County-Level Structural Vulnerabilities in Maternal Health and Geographic Variation in Infant Mortality.

OBJECTIVE: To evaluate whether community factors that differentially affect the health of pregnant people contribute to geographic differences in infant mortality across the US. STUDY DESIGN: This retrospective cohort study sought to characterize the association of a novel composite measure of county-level maternal structural vulnerabilities, the Maternal Vulnerability Index (MVI), with risk of infant death. We evaluated 11 456 232 singleton infants born at 22 0 of 7 through 44 6 of 7 weeks' gestation from 2012 to 2014. Using county-level MVI, which ranges from 0 to 100, multivariable mixed effects logistic regression models quantified associations per 20-point increment in MVI, with odds of death clustered at the county level and adjusted for state, maternal, and infant covariates. Secondary analyses stratified by the social, physical, and health exposures that comprise the overall MVI score. Outcome was also stratified by cause of death. RESULTS: Rates of death were higher among infants from counties with the greatest maternal vulnerability (0.62% in highest quintile vs 0.32% in lowest quintile, [P < .001]). Odds of death increased 6% per 20-point increment in MVI (aOR: 1.06, 95% CI 1.04, 1.07). The effect estimate was highest with theme of Mental Health and Substance Abse (aOR 1.08; 95% CI 1.06, 1.09). Increasing vulnerability was associated with 6 of 7 causes of death. CONCLUSIONS: Community-level social, physical, and healthcare determinants indicative of maternal vulnerability may explain some of the geographic variation in infant death, regardless of cause of death. Interventions targeted to county-specific maternal vulnerabilities may reduce infant mortality.

Factors of success, barriers, and the role of frontline workers in Indigenous maternal-child health programs: a scoping review.

BACKGROUND: Despite considerable investment in maternal-child programs in Canada, there has been little positive impact on the health of Indigenous mothers and their children. The reasons for this are unclear and there is a need to identify how such programs can be successfully implemented. Community input is essential for successful programs; however, it is unclear what the contributions of frontline workers have been in the health program process, i.e., program development, delivery, and evaluation. Based on these identified gaps, this scoping review aimed to: (1) identify factors of success and barriers to successful Indigenous maternal-child community health programs for mothers and their children aged 0-6 years; and (2) explore how frontline workers are included in the program process. METHODS: This scoping review was completed using the Arksey and O'Malley framework, informed by Levac et al. Four data bases (Medline, CINAHL, Embase, and Scopus), grey literature, and reference lists were searched for relevant materials from 1990-2019. Data was extracted from included articles and analysed using descriptive statistics, thematic analysis with the Braun and Clarke framework, and a Principal Component Analysis. RESULTS: Forty-five peer-reviewed and grey articles were included in the review. Factors of program success included: relationship building; cultural inclusion; knowledge transmission styles; community collaboration; client-centred approaches; Indigenous staff; and operational considerations. Barriers included: impacts of colonization; power structure and governance; client and community barriers to program access; physical and geographical challenges; lack of staff; and operational deficits. Frontline workers were found to have a role in program delivery (n = 45) and development (n = 25). Few (n = 6) had a role in program evaluation. CONCLUSION: Although a better understanding of the frontline worker role in maternal-child health programs was obtained from the review, in a large proportion of literature the authors could not determine if the role went beyond program delivery. In addition, no direct input from frontline workers and their perspectives on program success or barriers were identified, suggesting areas to explore in future research. This review's findings have been applied to inform a community-based participatory research project and may also help improve the development, delivery, and evaluation of Indigenous maternal-child health programs.

Caesarean section and associated factors in Nigeria: assessing inequalities between rural and urban areas-insights from the Nigeria Demographic and Health Survey 2018.

