Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women.

CONTEXT: Long-acting reversible contraceptive (LARC) methods are recommended for young women, but access is limited by cost and lack of knowledge among providers and consumers. The Colorado Family Planning Initiative (CFPI) sought to address these barriers by training providers, financing LARC method provision at Title X-funded clinics and increasing patient caseload. METHODS: Beginning in 2009, 28 Title X-funded agencies in Colorado received private funding to support CFPI. Caseloads and clients' LARC use were assessed over the following two years. Fertility rates among low-income women aged 15-24 were compared with expected trends. Abortion rates and births among high-risk women were tracked, and the numbers of infants receiving services through the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were examined. RESULTS: By 2011, caseloads had increased by 23%, and LARC use among 15-24-year-olds had grown from 5% to 19%. Cumulatively, one in 15 young, low-income women had received a LARC method, up from one in 170 in 2008. Compared with expected fertility rates in 2011, observed rates were 29% lower among low-income 15-19-year-olds and 14% lower among similar 20-24-year-olds. In CFPI counties, the proportion of births that were high-risk declined by 24% between 2009 and 2011; abortion rates fell 34% and 18%, respectively, among women aged 15-19 and 20-24. Statewide, infant enrollment in WIC declined 23% between 2010 and 2013. CONCLUSIONS: Programs that increase LARC use among young, low-income women may contribute to declines in fertility rates, abortion rates and births among high-risk women.

Short-lived success: assessment of an intervention to improve pregnancy weight gain in Colorado.

Inadequate weight gain in pregnancy is a major contributor to low birth weight in Colorado, where the low birth weight rate is among the highest in the nation. In 2004, the Colorado Department of Public Health and Environment implemented a population-based intervention in 9 counties, including provider training and a public media campaign, to encourage pregnant women to gain an adequate amount of weight in pregnancy as defined by the 1990 Institute of Medicine guidelines. Pregnancy Risk Assessment Monitoring System survey data were used to track weight gain in pregnancy in 1997 through 2004 (baseline), 2005 (post-intervention), and 2006 and 2007 (after the intervention had concluded). During the period immediately after the implementation of the intervention, the percentage of women delivering in the 9 study counties who gained an inadequate amount of weight during pregnancy dropped from 18.4 at baseline to 12.8 in 2005. However, this progress was reversed in 2006, when the percentage of women with inadequate weight gain rose to 19.7. Training providers to educate women about the importance of adequate weight gain in pregnancy, in conjunction with a social marketing campaign, appears to be a promising approach to addressing a major contributor to low birth weight. However, a time-limited intervention is likely to have temporary results.

Evaluating the SIDS diagnosis process utilized by coroners in Mississippi.

To assess the consistency of Mississippi coroners' practices in identifying Sudden Infant Death Syndrome (SIDS) cases, coroners were surveyed about diagnostic protocols. Findings were compared with published Centers for Disease Control guidelines and Mississippi law. One-third of coroners report they sometimes or never perform investigations at the place of infant death. The agency responsible for transferring the infant and the turn-around time for autopsy reports also varies. This study demonstrates inconsistency in SIDS diagnostic protocols among Mississippi coroners.

Factors associated with access to dental care for children with special health care needs.

BACKGROUND: The authors examined the relationship between receipt of routine medical care and receipt of dental care among children with special health care needs (CSHCN) who resided in the American Dental Association's Fifth Trustee District, which includes Alabama, Georgia and Mississippi. METHODS: The authors conducted a cross-sectional study using data from the 2001 National Survey of Children with Special Health Care Needs, a module of that year's State and Local Area Integrated Telephone Survey (sponsored by the U.S. Department of Health and Human Services' Maternal and Child Health Bureau of the Health Resources and Service Administration, Rockville, Md., and conducted by the Centers for Disease Control and Prevention, Atlanta). The authors used bivariate and logistic regression analyses to explore the relationships (n = 2,092) between predisposing, enabling and need factors and receipt of dental care. RESULTS: The parents of an estimated 76 percent of CSHCN in the district reported that their child had a need for dental care in the previous 12 months. Of these, 13.1 percent did not receive care. Failure to obtain needed dental care was associated with failure to obtain routine medical care, as was having a lower income. CONCLUSIONS: Failure to obtain routine medical care may be a risk factor for failure to obtain dental care. Any income below 400 percent of the federal poverty guidelines appears to be a barrier to receiving dental care for CSHCN. PRACTICE IMPLICATIONS: Providers of routine medical care may play an important role in linking CSHCN to dental care. Investigators need to examine other barriers to dental care for CSHCN. Strategies to optimize access to dental care for CSHCN at all income levels are needed.

