0.0135). CONCLUSION: The prevalence of no known CVD risk factors among Mississippi adults significantly decreased from 2001 to 2009 with observed differences by race, age group, sex, and annual household income.

Priorities for Well Child Care of Families Affected by Parental Opioid Use Disorder.

BACKGROUND AND OBJECTIVES: Parenting women in treatment for opioid use disorder (OUD) report a lack of family centeredness and anticipatory guidance within well child care (WCC), and WCC utilization is low among affected children. We explore priorities for WCC visit content to inform primary care recommendations for this population. METHODS: This study is a qualitative study of parenting women from one urban, academic OUD treatment program and pediatric primary care clinicians from a nearby affiliated pediatric practice. Eligible parent participants had a child ≤2 years old and were English speaking. Semistructured interviews elicited perspectives on WCC, with questions and prompts related to visit content. Inductive thematic analysis was led by 2 investigators using open coding procedures. RESULTS: Among 30 parent participants, the majority were White (83%) and unmarried (90%). Approximately 60% reported their child received pharmacotherapy for neonatal opioid withdrawal syndrome. Of 13 participating clinicians, 9 were attending pediatricians. Five themes emerged from parental and clinician interviews: (1) improving knowledge and confidence related to child development, behavior, and nutrition; (2) mitigating safety concerns; (3) addressing complex health and subspecialty needs through care coordination; (4) acknowledging parental health and wellbeing in the pediatric encounter; and (5) supporting health education and care related to neonatal opioid withdrawal syndrome. Parents and clinicians expressed difficulty comprehensively addressing such issues due to time constraints, social determinants of health, and significant informational needs. CONCLUSIONS: Parenting women in treatment for OUD and pediatric clinicians share multiple priorities for anticipatory guidance within WCC visits and barriers to addressing them comprehensively.

Perceptions of Primary Care Among Women in Treatment for Opioid Use Disorder: A Qualitative Study.

BACKGROUND: Underutilization of primary care and receipt of preventive health services have been reported among women with opioid use disorder. The aim of this study was to describe perceptions of primary care among women in treatment for opioid use disorder. METHODS: Between May and June 2022, 27 women who were receiving treatment for opioid use disorder from one opioid treatment program participated in this study. Participants completed one data collection session which involved a brief questionnaire followed by a semi-structured interview. Participants were asked questions about their overall experience with primary care as well as perceived facilitators and barriers to primary care utilization and quality. Interview transcripts were analyzed using an inductive thematic approach. RESULTS: Three themes emerged from the interviews within the domain of "Facilitators to Primary Care," including: (1) coordination of care, (2) continuity of care, and (3) relationship with health care providers. Four themes emerged from the interviews within the domain of "Barriers to Primary Care," including: (1) perceived judgment from health care providers, (2) childcare needs, (3) issues related to location, and (4) issues related to time. CONCLUSION: Approaches to primary care that help alleviate barriers to care and highlight the aspects of care that are valued may improve quality and utilization of care, thus enhancing the health and well-being of a vulnerable population.

Racial differences in ideal cardiovascular health metrics among Mississippi adults, 2009 Mississippi Behavioral Risk Factor Surveillance System.

INTRODUCTION: Cardiovascular disease is a leading cause of death and health disparities in Mississippi. Identifying populations with poor cardiovascular health may help direct interventions toward those populations disproportionately affected, which may ultimately increase cardiovascular health and decrease prominent disparities. Our objective was to assess racial differences in the prevalence of cardiovascular health metrics among Mississippi adults. METHODS: We used data from the 2009 Mississippi Behavioral Risk Factor Surveillance System to determine age-standardized prevalence estimates and 95% confidence intervals of cardiovascular health metrics among 2,003 black and 5,125 white adults. Logistic regression models were used to evaluate the relationship between race and cardiovascular health metrics. The mean cardiovascular metrics score and percentage of the population with ideal and poor cardiovascular health were calculated by subgroup. RESULTS: Approximately 1.3% of blacks and 2.6% of whites exhibited ideal levels of all 7 cardiovascular health metrics. The prevalence of 4 of the 7 cardiovascular health metrics was significantly lower among the total population of blacks than among whites, including a normal body mass index (20.8% vs 32.3%, P < .001), no history of diabetes (85.1% vs 91.3%, P < .001), no history of hypertension (53.9% vs 67.9%, P < .001), and physical activity (52.8% vs 62.2%, P < .001). The logistic regression models revealed significant race-by-sex interactions; differences between blacks and whites for normal body mass index, no history of diabetes mellitus, and no current smoking were found among women but not among men. CONCLUSION: Cardiovascular health is poor among Mississippi adults overall, and racial differences exist.

