Perinatal Periods of Risk Analysis: Disentangling Race and Socioeconomic Status to Inform a Black Infant Mortality Community Action Initiative.

Objectives The goal of this study is to use Perinatal Periods of Risk (PPOR) analysis to differentiate broad areas of risk (Maternal-Health/Prematurity, Maternal Care, Newborn Care, and Infant Health) associated with being Black from those associated with being poor. Methods Phase I PPOR compared two target populations (Black women/infants and poor women/infants) against a gold standard reference group (White, non-Hispanic women, aged 20+ years with 13+ years of education), then against each other. Phase II PPOR further partitioned excess risk into (1) Very-low-birthweight-risk and (2) Birthweight-specific-mortality-risk and identified individual-level risk factors. Results Phase I PPOR revealed Black excess mortality within the Maternal-Health/Prematurity category (67% of total excess mortality). Phase II PPOR revealed that Black excess mortality within this category was primarily due to premature deliveries of very-low-birthweight infants. In a unique extension of the PPOR methodology, a poverty-excess-PPOR was subtracted from the Black-excess-PPOR, and showed that Black women have substantial excess mortality above and beyond that associated with poverty. Subsequent analyses to identify Black-specific risks, controlling for poverty, found that vaginal bleeding, premature rupture of membranes, history of preterm delivery, and having no prenatal care significantly predicted preterm delivery. Conclusions This study demonstrated the utility of PPOR, a standardized risk assessment approach for focusing health promotion efforts. In the study community, PPOR identified that maternal preconception and prenatal factors contributed the greatest risk for Black infants due to prematurity and low birthweight. Higher socioeconomic status did little to mitigate this risk. These findings informed a community-wide plan that integrated evidence-based strategies for addressing systematic racial inequity with strategies for addressing systematic socioeconomic disadvantage.

Intimate Partner Violence Associated with Postpartum Depression, Regardless of Socioeconomic Status.

Objective This study examined whether socioeconomic status moderated the association between intimate partner violence (IPV) and postpartum depression among a community-based sample of women. Defining the role of poverty in the risk of postpartum depression for IPV victims enables prioritization of health promotion efforts to maximize the effectiveness of existing maternal-infant resources. Methods This cross-sectional telephone-survey study interviewed 301 postpartum women 2 months after delivery, screening them for IPV and depression [using Edinburgh Postnatal Depression Scale (EPDS)]. Socioeconomic status was defined by insurance (Medicaid-paid-delivery or not). This analysis controlled for the following covariates, collected through interview and medical-record review: demographics, obstetric history, prenatal health and additional psychosocial risk factors. After adjusting for significant covariates, multiple linear regression was conducted to test whether socioeconomic status confounded or moderated IPV's relationship with EPDS-score. Results Ten percent of participants screened positive for postpartum depression, 21.3 % screened positive for current or previous adult emotional or physical abuse by a partner, and 32.2 % met poverty criteria. IPV and poverty were positively associated with each other (χ(2) (1) = 11.76, p < .001) and with EPDS score (IPV: beta 3.2 (CI 2.0, 4.5) p < .001, poverty: beta 1.3 (CI 0.2, 2.4) p = .017). In the multiple linear regression, IPV remained significantly associated, but poverty did not (IPV: adjusted beta 3.1 (CI 1.8, 4.3) p < .001, poverty: adjusted beta 0.8 (CI -0.3, 1.9) p = .141), and no statistically significant interaction between IPV and poverty was found. Conclusions Study findings illustrated that IPV was strongly associated with postpartum depression, outweighing the influence of socioeconomic status upon depression for postpartum women.

The interplay of race, socioeconomic status and neighborhood residence upon birth outcomes in a high black infant mortality community.