INTRODUCTION: When medically indicated, caesarean section (CS) can be a life-saving intervention for mothers and their newborns. This study assesses the prevalence of CS and its associated factors, focussing on inequalities between rural and urban areas in Nigeria. METHODS: We disaggregated the Nigeria Demographic and Health Survey 2018 and performed analyses separately for Nigeria's overall, rural, and urban residences. We summarised data using frequency tabulations and identified factors associated with CS through multivariable logistic regression analysis. RESULTS: CS prevalence was 2.7% in Nigeria (overall), 5.2% in urban and 1.2% in rural areas. The North-West region had the lowest prevalence of 0.7%, 1.5% and 0.4% for the overall, urban and rural areas, respectively. Mothers with higher education demonstrated a greater CS prevalence of 14.0% overall, 15.3% in urban and 9.7% in rural residences. Frequent internet use increased CS prevalence nationally (14.3%) and in urban (15.1%) and rural (10.1%) residences. The southern regions showed higher CS prevalence, with the South-West leading overall (7.0%) and in rural areas (3.3%), and the South-South highest in urban areas (8.5%). Across all residences, rich wealth index, maternal age ≥ 35, lower birth order, and ≥ eight antenatal (ANC) contacts increased the odds of a CS. In rural Nigeria, husbands' education, spouses' joint healthcare decisions, birth size, and unplanned pregnancy increased CS odds. In urban Nigeria, multiple births, Christianity, frequent internet use, and ease of getting permission to visit healthcare facilities were associated with higher likelihood of CS. CONCLUSION: CS utilisation remains low in Nigeria and varies across rural-urban, regional, and socioeconomic divides. Targeted interventions are imperative for uneducated and socioeconomically disadvantaged mothers across all regions, as well as for mothers in urban areas who adhere to Islam, traditional, or 'other' religions. Comprehensive intervention measures should prioritise educational opportunities and resources, especially for rural areas, awareness campaigns on the benefits of medically indicated CS, and engagement with community and religious leaders to promote acceptance using culturally and religiously sensitive approaches. Other practical strategies include promoting optimal ANC contacts, expanding internet access and digital literacy, especially for rural women (e.g., through community Wi-Fi programs), improving healthcare infrastructure and accessibility in regions with low CS prevalence, particularly in the North-West, and implementing socioeconomic empowerment programs, especially for women in rural areas.

Parent-identified gaps in preparation for the postpartum period in the United States: An integrative review.

BACKGROUND: In the United States, 35% of all pregnancy-related deaths occur between 24 h and 6 weeks after delivery, yet the first outpatient visit is not typically scheduled until 6 weeks postpartum. Thus, the ability to independently navigate this period is critical to maternal well-being and safety. However, previous research suggests that many women feel unprepared to manage the challenges they encounter during this time, and there is a current need to synthesize the existing evidence. Therefore, the purpose of this integrative review is to describe parent-identified gaps in preparation for the postpartum period in the United States. METHODS: Using the Integrative Review framework by Whittemore and Knafl, a systematic search of Medline, CINAHL, PsychInfo, Web of Science, and a hand-search was conducted for peer-reviewed articles published in English between 1995 and 2023. Results were reported according to PRISMA 2020 guidelines. Studies that met eligibility criteria were synthesized in a literature matrix. RESULTS: Twenty-two studies met inclusion criteria. Four themes were identified: Mental Health Concerns, Physical Concerns, Infant Feeding and Care Concerns, and General Concerns and Recommendations. Many women, regardless of parity, reported feeling unprepared for numerous postpartum experiences, including depression, anxiety, physical recovery, breastfeeding, and infant care. Parents reported difficulty differentiating normal postpartum symptoms from complications. Hospital discharge teaching was viewed as simultaneously overwhelming and inadequate. Parent recommendations included the need for earlier and more comprehensive postpartum preparation during pregnancy, delivered in multiple formats and settings. Parents also reported the need for earlier postpartum visits and improved outpatient support. CONCLUSIONS: Our findings indicate that many parents in the United States feel unprepared to navigate a wide variety of emotional, physical, breastfeeding, and infant-care experiences. Future research should explore innovative educational approaches to postpartum preparation during pregnancy as well as outpatient programs to bridge the current gaps in postpartum care.

Concordance of weight status between mothers and children: a secondary analysis of the Pakistan Demographic and health survey VII.