Outcomes of Menstrual Management Use in Transgender and Gender-Diverse Adolescents.

OBJECTIVE: To describe and compare the outcomes of various menstrual-management methods, including method choice, continuation, bleeding patterns, amenorrhea rates, effect on moods and dysphoria, and side effects, in transgender and gender-diverse adolescents. METHODS: This was a retrospective chart review of all patients seen in a multidisciplinary pediatric gender program from March 2015 to December 2020 who were assigned female at birth, had achieved menarche, and used a menstrual-management method during the study period. Data were abstracted on patient demographics and menstrual-management method continuation, bleeding patterns, side effects, and satisfaction at 3 months (T1) and 1 year (T2). Outcomes were compared between method subgroups. RESULTS: Among the 101 included patients, 90% chose either oral norethindrone acetate or a 52-mg levonorgestrel (LNG) intrauterine device (IUD). There were no differences in continuation rates for these methods at either follow-up time. Almost all patients had improved bleeding at T2 (96% for norethindrone acetate and 100% for IUD users), with no difference between subgroups. Amenorrhea rates were 84% for norethindrone acetate and 67% for IUD at T1 and 97% and 89%, respectively, at T2, with no differences at either point. The majority of patients had improved pain, menstrually related moods, and menstrually related dysphoria at both follow-up points. There were no differences in side effects between subgroups. There were no differences in method satisfaction between the groups at T2. CONCLUSION: Most patients chose norethindrone acetate or an LNG IUD for menstrual management. Continuation, amenorrhea, and improved bleeding, pain, and menstrually related moods and dysphoria were high for all patients, indicating that menstrual management is a viable intervention for gender-diverse patients who experience increased dysphoria related to menses.

Pediatric Primary Care Diagnoses Among Children with Intrauterine Opioid Exposure.

BACKGROUND AND OBJECTIVES: Characterizing common concerns for children with intrauterine opioid exposure (IOE) can inform tailored primary care. METHODS: Retrospective analysis of primary care data of children with IOE from birth to age two years within one multi-state pediatric health system. Well child care (WCC) and problem-based visit diagnoses were categorized, and descriptive statistics were tabulated. RESULTS: Three hundred and eighty-five (385) children with IOE had 3,622 primary care visits, of which 51.4% were WCC and 48.6% were problem-based. Most frequent visit diagnoses were upper respiratory complaints (14.8% of visits), feeding difficulties (12.2%), and perinatal viral exposure (9.8%). Although visit type (WCC vs. problem-based) varied across diagnostic category, frequent utilization of both visit types were documented for several diagnoses in infancy (e.g., fussiness/colic, feeding difficulties). CONCLUSIONS: Well child care visits for children with IOE are key opportunities for anticipatory guidance with an emphasis on problems that may contribute to acute health care utilization, particularly in early infancy.

Opportunities to Increase Well-Child Care Engagement for Families Affected by Maternal Opioid Use Disorder: Perceptions of Mothers and Clinicians.

OBJECTIVE: Previous research suggests gaps in well-child care (WCC) adherence, quality, and effectiveness for children impacted by parental opioid use disorder (OUD). The objective of this study was to gather in-depth information regarding maternal and clinician-reported factors that enhance ("facilitators") or hinder ("barriers") WCC engagement as well as mothers' experiences during WCC visits. METHODS: Thirty mothers who were in treatment for OUD and 13 clinicians working at a pediatric primary care clinic participated in this qualitative study. All participants completed one data collection telephone session which involved a brief questionnaire followed by a semi-structured interview. Thematic analyses of the interview transcripts were conducted using an inductive approach. RESULTS: Three broad themes were identified as facilitators of WCC by mothers and clinicians, including: 1) continuity in care, 2) addressing material needs, and 3) clinician OUD training and knowledge. Themes identified as barriers to WCC included: 1) stigma toward mothers with OUD, 2) gaps in basic parenting knowledge, 3) competing specialized health care needs, and 4) insufficient time to address all concerns. CONCLUSION: WCC programs or clinical pathways designed for families affected by maternal OUD should consider these barriers and facilitators of WCC engagement and affect experiences of WCC for mothers and clinicians.