Association of maternal chronic disease and negative birth outcomes in a non-Hispanic Black-White Mississippi birth cohort.

OBJECTIVE: To investigate the impact of selected maternal chronic medical conditions, race, and age on preterm birth (PTB), low birth weight (LBW), and infant mortality among Mississippi mothers from 1999 to 2003. DESIGN: A retrospective cohort analysis of linked birth and death certificates. SAMPLE: The 1999-2003 Mississippi birth cohort comprising 202,931 singleton infants born to African American and White women. MEASUREMENTS: The relationship between maternal chronic conditions and the dependent variables of PTB, LBW, and infant mortality were investigated using logistic regression analysis. RESULTS: PTB, LBW, and infant mortality were more prevalent among African American women, very young women (< or =15 years), and women with certain chronic medical conditions. Among White mothers, maternal chronic hypertension was significantly associated with PTB and LBW, and maternal diabetes with PTB and infant mortality. Among African American mothers, maternal cardiac disease was significantly associated with PTB and LBW; maternal chronic hypertension was significantly associated with LBW and infant mortality; and maternal diabetes with PTB. CONCLUSIONS: Maternal chronic hypertension and diabetes were significantly associated with negative birth outcomes regardless of maternal race. Maternal cardiac disease was only significantly associated with PTB and LBW among African Americans.

Effect of "this side up" T-shirts on infant sleep position.

OBJECTIVES: To assess the impact of "This Side Up" T-shirts on parental practices in Nebraska. METHODS: A random sample of 3,210 Nebraska women who gave birth in 2004, stratified by race/ethnicity, was mailed a brief questionnaire on their receipt of a T-shirt and SIDS risk reduction materials at their birthing hospital, and on infant sleep position. RESULTS: Response rates were low (25.9%), ranging from 10.6% for Native American mothers to 46.4% for White mothers. Half (52.0%) had received a T-shirt and 71.6% had received SIDS information. Two-thirds (64.0%) reported that their infants slept on their backs; African-American and Hispanic infants were significantly less likely to back sleep. In univariate logistic regression models, African-American race, Hispanic ethnicity and maternal age 30-39 were significant negative predictors of back sleeping; White race and having received a SIDS brochure were positive predictors. In the fully controlled model African American and Asian race and Hispanic ethnicity were negative predictors of back sleeping; neither receiving SIDS information nor the infant T-shirt was significant. Effects of maternal age and a SIDS informational brochure appeared in models stratified by race/ethnicity. CONCLUSIONS: In these data, receiving an infant T-shirt was not related to how mothers placed their infants to sleep. Additional research is needed on effective methods of delivering targeted counseling and promoting safe sleep practices among families, particularly among racial and ethnic subgroups.

Parental English proficiency and children's health services access.

OBJECTIVES: We examined the relation between parents' level of English proficiency and their children's access to health care. METHODS: Using the 2001 California Health Interview Survey, we conducted bivariate and multivariate analyses of several measures of children's access to health care (current health insurance status, usual source of care, emergency room visits, delayed or forgone care, traveling to another country for health care, and perceived discrimination in health care) and their association with parents' English proficiency. RESULTS: Compared with English-speaking households, children in non-English-speaking households were more likely to lack health insurance, to not have doctor contact, and to go to other countries for health care and were less likely to use emergency rooms. Their parents were less likely to report their children's experiencing delayed or forgone care or discrimination in health care. CONCLUSION: English proficiency is a strong predictor of access to health insurance for children, and children in non-English-speaking families are especially likely to rely on other countries for their health care. English proficiency may mitigate the effects of race/ethnicity commonly observed in health care access and utilization studies.