BACKGROUND: Familial concordance of weight status is an emerging field of study that may guide the development of interventions that operate beyond the individual and within the family context. There is a dearth of published data for concordance of weight status within Pakistani households. METHODS: We assessed the associations between weight status of mothers and their children in a nationally representative sample of households in Pakistan using Demographic and Health Survey data from 2017-18. Our analysis included 3465 mother-child dyads, restricting to children under-five years of age with body mass index (BMI) information on their mothers. We used linear regression models to assess the associations between maternal BMI category (underweight, normal weight, overweight, obese) and child's weight-for-height z-score (WHZ), accounting for socio-demographic characteristics of mothers and children. We assessed these relationships in all children under-five and also stratified by age of children (younger than 2 years and 2 to 5 years). RESULTS: In all children under-five and in children 2 to 5 years, maternal BMI was positively associated with child's WHZ. For all children under-five, children of normal weight, overweight, and obese women had WHZ scores that were 0.21 [95% CI (confidence interval): 0.04, 0.37], 0.43 [95% CI: 0.25, 0.62], and 0.51 [95% CI: 0.30, 0.71] units higher than children of underweight women, respectively. For children ages 2 to 5, children of normal weight, overweight, and obese women had WHZ scores that were 0.26 [95% CI: 0.08, 0.44), 0.50 [95% CI: 0.30, 0.71), and 0.61 [95% CI: 0.37, 0.84] units higher than children of underweight women, respectively. There was no association between maternal BMI and child WHZ for children under-two. CONCLUSIONS: The findings indicate that the weight status of mother's is positively associated with that of their children, particularly after age 2. These associations further strengthen the call for research regarding interventions and policies aimed at healthy weight promotion among mothers and their children collectively, rather than focusing on individuals in isolation.

Breastfeeding interventions and programmes conducted in Portuguese-speaking sovereign states: A scoping review.

AIM: This scoping review aimed to identify and appraise the effectiveness and impact of breastfeeding promotion interventions conducted across Portuguese-speaking sovereign countries. METHODS: Using the PRISMA-ScR guidelines, we searched 14 electronic databases for publications published through 31 July 2023. The search terms were designed to find studies promoting breastfeeding or exclusive breastfeeding in pre-defined Portuguese-speaking countries. RESULTS: Of the 5263 papers initially retrieved, 30 interventional studies on breastfeeding met the inclusion criteria across three countries: Brazil (N = 26), Portugal (N = 2) and Guinea Bissau (N = 2). Participants ranged from pregnant women, mothers, mother-infant pairs, healthcare professionals, and school children. Overall, the interventions increased exclusive breastfeeding and better breastfeeding practices, such as a higher duration of breastfeeding. The interventions positively affected maternal breastfeeding self-efficacy, knowledge and perception. Only four studies used a theoretical framework. CONCLUSION: While the results were often statistically significant, no study had an outcome close to the recommended UNICEF and WHO goal of 70% breastfeeding at six months. The need to determine what works for the recommended six months postpartum period is critical for maximising children's health in Portuguese-speaking countries.

Structural and relational factors for successful cross-sector collaboration in home visiting: a multiple case study.

BACKGROUND: Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States. MATERIALS AND METHODS: We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration. RESULTS: Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families' needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting. CONCLUSIONS: We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

Addressing Perinatal Opioid Use at a Local Health Department in Florida.

PURPOSE: Perinatal substance use disorders (SUDs) remain an urgent public health concern in the United States and are associated with increased maternal and infant morbidity and mortality. Establishing holistic prenatal care among this population allows for engaging or re-engaging the pregnant population in appropriate medical care, including treatment for SUD. DESCRIPTION: The Florida Department of Health in Citrus County (DOH-Citrus) noticed an increase in SUD among their pregnant population and developed a pilot program that incorporates Medication for Opioid Use Disorder (MOUD) and mental health services during routine prenatal care appointments. ASSESSMENT: Since the launch of the pilot program, DOH-Citrus has provided prenatal programs with buprenorphine assistance to 23 members of the community. CONCLUSION: A growing number of local health departments (LHDs) provide harm reduction supplies, overdose prevention education, and local resources for treatment and other life-saving services. In many communities, LHDs are typically the most accessible sources of public health information and health care services. By framing the pilot program as a prenatal care center that incorporates SUD treatment as the prescribed standard of care, DOH-Citrus has implemented a holistic model for treating SUD and reducing barriers while improving continuity of care. LHDs are uniquely positioned to implement harm reduction strategies that address perinatal SUDs, treatment, and recovery within maternal and child health populations. As a health department located in a state without expanded Medicaid and with high rates of uninsured people, this pilot program has the potential to be replicated in other states facing similar challenges.

Building Collective Power to Advance Maternal and Child Health Equity: Lessons from the New Orleans Maternal and Child Health Coalition.

