Community and federal collaboration to assess pregnancy outcomes in Alaska Native women, 1997-2005.

The objectives are to report the estimated prevalence of pregnancy complications and adverse pregnancy outcomes in a defined population of Alaska Native women and also examine factors contributing to an intensive and successful collaboration between a tribal health center and the Centers for Disease Control and Prevention. Investigators abstracted medical record data from a random sample of singleton deliveries to residents of the study region occurring between 1997 and 2005. We used descriptive statistics to estimate the prevalence and 95% confidence intervals of selected pregnancy complications and adverse pregnancy outcomes. Records were examined for 505 pregnancies ending in a singleton delivery to 469 women. Pregnancy complication rates were 5.9% (95% CI 4.0, 8.4) for gestational diabetes mellitus, 6.1% (95% CI 4.2, 8.6%) for maternal chronic hypertension and 11.5% (95% CI 8.8, 14.6) for pregnancy associated hypertension, and 22.9% (95% CI 19.2-26.5 %) for anemia. The cesarean section rate was 5.5% (95% CI 3.5, 7.5) and 3.8% (95% CI 2.3, 5.8) of newborns weighed >4,500 g. Few previous studies reported pregnancy outcomes among Alaska Native women in a specific geographic region of Alaska and regarding the health needs in this population. We highlight components of our collaboration that contributed to the success of the study. Studies focusing on special populations such as Alaska Native women are feasible and can provide important information on health indicators at the local level.

Effects of maternal smokeless tobacco use on selected pregnancy outcomes in Alaska Native women: a case-control study.

OBJECTIVE: To examine the potential effects of prenatal smokeless tobacco use on selected birth outcomes. DESIGN: A population-based, case-control study using a retrospective medical record review. POPULATION: Singleton deliveries 1997-2005 to Alaska Native women residing in western Alaska. METHODS: Hospital discharge codes were used to identify potential case deliveries and a random control sample. Data on tobacco use and confirmation of pregnancy outcomes were abstracted from medical records for 1123 deliveries. Logistic regression was used to examine associations between tobacco use and pregnancy outcomes. Adjusted odds ratios (OR), 95% confidence intervals (95% CI), and p-values were calculated. MAIN OUTCOMES MEASURES: Preterm delivery, pregnancy-associated hypertension, and placental abruption. RESULTS: In unadjusted analysis, smokeless tobacco use was not significantly associated with preterm delivery (OR 1.44, 95% CI 0.97-2.15). After adjustment for parity, pre-pregnancy body mass index, and maternal age, the point estimate was attenuated and remained non-significant. No significant associations were observed between smokeless tobacco use and pregnancy-associated hypertension (adjusted OR 0.92, 95% CI 0.56-1.51) or placental abruption (adjusted OR 1.11, 95% CI 0.53-2.33). CONCLUSIONS: Prenatal smokeless tobacco use does not appear to reduce risk of pregnancy-associated hypertension or to substantially increase risk of abruption. An association between smokeless tobacco and preterm delivery could not be ruled out. Components in tobacco other than nicotine likely play a major role in decreased pre-eclampsia risk in smokers. Nicotine adversely affects fetal neurodevelopment and our results should not be construed to mean that smokeless tobacco use is safe during pregnancy.

Maternal smokeless tobacco use in Alaska Native women and singleton infant birth size.

OBJECTIVE: To examine the effects of maternal prenatal smokeless tobacco use on infant birth size. DESIGN: A retrospective medical record review of 502 randomly selected deliveries. POPULATION AND SETTING: Singleton deliveries to Alaska Native women residing in a defined geographical region in western Alaska, 1997-2005. METHODS: A regional medical center's electronic records were used to identify singleton deliveries. Data on maternal tobacco exposure and pregnancy outcomes were abstracted from medical records. Logistic models were used to estimate adjusted mean birthweight, length and head circumference for deliveries to women who used no tobacco (n=121), used smokeless tobacco (n=237) or smoked cigarettes (n=59). Differences in mean birthweight, length and head circumference, 95% confidence intervals and p-values were calculated using non-users as the reference group. MAIN OUTCOME MEASURES: Infant birthweight, crown-heel length and head circumference. RESULTS: After adjustment for gestational age and other potential confounders, the mean birthweight of infants of smokeless tobacco users was reduced by 78 g compared with that of infants of non-users (p=0.18) and by 331 g in infants of smokers (p<0.01). No association was found between maternal smokeless tobacco use and infant length or infant head circumference. CONCLUSIONS: We found a modest but non-significant reduction in the birthweight of infants of smokeless tobacco users compared with infants of tobacco non-users. Because smokeless tobacco contains many toxic compounds that could affect other pregnancy outcomes, results of this study should not be construed to mean that smokeless tobacco use is safe during pregnancy.

Geographic variation in trends and characteristics of teen childbearing among American Indians and Alaska Natives, 1990-2007.