Factors influencing inadequate and excessive weight gain in pregnancy: Colorado, 2000-2002.

OBJECTIVES: To identify the biological, psychosocial, and behavioral characteristics that are associated with inadequate and/or excessive weight gain in pregnancy. METHODS: Univariate, bivariate, and multiple logistic regression analyses were conducted using data from Colorado's 2000-2002 Pregnancy Risk Assessment Monitoring System (PRAMS). Independent variables included biological risk factors (prepregnancy BMI, parity, preterm labor, maternal morbidity), psychosocial risk factors (pregnancy intention, WIC and Medicaid enrollment, area of residence, age, race/ethnicity, education, and stressors), and behavioral risk factors (smoking and drinking alcohol in the last trimester of pregnancy). RESULTS: In the bivariate analysis, all the biological risk factors were significantly associated with the pregnancy weight gain distribution, as were several of the psychosocial risk factors (WIC and Medicaid enrollment, area of residence, race/ethnicity, and maternal education). Smoking and alcohol use were not significant. After controlling for other variables through logistic regression, the only characteristics associated with inadequate weight gain were parity, underweight or obesity, preterm labor, nausea, residence in a rural area, low levels of education, and smoking. The characteristics associated with excessive weight gain were overweight or obesity, high blood pressure, and having 12 years of education. CONCLUSION: Having a pre-pregnancy BMI above 29 greatly increases the risk for both inadequate and excessive weight gain. Unfortunately, obesity, like the other major risk factors identified here (maternal education and parity) are not modifiable after a given pregnancy begins. To address these problems, a sustained approach to women's health, education, and well-being across the lifespan will be required, rather than a reliance upon targeted interventions during pregnancy.

Reducing low birthweight by resolving risks: results from Colorado's prenatal plus program.

OBJECTIVES: We examined low-birthweight (LBW) rates among participants in Colorado's Prenatal Plus program by prenatal risk factors (smoking, inadequate weight gain during pregnancy, and psychosocial problems) and the effect of successful resolution of these risks during pregnancy. METHODS: Data for 3569 Medicaid-eligible women who received care coordination, nutritional counseling, or psychosocial counseling through the Prenatal Plus Program in 2002 were analyzed to determine the prevalence of specific risks, the proportion of women who resolved each specific risk, and the low birthweight rates for births to women who did and did not resolve risk. LBW rates were analyzed with chi(2) tests of significance. RESULTS: Women who quit smoking had an LBW rate of 8.5%, compared with an LBW rate of 13.7% among women who did not. Women with adequate weight gain had an LBW rate of 6.7%, compared with 17.2% among women with inadequate weight gain. Women who resolved all of their risks had a low-birthweight rate of 7.0%, compared with a rate of 13.2% among women who resolved no risks. Women who had at least 10 Prenatal Plus visits were more likely to resolve their risks than were women who had fewer visits. CONCLUSIONS: Multidisciplinary prenatal interventions targeted toward specific risks demonstrate success at significantly improving infant birthweight.

Economic impact on families caring for children with special health care needs in New Hampshire: the effect of socioeconomic and health-related factors.

OBJECTIVES: To describe the economic impact on families of caring for children with special health care needs (CSHCN), and to determine the relative contributions of socioeconomic and health-related factors to these impacts on families in the State of New Hampshire. METHODS: Seven hundred and fifty families with CSHCN in New Hampshire were interviewed in the National Survey of Children with Special Health Needs. Among respondents with CSHCN, univariate and bivariate analyses were conducted to examine economic impact and independent factors (income, insurance type, and impact of condition). Multiple logistic and linear regression models were used to examine relationships between impact and independent factors, controlling for race/ethnicity. RESULTS: Compared to typical children, CSHCN were more likely to have public insurance (12% and 21%, respectively) and less likely to live in higher income families (56% and 48%, respectively). Among CSHCN, nearly one-quarter were greatly affected by their condition, 31% had inadequate insurance, families of 21% had financial problems, parents of 27% had to cut work hours, and almost 15% needed professional care coordination. Adjusting for other factors in regression models, the impact of the condition was associated with all measures of impact, insurance type was associated with out-of-pocket costs, and income was associated with the total number of impacts. Parents of children who are usually or always affected by their conditions were 14 times more likely than those who are never affected to need care coordination. CONCLUSION: A family's need for support services, and particularly for care coordination, may depend less on the family's means than on the impact of their child's condition.