OBJECTIVES: The New Orleans Maternal Child Health Coalition convenes to support and amplify the work of New Orleans-based individuals and organizations working to reduce disparities and protect the health of birthing families in the New Orleans area. The objectives of this qualitative study were to identify successes, challenges, and areas of growth for the Coalition and develop broadly generalizable recommendations for similar groups seeking to mobilize and advance health equity in their own communities. METHODS: Using purposive sampling, we conducted semi-structured interviews with 12 key informants from within and outside of the Coalition. Interviews were transcribed verbatim, and data was analyzed using inductive and deductive coding approaches. RESULTS: We identified themes relating to the barriers and facilitators to the maintenance of the Coalition, as well as opportunities to advance the mission of the Coalition. Some themes included structural- and systemic-level barriers to achieving the mission, varying perspectives on the effectiveness of the Coalition, opportunities to enhance the operations of the Coalition's work, and opportunities to involve other individuals, particularly those with lived experience, and non-MCH related sectors in Coalition's work. CONCLUSIONS FOR PRACTICE: As the maternal health crisis continues, coalitions like the New Orleans MCH Coalition provide a vehicle to amplify the mission-driven work of people and organizations. Recommendations put forth by the Coalition can also be utilized by coalitions in other jurisdictions.

A Model for Engaging Citizen Scientists: A Community-Partnered Research Collaboration to Address Inequities for Black Birthing People.

PURPOSE: Co-creation of a citizen-science research initiative with a collaborative team of community members and university-based scientists to address regional disparities in maternal and fetal health outcomes for Black birthing people. DESCRIPTION: Citizen scientist-led projects, where community members actively contribute to each discovery step, from setting a research agenda to collecting data and disseminating results, can extend community participatory research initiatives and help reconceptualize traditional research processes. The Pregnancy Collaborative is a citizen-science research initiative and one of nine scientific committees of The Pittsburgh Study-a longitudinal, community-partnered study designed to bring together collaborators to improve child thriving. ASSESSMENT: Ten community members and five university-based scientists participated during all phases of developing a citizen-scientist collaboration over an initial two-and-a-half-year period. Phases include forming the Pregnancy Collaborative and group research ethics training; co-creating a research agenda grounded in shared principles; and community-partnered data collection, analysis, and dissemination. These phases produced three key co-designed products: (1) a mission and vision statement of the Pregnancy Collaborative, (2) a Collaborative-endorsed research agenda, and (3) a citizen-scientist-executed research survey. CONCLUSION: Lessons learned from the formation of the Pregnancy Collaborative highlight the importance of equitable power distribution through bidirectional knowledge sharing and by centering intellectual effort, lived experience, and tools and resources of those affected by health inequities. Using a citizen science approach to co-designing and executing research helps us move maternal health inequity work from "research on" to "research with."

Public Health Nurses' Competence Related to Long-Term Breastfeeding in the Context of Maternity and Child Health Clinics.

AIM: To explore public health nurses' competence (namely knowledge, skills, and attitudes) in relation to long-term breastfeeding and their experience of the need for additional training on the subject. DESIGN: The study design was quantitative, descriptive, and cross-sectional. SAMPLE: Public health nurses (n = 270). METHODS: Data were collected with the Long-Term Breastfeeding Competence Scale (LBCS) online survey. Data analysis was done with Spearman's correlation analysis and binary logistic regression analysis. RESULTS: Slightly more than half of the respondents had a good level of knowledge and skills. The majority had a baseline positive attitude toward long-term breastfeeding, but the attitude became more negative as the age of the breastfed child increased. Better competence was associated with younger age, parenthood, an additional degree in midwifery, and breastfeeding specialist certification. Knowledge and skills, and attitudes revealed a high correlation: the higher the knowledge and skills level, the more positive attitudes. Respondents with better knowledge and skills experienced more often the need for additional training on the subject. CONCLUSIONS: This study addresses that public health nurses lack competence in relation to long-term breastfeeding. This may compromise the quality of breastfeeding guidance for families in healthcare settings.

Predictors of parenting difficulties at the 18-month health checkups: A retrospective study using administrative data from infant health checkups.

