Mother-Father Relationship and Depressive Symptoms Among Pregnant Black Women.

BACKGROUND: Black women report higher levels of depressive symptoms during pregnancy than white women. A supportive relationship with the father of the baby may be protective and decrease depressive symptoms. OBJECTIVE: We sought to examine the association between mother-father relationship and depressive symptoms among pregnant black women. METHODS: Using a cross-sectional design, we conducted a secondary data analysis from a subsample of 405 pregnant black women who participated in the Biosocial Impact on Black Births study, a prospective cohort study. Participants completed questionnaires at 19- to 29-week gestation, including 6 measures of their relationship with the father of the baby: (1) contact, (2) involvement, (3) overall relationship, (4) change in relationship from prior to pregnancy to during pregnancy, (5) support, and (6) conflict. Latent class analysis was used to identify and classify the relationship construct. The Center for Epidemiologic Studies-Depression (CES-D) scale was used, with scores ≥23 considered high levels of depressive symptoms. Data were analyzed with logistic regression. RESULTS: Following adjustment for maternal sociodemographic characteristics, comorbid conditions, and health behaviors, women in a conflictual relationship had higher odds of having depressive symptom scores ≥23 (adjusted odds ratio: 3.50, 95% confidence interval: 2.00, 6.12) than those having no relationship (adjusted odds ratio: 2.81, 95% confidence interval: 1.43, 5.52), when compared with those with a good relationship. CONCLUSIONS: These findings suggest that having either a conflictual or no relationship with the father of the baby during pregnancy increases the odds for higher maternal depressive symptoms (CES-D scores ≥ 23) among pregnant black women.

Measuring the Effect of Neighborhood Racial Segregation on Fetal Growth.

Prior studies of neighborhood racial segregation and intrauterine growth have not accounted for confounding factors in early life. We used the Life-Course Influences on Fetal Environment Study of births to Black women in metropolitan Detroit, 2009-2011, (N = 1,408) to examine whether health and social conditions in childhood and adulthood confound or modify the association of neighborhood segregation (addresses during pregnancy geocoded to census tract racial composition) and gestational age-adjusted birthweight. Before adjusting for covariates, women living in a predominantly (≥75%) Black neighborhood gave birth to 47.3 grams (95% CI: -99.0, 4.4) lighter infants, on average, compared with women living in <75% Black neighborhoods. This association was confounded by adulthood (age at delivery, parity, neighborhood deprivation) and childhood (parental education, neighborhood racial composition) factors and modified by adulthood socioeconomic position. These findings underscore the complex relationship between neighborhood racial segregation and birth outcomes, which would be enhanced through a life course framework.

Determinants of all-cause in-hospital mortality among patients who presented with COVID-19 to a community teaching hospital in Michigan.

BACKGROUND & OBJECTIVES: Race plays an important role in healthcare disparities, often resulting in worse health outcomes. It is unclear if other patient factors and race interactions may influence mortality in patients with COVID-19. We aimed to evaluate how multiple determinants of all-cause in-hospital mortality from COVID-19 were linked to race. METHODS: A retrospective observational study was conducted at two hospitals in metropolitan Detroit. We identified patients aged ≥18 years-old who had tested positive for COVID-19 and were admitted between March 9 through May 16, 2020. Multivariable logistic regression was performed assessing predictors of all-cause in-hospital mortality in COVID-19. RESULTS: We identified 1064 unique patients; 74% were African Americans (AA). The all-cause in-hospital mortality was 21.7%, with the majority of deaths seen in AA (65.4%, P = 0.002) and patients 80 years or older (52%, P < 0.0001). AA women had lower all-cause mortality than AA men, white women, and white men based on race-gender interactions. In multivariable logistic regression analysis, older age (>80-year-old), dementia, and chronic kidney disease were associated with worse all-cause in-hospital mortality. Adjusted for race and body mass index (BMI), the main odds ratios (OR) and 95% confidence intervals (CI) are: Age 80 and older vs < 60 in females: OR = 7.4, 95% CI: 2.9, 18.7; in males OR = 7.3, 95% CI: 3.3, 16.2; Chronic Kidney Disease (CKD): OR = 1.7, 95% CI: 1.2, 2.6; Dementia: OR = 2.2, 95% CI: 1.5, 3.3. CONCLUSION: Gender significantly modified the association of race and COVID-19 mortality. African American females had the lowest all-cause in-hospital mortality risk compared to other gender-race groups.