Parental awareness of health and community resources among immigrant families.

OBJECTIVES: To examine the association between parental immigrant status and awareness of health and community resources to help address common family problems. METHODS: Using the 1999 National Survey of America's Families, a survey of the health, economic, and social characteristics of children and adults, bivariate and multivariate analyses were conducted on 35,938 children to examine the relationship between parents' immigrant status (U.S.-born citizens, naturalized citizens, and noncitizens) and their responses to questions about their awareness of specific health and community resources. RESULTS: Compared to U.S.-born citizens, noncitizens were at the highest risk of not being aware of health and community resources for most outcomes, followed by naturalized citizens. The services of which noncitizens were most likely to be unaware were places to get help for family discord, child care issues, and family violence. Multivariate analyses indicate that parental race/ethnicity, education level, employment status, and child age were other significant independent risk factors. CONCLUSIONS: Immigrant parents are at particularly high risk of alienation from systems of health care and support services that are available to low-income and other vulnerable populations in the United States. These findings clearly document disparate awareness among parents of different immigrant status. Community and health resources should reach out to immigrant populations, in linguistically and culturally appropriate ways, to alert them to the availability of their services.

Parent's language of interview and access to care for children with special health care needs.

OBJECTIVE: To examine the association between the parent's language of interview and the access to care for children with special health care needs (CSHCN). METHODS: We used the 2001 National Survey of Children with Special Health Care Needs to compare socio-demographic characteristics and health care access variables among CSHCN with parents who interviewed in English and another language. Additional multivariate analyses explored the effect of language of interview on access to health care for the subgroup of Hispanic respondents. RESULTS: CSHCN with non-English-speaking parents were from less-educated and lower-income families and were more likely to lack insurance and have conditions that greatly affected their activities. These children were also more likely to have inadequate insurance (odds ratio [OR]=11.29), have an unmet need for family support services (OR=1.88), lack a personal doctor or nurse (OR=1.98), lack a usual source of care (OR=1.89), and lack family-centered care (OR=1.74). Non-English-speaking parents were more likely to report having employment consequences (OR=1.94) and spending over $500 out-of-pocket annually on the child's health care needs (OR=1.49). The likelihood of Hispanic children experiencing health care access barriers compared with non-Hispanic children was reduced when language was controlled for and several disparities between Hispanic children and other children became insignificant. CONCLUSIONS: CSHCN with non-English-speaking parents were more likely to be from disadvantaged families and to experience barriers to access than were CSHCN with English-speaking parents. Systems of care for CSHCN should consider the needs and challenges experienced by families whose primary language is not English.

Acculturation and the health and well-being of U.S. immigrant adolescents.

PURPOSE: To examine the association of acculturation, as measured by language spoken at home, with the health, psychosocial, school, and parental risk factors of adolescents of various racial/ethnic groups. METHODS: Using the U.S. component of the 1997-98 World Health Organization Study of Health Behavior in School Children, bivariate and multiple logistic regression analyses were conducted of records for adolescents in four racial/ethnic groups to explore the relationship between the language spoken at home and outcome variables regarding health status and risks, psychosocial and school risk factors, and parental factors. Data were analyzed using Software for the Statistical Analysis of Correlated Data (SUDAAN). RESULTS: Adolescents of all racial and ethnic groups who primarily speak a language other than English at home are at elevated risk for psychosocial risk factors such as alienation from classmates and being bullied, and parental risk factors such as feeling that their parents are not able or willing to help them. Those who speak a combination of languages are also at risk for being bullied and for high parental expectations. Language spoken at home is generally not associated with health and safety measures for adolescents across racial/ethnic groups. CONCLUSIONS: Adolescents whose primary language at home is not English experience higher psychosocial, school, and parental risks than non-Hispanic white English-speakers. New immigrant youths of all races and ethnic groups would potentially benefit from preventive and risk-reduction services.

Factors that influence receipt of recommended preventive pediatric health and dental care.