OBJECTIVE: This study aimed to identify predictors of parenting difficulties at 18 months from the results of the 4-, 6-7-, and 9-10-month infant health checkups among caregivers who had not experienced difficulties at 4 months. DESIGN AND SAMPLES: This retrospective study used data from infant health checkups conducted in a city in Tokyo from November 2019 to October 2021. The participants were caregiver-child dyads of children who had undergone four checkups. Low birthweight, preterm, and multiple birth infants, and caregivers who experienced difficulties at 4 months were excluded. MEASUREMENTS: Data included caregiver, child-rearing environment, and child factors at the 4-, 6-7-, and 9-10-month checkups and caregivers' self-reported parenting difficulties at the 18-month checkup. RESULTS: Of the 555 caregivers, 48 (8.6%) experienced parenting difficulties at 18 months. Logistic regression analyses showed that mothers' physical condition (4 months), children being male, abnormal child growth (4 months), less than 10th percentile for children's height (6-7 and 9-10 months), and abnormal examination results (6-7 months) were significantly associated with parenting difficulties at 18 months. CONCLUSIONS: To prevent child abuse, public health nurses should consider the identified factors to detect and support caregivers with emerging parenting difficulties.

A Scoping Review of Breastfeeding Interventions and Programs Conducted Across Spanish-Speaking Countries.

Breastfeeding is vital to a child's lifelong health and has significant positive benefits to mother's health. World Health Organization recommends beginning exclusively breastfeeding within the first hour after birth and continuing during the first 6 months of infant's life. The purpose of this review is to identify and examine breastfeeding interventions conducted across the Spanish-speaking countries. A scoping review of the literature was conducted across 14 databases for relevant publications published through April 2023 to find studies in Spanish-speaking countries that involved breastfeeding as an intervention component. A total of 46 peer-reviewed articles were included in this review, across 12 Spanish-speaking countries. Participants ranged from pregnant women, mothers, mother-infant pair, and health care professionals. Intervention at the individual level in combination with support from trained health care professionals or peer counselors seemed to have higher improvements in breastfeeding rates. The greatest improvement in exclusively breastfeeding for 6 months was seen in interventions that included prenatal and postnatal intensive lactation education, for a period of 12 months. The most effective interventions that improved rates of any breastfeeding included promotional activities, educations workshop, and training of health care staff along with changes in hospital care. Breastfeeding promotion is an economical and effective intervention to increase breastfeeding behavior and thereby improving breastfeeding adherence across Spanish-speaking countries.

Exploring factors affecting adherence to multiple micronutrient supplementation during pregnancy in Cambodia: A qualitative analysis.

For decades, iron-folic acid (IFA) supplements have been provided to pregnant women in Cambodia through antenatal care (ANC) services. However, mounting evidence suggests that multiple micronutrient supplements (MMS) are superior to IFA supplements in achieving positive pregnancy outcomes. The possibility of transitioning from IFA supplements to MMS in government-run health centres is currently being assessed in Cambodia. A crucial component of this assessment involves identifying factors that can influence adherence to MMS, as low adherence can reduce supplement effectiveness. Consequently, this study aimed to explore the potential barriers and enablers to MMS adherence and identify the strengths and challenges of current ANC services. Data were collected through nine focus group discussions with pregnant women (n = 19), family members (n = 18) and midwives (n = 18) and three in-depth interviews with maternal and child health chiefs (n = 3) in Cambodia and analysed via content analysis. Factors found to influence MMS adherence included attitudes, perceptions and beliefs about MMS; knowledge related to supplementation; ANC counselling; family influence; physical health; access to ANC; supply of MMS; and supplementation norms. Noted strengths of ANC services were the quality of ANC materials, tailored patient education, midwife-patient relationships and flexibility of provided services. Primary challenges related to poor availability of ANC materials, inadequate midwife training, heavy workload, limited funding and suboptimal physical spaces for delivering ANC services. To effectively promote MMS adherence, strategies must involve pregnant women, family members and community leaders; seek to address knowledge gaps and misconceptions related to MMS; and enhance the availability and accessibility of ANC services.

Group Interpersonal Psychotherapy for minoritized Head Start mothers with depressive symptoms: A mixed method study.

This study explores minoritized mothers' experiences in group interpersonal psychotherapy (IPT-G) and relates their experiences to treatment outcomes. Quantitative and qualitative data were gathered from 26 Latinx and Black mothers who participated in IPT-G. Mothers were divided into three groups: (1) not depressed at follow-up, (2) depressed at follow-up, and (3) those with subclinical symptoms throughout the intervention, and similarities and differences across groups were examined. Results showed that mothers not depressed at follow-up reported high levels of emotional safety in IPT-G, facilitating emotional processing. Mothers depressed at follow-up referenced the impact of stigma and had greater difficulty sharing their feelings and also reported lower socioeconomic status and higher levels of trauma. It appears that high levels of environmental stressors and difficulty developing trusting therapeutic relationships were related to experiencing depression at the conclusion of treatment. Alternatively, for many mothers, IPT-G provided within head start was an effective therapeutic option.