The Child Healthcare at MATER Pediatric Study (CHAMPS): a 2-arm cluster randomized control trial of group well child care for mothers in treatment for opioid use disorder and their children.

BACKGROUND: Studies suggest that group-based well child care-a shared medical appointment where families come together as a group to receive pediatric primary care-increases patient-reported satisfaction and adherence to recommended care. Evidence supporting the use of group well child care for mothers with opioid use disorder, however, is lacking. The overall objective of the Child Healthcare at MATER Pediatric Study (CHAMPS) trial is to evaluate a group model of well child care for mothers with opioid use disorder and their children. METHODS: CHAMPS is a single-site 2-arm cluster randomized controlled trial. A total of 108 mother-child dyads will be enrolled into the study. Twenty-six clusters of approximately 4 mother-infant dyads each will be randomized 1:1 to one of two study arms (intervention or control). Clustering will be based on child's month of birth. In the intervention arm, group well child care will be provided on-site at a maternal substance use disorder treatment program. Mother-child dyads in the control arm will receive individual well child care from one nearby pediatric primary care clinic. Dyads in both study arms will be followed prospectively for 18 months, and data will be compared between the two study arms. Primary outcomes include well child care quality and utilization, child health knowledge, and parenting quality. DISCUSSION: The CHAMPS trial will provide evidence to determine if a group well child care offered on-site at an opioid treatment program for pregnant and parenting women is beneficial over individual well child care for families impacted by maternal opioid use disorder. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05488379. Registered on Aug. 04, 2022.

A training curriculum for an mHealth supported peer counseling program to promote exclusive breastfeeding in rural India.

BACKGROUND: Despite strong evidence about the benefits of exclusive breastfeeding, that is the baby receiving only breast milk, no other foods or liquids, rates have remained relatively unchanged over the past two decades in low- and middle-income countries. One strategy for increasing exclusive breastfeeding is through community-based programs that use peer counselors for education and support. The use of mobile health applications is also gaining increasing applicability in these countries. Minimal information is available about training peer counselors in the use of mobile technologies to support exclusive breastfeeding. The present article describes our curriculum in the state of Karnataka, India for supporting new mothers to exclusively breastfeed using a mobile health application in rural India. METHODS: Twenty-five women from the community surrounding the city of Belgavi, Karnataka, India were trained to be peer counselors and to use a mobile health application to conduct a structured curriculum to support new mothers in exclusive breastfeeding. The three-day interactive training, conducted in March 2018, was based on the WHO breastfeeding course, translated, and adapted to the local culture The curriculum, which included information collected during a formative research process, consisted of eight visits, two during the antenatal period and continuing for six months postpartum. Twelve nursing and obstetric experts validated curriculum content. Pre-post-evaluation of the training focused on breastfeeding knowledge, self-efficacy, skills, and app usability. RESULTS: We observed a significant increase in the mean scores for knowledge (P < 0.0001) and skills (P = 0.0006) from pre- to post-training. Age of the peer counselors and their own breastfeeding experience correlated significantly with the acquisition of knowledge and skills. The mobile health app showed high usability scores. CONCLUSIONS: The culturally adapted curriculum presented here, combined with an mHealth app, can be an important educational strategy for training rural women in the acquisition of exclusive breastfeeding knowledge and skills.

Preconception health indicators: a comparison between non-Appalachian and Appalachian women.

To compare preconception health indicators (PCHIs) among non-pregnant women aged 18-44 years residing in Appalachian and non-Appalachian counties in 13 U.S. states. Data from the 1997-2005 Behavioral Risk Factor Surveillance System were used to estimate the prevalence of PCHIs among women in states with ≥1 Appalachian county. Counties were classified as Appalachian (n = 36,496 women) or non-Appalachian (n = 88,312 women) and Appalachian counties were categorized according to economic status. Bivariate and multivariable logistic regression models examined differences in PCHIs among women by (1) Appalachian residence, and (2) economic classification. Appalachian women were younger, lower income, and more often white and married compared to women in non-Appalachia. Appalachian women had significantly higher odds of reporting