OBJECTIVE: This study examined the factors that affect children's receipt of recommended well-child and dental visits using nationally representative data. METHODS: We analyzed the Child Public Use File of the 1999 National Survey of America's Families, including 35 938 children who were younger than 18 years. Bivariate and multivariate analyses were conducted to examine the relationship between dependent variables, including receipt of well-child visits as recommended by the American Academy of Pediatrics' periodicity schedule and dental visits as recommended by the American Academy of Pediatric Dentistry and Bright Futures, and independent variables, including health status and sociodemographic and economic indicators. RESULTS: Overall, 23.4% of children did not receive the recommended well-child visits, whereas 46.8% did not receive the recommended number of dental visits. The factors that predict nonreceipt of care differed for well-child and dental care and with child's age. Logistic regression reveals that children who were young (<10 years old), uninsured, non-Hispanic white, had a parent who was less than college educated, or in poor health were least likely to meet the recommendations for well-child care. Children who did not meet the dental recommendation were more likely to be black, uninsured, from families with low incomes, have a parent who was less than college educated, and have postponed dental care in the last year. These risk factors increased with children's age. CONCLUSIONS: A substantial proportion of US children do not receive preventive care according to professionally recommended standards, particularly dental care. Publicly insured children experience higher rates of recommended well-child visits; however, much improvement is needed among public programs in providing recommended dental care, especially among adolescents and children in poor general health.

Factors associated with smoking cessation among U.S. pregnant women.

OBJECTIVES: This study examines smoking and smoking cessation behaviors among U.S. pregnant women and seeks to identify the sociodemographic correlates of smoking cessation in pregnancy. METHODS: The 1998 NHIS Pregnancy and Smoking supplement was analyzed, including 5288 U.S. women (weighted to represent 13,714,358 women) who gave birth to a liveborn infant in the past 5 years. Four categories of smoking behavior were analyzed: nonsmoking at last pregnancy, persistent smoking throughout pregnancy, attempting unsuccessfully to quit during pregnancy, and successfully quitting during pregnancy. Logistic regression was used to isolate risk factors for each of the smoking behaviors and to examine factors associated with attempted and successful cessation. RESULTS: The women most likely to attempt to quit smoking in pregnancy were Hispanic women (OR = 3.09) and women who have smoked for less than 10 years (OR = 2.75 for women aged 18-24.) In general, for the groups at highest risk of smoking at the start of pregnancy, the odds of being a persistent smoker were higher than the odds of being an unsuccessful quitter, which in turn were higher than the odds of quitting successfully. The factors associated with attempts to quit included Hispanic ethnicity, higher education, above-poverty income, and shorter duration of smoking, while the combined effect of age and smoking duration was the only one significantly associated with successful quitting. In every age group, longer smoking duration was associated with lower likelihood of attempting to quit as well as successful quitting. CONCLUSIONS: The factors most strongly associated with attempts to quit smoking were Hispanic ethnicity and the combined effect of age and smoking duration. Future smoking cessation and relapse prevention programs should be developed, taking into consideration the critical factors of age, ethnicity, income, geography, and addiction.

Association of language spoken at home with health and school issues among Asian American adolescents.

The study examined the association of language spoken at home with the school and health risks and behaviors of Asian American adolescents. Using the United States component of the 1997-1998 World Health Organization Study of Health Behavior in School Children, bivariate and multiple logistic regression analyses were conducted of records for Asian children to explore the relationship between language spoken at home and outcome variables regarding health behaviors, psychosocial and school risk factors, and parental factors. Compared to those who usually speak English at home, adolescents who usually speak another language, or who speak two languages equally, face a greater risk for health risk factors, psychosocial and school risk factors, and parental risk factors. Not speaking English at home was associated with higher health risks, including not wearing seat belts and bicycle helmets; higher psychosocial and school risk factors, including feeling that they do not belong at school, difficulty making new friends, and lacking confidence; and higher parental risks, including reporting that parents were not ready to help them or willing to talk to teachers. Adolescents less acculturated to the United States experience a variety of physical and psychosocial risks. School-based interventions such as early identification and outreach, needs assessment, and counseling and support services should be provided to immigrant students and their families.