Implementing universal maternal depression screening in Head Start: A convergent mixed methods study.

Aims: Implementing maternal depression screening in child-serving programs can help ensure that more mothers receive mental health services. This study examined the implementation of universal maternal depression screening in community-based Head Start programs. Methods: Quantitative and qualitative data were merged in a convergent mixed method design to assess four domains from the RE-AIM implementation science framework (Reach, Adoption, Implementation, and Maintenance). Qualitative data included interviews with stakeholders and meeting minutes from the implementation period. Quantitative data included intervention outcomes and administrative data. Results: In terms of reach, 85% of eligible Head Start mothers were screened for depression, and English-speaking mothers were more likely to refuse screening than Spanish-speaking or bilingual mothers. Barriers to screening included lack of availability, stigma, privacy concerns, lack of interest, and lack of trust. In terms of adoption, all sites and staff adopted screening due to organizational mandates. In terms of implementation, there was wide variation in rates of positive screenings across staff completing the screening (ranging from 0% to 46%), and barriers included concerns about staff role and lack of training. In terms of maintenance, screening was not sustained after the study period due to organizational priorities and lack of buy-in from staff. Conclusion: Universal maternal depression screening has the potential to reach low-income Head Start mothers, but additional efforts should be made to build staff capacity to engage mothers in screening.

Understanding the roles of state demographics and state policies in epidemiologic studies of maternal-child health disparities.

Disparities in maternal-child health outcomes by race and ethnicity highlight structural differences in the opportunity for optimal health in the United States. Examples of these differences include access to state-level social policies that promote maternal-child health. States vary in their racial and ethnic composition as a result of the complex history of policies and laws related to slavery, Indigenous genocide and relocation, segregation, immigration, and settlement in the United States. States also vary in the social policies they enact. As a result, correlations exist between the demographic makeup of a state's population and the presence or absence of social policies in that state. These correlations become a mechanism by which racial and ethnic disparities in maternal-child health outcomes can operate. In this commentary, we use the example of three labor-related policies actively under consideration at state and federal levels (paid parental leave, paid sick leave, and reasonable accommodations during pregnancy) to demonstrate how correlations between state demographics and presence of these state policies could cause or exacerbate racial and ethnic disparities in maternal-child health outcomes. We conclude with a call for researchers to consider how the geographic distribution of racialized populations and state policies could contribute to maternal-child health disparities.

Maternal Diet Quality During Pregnancy and Offspring Hepatic Fat in Early Childhood: The Healthy Start Study.

BACKGROUND: Overnutrition in utero may increase offspring risk of nonalcoholic fatty liver disease (NAFLD), but the specific contribution of maternal diet quality during pregnancy to this association remains understudied in humans. OBJECTIVES: This study aimed to examine the associations of maternal diet quality during pregnancy with offspring hepatic fat in early childhood (median: 5 y old, range: 4-8 y old). METHODS: Data were from 278 mother-child pairs in the longitudinal, Colorado-based Healthy Start Study. Multiple 24-h recalls were collected from mothers during pregnancy on a monthly basis (median: 3 recalls, range: 1-8 recalls starting after enrollment), and used to estimate maternal usual nutrient intakes and dietary pattern scores [Healthy Eating Index-2010 (HEI-2010), Dietary Inflammatory Index (DII), and Relative Mediterranean Diet Score (rMED)]. Offspring hepatic fat was measured in early childhood by MRI. Associations of maternal dietary predictors during pregnancy with offspring log-transformed hepatic fat were assessed using linear regression models adjusted for offspring demographics, maternal/perinatal confounders, and maternal total energy intake. RESULTS: Higher maternal fiber intake and rMED scores during pregnancy were associated with lower offspring hepatic fat in early childhood in fully adjusted models [Back-transformed ß (95% CI): 0.82 (0.72, 0.94) per 5 g/1000 kcal fiber; 0.93 (0.88, 0.99) per 1 SD for rMED]. In contrast, higher maternal total sugar and added sugar intakes, and DII scores were associated with higher offspring hepatic fat [Back-transformed ß (95% CI): 1.18 (1.05, 1.32) per 5% kcal/d added sugar; 1.08 (0.99, 1.18) per 1 SD for DII]. Analyses of dietary pattern subcomponents also revealed that lower maternal intakes of green vegetables and legumes and higher intake of "empty calories" were associated with higher offspring hepatic fat in early childhood. CONCLUSIONS: Poorer maternal diet quality during pregnancy was associated with greater offspring susceptibility to hepatic fat in early childhood. Our findings provide insights into potential perinatal targets for the primordial prevention of pediatric NAFLD.