To study teen birth rates, trends, and socio-demographic and pregnancy characteristics of AI/AN across geographic regions in the US. The birth rate for US teenagers 15-19 years reached a historic low in 2009 (39.1 per 1,000) and yet remains one of the highest teen birth rates among industrialized nations. In the US, teen birth rates among Hispanic, non-Hispanic black, and American Indian/Alaska Native (AI/AN) youth are consistently two to three times the rate among non-Hispanic white teens. Birth certificate data for females younger than age 20 were used to calculate birth rates (live births per 1,000 women) and joinpoint regression to describe trends in teen birth rates by age (<15, 15-17, 18-19) and region (Aberdeen, Alaska, Bemidji, Billings, California, Nashville, Oklahoma, Portland, Southwest). Birth rates for AI/AN teens varied across geographic regions. Among 15-19-year-old AI/AN, rates ranged from 24.35 (California) to 123.24 (Aberdeen). AI/AN teen birth rates declined from the early 1990s into the 2000s for all three age groups. Among 15-17-year-olds, trends were approximately level during the early 2000s-2007 in six regions and declined in the others. Among 18-19-year-olds, trends were significantly increasing during the early 2000s-2007 in three regions, significantly decreasing in one, and were level in the remaining regions. Among AI/AN, cesarean section rates were lower in Alaska (4.1%) than in other regions (16.4-26.6%). This is the first national study to describe regional variation in AI/AN teen birth rates. These data may be used to target limited resources for teen pregnancy intervention programs and guide research.

Validation of algorithm to identify American Indian/Alaska Native pregnant women at risk from pandemic H1N1 influenza.

Pregnant women and American Indian and Alaska Native people are at elevated risk of severe disease and mortality from 2009 pandemic influenza A/H1N1. We validated an electronic health record-based algorithm used by Indian Health Service to identify pregnant women in near real-time surveillance of pandemic influenza A/H1N1. We randomly selected a stratified sample of 515 patients at 3 Indian Health Service-funded hospitals with varied characteristics. With comprehensive review of patients' electronic health records as the gold standard, we calculated the positive predictive value and sensitivity of the pregnancy algorithm. The sensitivity of the algorithm at individual hospitals ranged from 94.1-96.0%. Positive predictive value ranged from 94.4-98.3%. Despite differences among hospitals on key characteristics, the pregnancy algorithm performed nearly equivalently with high positive predictive value and sensitivity at all facilities. It may prove helpful for surveillance during future epidemics and for targeting interventions for pregnant women and infants.

How can PRAMS survey response rates be improved among American Indian mothers? Data from 10 states.

OBJECTIVES: To examine the low response rates to the Pregnancy Risk Assessment and Monitoring System (PRAMS) survey for American Indian (AI) mothers by comparing characteristics of AI participants, AI non-participants, non-Hispanic White (NHW) participants, and NHW non-participants. METHODS: We analyzed 2000-2002 data from states whose population was at least 5% AI or Alaska Native (AN) (n = 10). Mothers who returned a questionnaire (regardless of completion) or who spoke by telephone with PRAMS personnel were defined as contacts. Mothers who completed a PRAMS questionnaire were defined as respondents. We described overall and state-specific maternal characteristics from birth certificates for both those who were contacted and those not contacted and computed contact and response rates. RESULTS: Contact rates varied by state, ranging from 49% to 92% for AI and AN mothers and 82-93% for NHW mothers. However, once contacted, most mothers completed a questionnaire (85-99%). Both AI and NHW mothers were less likely to be contacted if they were <29 years of age, unmarried, multiparous and had

The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates.

OBJECTIVES: We sought to determine whether differences in the prevalences of 5 specific pregnancy complications or differences in case fatality rates for those complications explained the disproportionate risk of pregnancy-related mortality for Black women compared with White women in the United States. METHODS: We used national data sets to calculate prevalence and case-fatality rates among Black and White women for preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage for the years 1988 to 1999. RESULTS: Black women did not have significantly greater prevalence rates than White women. However, Black women with these conditions were 2 to 3 times more likely to die from them than were White women. CONCLUSIONS: Higher pregnancy-related mortality among Black women from preeclampsia, eclampsia, abruptio placentae, placenta previa, and postpartum hemorrhage is largely attributable to higher case-fatality rates. Reductions in case-fatality rates may be made by defining more precisely the mechanisms that affect complication severity and risk of death, including complex interactions of biology and health services, and then applying this knowledge in designing interventions that improve pregnancy-related outcomes.

Adoption of preventive behaviors in response to the 2009 H1N1 influenza pandemic: a multiethnic perspective.

BACKGROUND: As public health leaders prepare for possible future influenza pandemics, the rapid spread of 2009 H1N1 influenza highlights the need to focus on measures the public can adopt to help slow disease transmission. Such measures may relate to hygiene (e.g., hand washing), social distancing (e.g., avoiding places where many people gather), and pharmaceutical interventions (e.g., vaccination). Given the disproportionate impact of public health emergencies on minority communities in the United States, it is important to understand whether there are differences in acceptance across racial/ethnic groups that could lead to targeted and more effective policies and communications. OBJECTIVES: This study explores racial/ethnic differences in the adoption of preventive behaviors during the 2009 H1N1 influenza pandemic. PATIENTS/METHODS: Data are from a national telephone poll conducted March 17 to April 11, 2010, among a representative sample of 1123 white, 330 African American, 317 Hispanic, 268 Asian, and 262 American Indian/Alaska Native adults in the USA. RESULTS: People in at least one racial/ethnic minority group were more likely than whites to adopt several behaviors related to hygiene, social distancing, and healthcare access, including increased hand washing and talking with a healthcare provider (P-values <0.05). Exceptions included avoiding others with influenza-like illnesses and receiving 2009 H1N1 and seasonal influenza vaccinations. After we controlled the data for socioeconomic status, demographic factors, healthcare access, and illness- and vaccine-related attitudes, nearly all racial/ethnic differences in behaviors persisted. CONCLUSIONS: Minority groups appear to be receptive to several preventive behaviors, but barriers to vaccination are more pervasive.