This study examined the interrelationship of race and socioeconomic status (SES) upon infant birthweight at the individual and neighborhood levels within a Midwestern US county marked by high Black infant mortality. The study conducted a multi-level analysis utilizing individual birth records and census tract datasets from 2010, linked through a spatial join with ArcGIS 10.0. The maternal population of 2861 Black and White women delivering infants in 2010, residing in 57 census tracts within the county, constituted the study samples. The main outcome was infant birthweight. The predictors, race and SES were dichotomized into Black and White, low-SES and higher-SES, at both the individual and census tract levels. A two-part Bayesian model demonstrated that individual-level race and SES were more influential birthweight predictors than community-level factors. Specifically, Black women had 1.6 higher odds of delivering a low birthweight (LBW) infant than White women, and low-SES women had 1.7 higher odds of delivering a LBW infant than higher-SES women. Moderate support was found for a three-way interaction between individual-level race, SES and community-level race, such that Black women achieved equity with White women (4.0% Black LBW and 4.1% White LBW) when they each had higher-SES and lived in a racially congruous neighborhood (e.g., Black women lived in disproportionately Black neighborhood and White women lived in disproportionately White neighborhood). In sharp contrast, Black women with higher-SES who lived in a racially incongruous neighborhood (e.g., disproportionately White) had the worst outcomes (14.5% LBW). Demonstrating the layered influence of personal and community circumstances upon health, in a community with substantial racial disparities, personal race and SES independently contribute to birth outcomes, while environmental context, specifically neighborhood racial congruity, is associated with mitigated health risk.

Does gender matter? Exploring mental health recovery court legal and health outcomes.

BACKGROUND: Based upon therapeutic justice principles, mental health courts use legal leverage to improve access and compliance to treatment for defendants who are mentally ill. Justice-involved women have a higher prevalence of mental illness than men, and it plays a greater role in their criminal behavior. Despite this, studies examining whether women respond differently than men to mental health courts are lacking. Study goals were to examine gender-related differences in mental health court participation, and in criminal justice, psychiatric and health-related outcomes. METHODS: This study utilized a quasi-experimental pre-posttest design without a control group. The data were abstracted from administrative records of Kalamazoo Community Mental Health and Substance Abuse agency, the county jail and both county hospitals, 2008 through 2011. Generalized estimating equation regression was used to assess gender-differences in pre-post program outcomes (jail days, psychiatric and medical hospitalization days, emergency department visits) for the 30 women and 63 men with a final mental health court disposition. RESULTS: Program-eligible females were more likely than males to become enrolled in mental health court. Otherwise they were similar on all measured program-participation characteristics: treatment compliance, WRAP participation and graduation rate. All participants showed significant reductions in emergency department visits, but women-completers had significantly steeper drops than males: from 6.7 emergency department visits to 1.3 for women, and from 4.1 to 2.4 for men. A similar gender pattern emerged with medical-hospitalization-days: from 2.2 medical hospital days down to 0.1 for women, and from 0.9 days up to 1.8 for men. While women had fewer psychiatric hospitalization days than men regardless of program involvement (2.5 and 4.6, respectively), both genders experienced fewer days after MHRC compared to before. Women and men showed equal gains from successful program completion in reduced jail days. CONCLUSIONS: Despite similar participation characteristics, findings point to greater health gains by female compared to male participants, and to lower overall psychiatric acuity. Mental-health-court participation was associated with decreased psychiatric hospitalization days and emergency department visits. Successful program completion correlated to fewer jail days for both women and men.

Victim Participation in Intimate Partner Violence Prosecution: Implications for Safety.

Are intimate partner violence (IPV) victims safer if they use the criminal justice system? Concerns about perpetrator retaliation, in the face of data that protection orders can reduce future harm, make it important to understand how victim utilization (calling 911, talking to the prosecutor, and proceeding with prosecution) affects subsequent safety. We hypothesized participation would improve victims' safety, measured by decreases in subsequent IPV-related 911 calls and/or emergency department visits. Findings support contact with the prosecutor's office was associated with reduction in police-reported IPV, regardless of the victim's wish to proceed. Policy implications support pro-prosecution strategies coupled with victim contact.