Who Delivers Maternal and Child Health Services? The Contributions of Public Health and Other Community Partners.

Policy Points Local health departments with direct maternal and child health service provisions exhibit greater social service collaboration, thereby enhancing community capacity to improve health care access and social determinant support. These findings may prioritize collaboration as a community-based effort to reduce disparities in maternal and child health and chronic disease. CONTEXT: Improving maternal and child health (MCH) care in the United States requires solutions to address care access and the social determinants that contribute to health disparities. Direct service provision of MCH services by local health departments (LHDs) may substitute or complement public health services provided by other community organizations, impacting local service delivery capacity. We measured MCH service provision among LHDs and examined its association with patterns of social service collaboration among community partners. METHODS: We analyzed the 2018 National Longitudinal Survey of Public Health Systems and 2016 National Association of County and City Health Officials Profile data to measure the LHD provision of MCH services and the types of social services involved in the implementation of essential public health activities. We compared the extensive and intensive margins of social service collaboration among LHDs with any versus no MCH service provision. We then used latent class analysis (LCA) to classify collaboration and logistic regression to estimate community correlates of collaboration. FINDINGS: Of 620 LHDs, 527 (85%) provided at least one of seven observed MCH services. The most common service was Special Supplemental Nutrition Program for Women, Infants, and Children (71%), and the least common was obstetric care (15%). LHDs with MCH service provision were significantly more likely to collaborate with all types of social service organizations. LCA identified two classes of LHDs: high (n = 257; 49%) and low (n = 270; 51%) collaborators. Between 74% and 96% of high collaborators were engaged with social service organizations that provided basic needs services, compared with 31%-60% of low collaborators. Rurality and very high maternal vulnerability were significantly correlated with low collaboration among MCH service-providing LHDs. CONCLUSIONS: LHDs with direct MCH service provision exhibited greater social service collaboration. Collaboration was lowest in rural communities and communities with very high maternal vulnerability. Over half of MCH service-providing LHDs were classified as low collaborators, suggesting unrealized opportunities for social service engagement in these communities.

Triple Benefit: Impact of an Integrated Early Childhood Development and PMTCT Intervention on ART Outcomes Among Mothers Living with HIV and Infants in Malawi-An Endline Evaluation.

We conducted a programmatic, observational cohort study with mother-infant pairs (MIPs) enrolled in prevention-of-mother-to-child-transmission (PMTCT) programs in Malawi to assess the feasibility and potential HIV-related benefits of integrating Early Childhood Development (ECD) services into PMTCT programs. Six health facilities were included in the intervention. We offered ECD counseling from the WHO/UNICEF Care for Child Development package in PMTCT waiting spaces while MIPs waited for PMTCT and broader treatment consultations. Primary outcomes were mothers' retention in HIV care at 12 months and infant HIV testing at 6 weeks and 12 months after birth. Routine facility-level data from six comparison health facilities were collected as an adhoc standard of care comparison and used to calculate the cost of delivering the intervention. A total of 607 MIPs were enrolled in the integrated ECD-PMTCT intervention between June 2018 and December 2019. The average age of MIPs was 30 years and 7 weeks respectively. We found that 86% of mothers attended ≥ 5 of the 8 ECD sessions over the course of 12 months; 88% of intervention mothers were retained in PMTCT versus 59% of mothers in comparison health facilities, and 96% of intervention infants were tested for HIV by six weeks compared to 66% of infants in comparison health facilities. Costing data demonstrated the financial feasibility of integrating ECD and PMTCT programs in government health facilities in Malawi. Integrating ECD into PMTCT programs was feasible, acceptable, resulted in better programmatic outcomes for both mothers and infants. Further investigation is required to determine optimal delivery design for scale-up.