Improved birth weight for Black infants: outcomes of a Healthy Start program.

OBJECTIVES: We determined whether participation in Healthy Babies Healthy Start (HBHS), a maternal health program emphasizing racial equity and delivering services through case management home visitation, was associated with improved birth outcomes for Black women relative to White women. METHODS: We used a matched-comparison posttest-only design in which we selected the comparison group using propensity score matching. Study data were generated through secondary analysis of Michigan state- and Kalamazoo County-level birth certificate records for 2008 to 2010. We completed statistical analyses, stratified by race, using a repeated-measures generalized linear model. RESULTS: Despite their smoking rate being double that of their matched counterparts, Black HBHS participants delivered higher birth-weight infants than did Black nonparticipants (P = .05). White HBHS participants had significantly more prenatal care than did White nonparticipants, but they had similar birth outcomes (P = .7 for birth weight; P = .55 for gestation). CONCLUSIONS: HBHS participation is associated with increased birth weights among Black women but not among White women, suggesting differential program gains for Black women.

Protection orders protect against assault and injury: a longitudinal study of police-involved women victims of intimate partner violence.

The objective of this study was to measure the efficacy of protection orders (POs) in reducing assault and injury-related outcomes using a matched comparison group and tracking outcomes over time. This study was a retrospective review of police, emergency department, family court, and prosecutor administrative records for a cohort of police-involved female IPV victims; all events over a 4-year study period were abstracted. Victims who obtained POs were compared with a propensity-score-based match group without POs over three time periods: Before, During, and After the issuance of a PO. Having a PO in place was associated with significantly more calls to police for nonassaultive incidents and more police charging requests that were of multiple-count and felony-level. Comparing outcomes, PO victims had police incident rates that were more than double the matched group prior to the PO but dropped to the level of the matched group during and after the order. ED visits dropped over time for both groups. This study confirmed the protective effect of POs, which are associated with reduced police incidents and emergency department visits both during and after the order and reduced police incidents compared with a matched comparison group.

Intimate partner violence identification and response: time for a change in strategy.

BACKGROUND: While victims of intimate partner violence (IPV) present to health care settings for a variety of complaints; rates and predictors of case identification and intervention are unknown. OBJECTIVE: Examine emergency department (ED) case finding and response within a known population of abused women. DESIGN: Retrospective longitudinal cohort study. SUBJECTS: Police-involved female victims of IPV in a semi-rural Midwestern county. MAIN MEASURES: We linked police, prosecutor, and medical record data to examine characteristics of ED identification and response from 1999-2002; bivariate analyses and logistic regression analyses accounted for the nesting of subjects' with multiple visits. RESULTS: IPV victims (N = 993) generated 3,426 IPV-related police incidents (mean 3.61, median 3, range 1-17) over the 4-year study period; 785 (79%) generated 4,306 ED visits (mean 7.17, median 5, range 1-87), which occurred after the date of a documented IPV assault. Only 384 (9%) ED visits occurred within a week of a police-reported IPV incident. IPV identification in the ED was associated with higher violence severity, being childless and underinsured, more police incidents (mean: 4.2 vs 3.3), and more ED visits (mean: 10.6 vs 5.5) over the 4 years. The majority of ED visits occurring after a documented IPV incident were for medical complaints (3,378, 78.4%), and 72% of this cohort were never identified as victims of abuse. IPV identification was associated with the day of a police incident, transportation by police, self-disclosure of "domestic assault," and chart documentation of mental health and substance abuse issues. When IPV was identified, ED staff provided legally useful documentation (86%), police contact (50%), and social worker involvement (45%), but only assessed safety in 33% of the women and referred them to victim services 25% of the time. CONCLUSION: The majority of police-identified IPV victims frequently use the ED for health care, but are unlikely to be identified or receive any intervention in that setting.

Assessing maternal risk for fetal-infant mortality: a population-based study to prioritize risk reduction in a healthy start community.

Study goals were to distinguish between maternal risk factors for fetal versus infant mortality, and to identify which maternal characteristics contributed the greatest risk of mortality overall. This case-control retrospective study abstracted data on more than forty maternal characteristics from 261 prenatal and delivery records: all 26 fetal deaths, all 40 infant deaths and 195 randomly selected surviving births in a high-mortality Healthy Start community. Bivariate and multivariate analyses were conducted. The fetal-mortality population was significantly more likely than the infant-mortality population to have no insurance (P = .047), inadequate prenatal care (P = .039) and previous fetal death (P = .021). Comparing the combined mortality population with the surviving sample, two tiers of risk emerged: Rare-but-lethal risks, including no prenatal care (P < .001) and Child-Protective-Service involvement (P = .001), and common-and-dangerous risks, including inadequate maternal weight gain (OR = 13.55), drug or alcohol abuse (OR = 8.67), obesity (OR = 2.77) and anemia (OR = 3.61). Both fetal and infant mortality groups must be considered when identifying maternal risks. Inadequate prenatal weight gain, obesity and anemia contribute as much to feto-infant mortality as substance abuse. Public health efforts to improve maternal nutrition and healthy weight should be redoubled.

Perinatal status and help-seeking for intimate partner violence.

BACKGROUND: Although there has been much research examining the relationship between pregnancy and abuse, this study is one of the few to investigate whether perinatal status (defined as pregnancy or early postpartum) impacts the help seeking of abused women. METHODS: We retrospectively reviewed 3 years of prosecutor administrative records, police incident reports, and hospital medical records for a countywide population of adult females (n = 964) assaulted by an intimate partner in 2000. Perinatal and nonperinatal victims were compared using chi-square and a series of logistic regression models, controlling for all demographic and incident-related factors. RESULTS: Compared with women across the county, abused women were twice as likely to become pregnant (p < 0.001). Perinatal status did not change the rate of help seeking from police (OR 1.1, p = 0.67) or emergency departments (ED) (OR 1.1, p = 0.94), but it did change the pattern of help seeking with higher ED use in the 6 months prior to the assault (p < 0.01) and a trend toward seeking help with fewer injuries (p = 0.10). CONCLUSIONS: Abused women are more likely to become pregnant. Perinatal status impacts how victims seek help from criminal justice agencies and EDs.

Missed opportunities: emergency department visits by police-identified victims of intimate partner violence.

STUDY OBJECTIVE: We examine all emergency department (ED) utilization by police-identified women victims of intimate partner violence as part of an intimate partner violence ED surveillance study to determine the frequency and characteristics of visits and the extent of intimate partner violence screening and identification by ED staff. METHODS: We conducted a retrospective observational case series reviewing countywide EDs visits, 1999 to 2001, for women victims in the 2000 prosecutor's intimate partner violence database. Stratifying visits by whether the woman presented with an injury, we assessed documentation of intimate partner violence screening and identification and mental health and substance abuse in the medical records. RESULTS: Of 964 female intimate partner violence victims in the 2000 prosecutor's intimate partner violence database, 616 (63.9 %) received care in at least 1 ED in the year of the index assault. During the 3-year study period, 788 (81.7%) victims generated a total of 4,456 ED visits. Intimate partner violence screening was documented in 1,349 (30.3%) of the 4,456 visits but resulted in only 259 (5.8%) positive screens. However, because they use the ED so frequently, 23.0% of individual intimate partner violence victims were eventually identified. The median number of visits for victim ED users was 4 (range 1 to 71), and visits were just as likely to occur before the known intimate partner violence incident as after, although ED visits tended to peak in the month of the incident. Injury-related visits were 50% more likely to have documented IPV screening, however, most visits (71.2%) by IPV victims were for noninjury-related complaints. CONCLUSION: Police-identified intimate partner violence victims utilize emergency care at extremely high rates, usually without identification or referral to intimate partner violence resources.