Timing of Prenatal Care Initiation and Psychological Wellbeing in Black Women.

PURPOSE: The purpose of this study was to see if timing of prenatal care initiation was related to psychological wellbeing of Black women. STUDY DESIGN AND METHODS: Using a cross-sectional design, a sample of 197 pregnant Black women completed a self-reported survey between 8 weeks and less than 30 weeks gestation as part of the Biosocial Impact on Black Births study. The questions asked about the initiation of prenatal care, perceived stress, depressive symptoms, and psychological wellbeing. Multiple linear regression was used to examine if timing of prenatal care initiation was related to psychological variables. RESULTS: Sixty-three women (32%) reported they were not able to initiate their first prenatal care visit as early as they wanted due to various barriers. After adjusting for cofounders, not initiating prenatal care as early as women wanted predicted lower levels of psychological wellbeing. CLINICAL IMPLICATIONS: Perinatal nurses should assess psychological wellbeing in Black women throughout pregnancy; advocate for Black women who report high levels of stress, psychological distress, or depressive symptoms for further mental health evaluation by their health care provider; and provide resources and education (e.g., support groups, counseling) for these women.

How Depressive Symptoms among African American Women Relate to Measures of Social Disorder in Her Childhood and Pregnancy Neighborhood.

Pregnant African American women who report higher levels of social disorder (e.g., vacant housing, drug dealing) in their neighborhoods also report higher levels of depressive symptoms. The effects of social disorder in the neighborhood during childhood on depressive symptoms during pregnancy are not known. Also unknown is the interaction between social disorders in the neighborhood during childhood and during pregnancy regarding depressive symptoms during pregnancy. The purpose of this study was to examine whether higher levels of social disorder in the neighborhood during pregnancy buffered the association of social disorder in the neighborhood during childhood (at age 10 as reference) with depressive symptoms during pregnancy among African American women. We conducted a secondary data analysis of 1383 African American women from the Life-course Influences on Fetal Environments (LIFE) Study (Detroit, Michigan, 2009-2011). Women were interviewed in the hospital 24-72 h after the births. The Center for Epidemiological Studies-Depression (CES-D) scale measured depressive symptoms. Scales measuring social disorder in the neighborhood both during childhood and during pregnancy were also included in the interviews. Women with CES-D scores ≥ 16 were younger, were more likely to be single, and had lower levels of education and household income compared with women with CES-D < 16. There was a significant association between women who report social disorder in their neighborhoods during childhood and depressive symptoms during pregnancy. This effect was moderated by measures of social disorder in the neighborhood during pregnancy (p = .037). Women who reported both low levels of social disorder in their neighborhoods during childhood and during pregnancy had the lowest CES-D scores after controlling for maternal age, marital status, years of education, and family income. The model had a good fit to the data (χ2(6) = 6.36, p = .38). Health care providers should inquire about neighborhood conditions during childhood and during pregnancy and provide referrals for appropriate professional and community support for women who report social disorder in their neighborhoods and depressive symptoms.

Pregnant African American Women's Perceptions of Neighborhood, Racial Discrimination, and Psychological Distress as Influences on Birth Outcomes.

BACKGROUND: African American women are more likely to experience preterm birth compared with White women. Social factors such as neighborhood disorder and experiences of racial discrimination, which disproportionately affect African American women, may partially explain these disparities. PURPOSE: The purpose of this study was to examine pregnant African American women's perceptions of neighborhood disorder, racial discrimination, and psychological distress and whether these concepts were viewed as influences on birth outcomes. STUDY DESIGN AND METHODS: Using a mixed-methods approach, seven pregnant African American women completed questionnaires including scales for neighborhood disorder (Ross Neighborhood Disorder Scale), racial discrimination (Experiences of Discrimination), and psychological distress (Center for Epidemiological Studies Depression Scale; Psychological General Well-Being Index). All constructs were also assessed by semistructured interviews. Within- and across-case analyses were conducted to compare agreement and discordance between the data sources for each construct and to note patterns in the data. RESULTS: The qualitative interviews provided data about women's experiences that were not captured by questionnaires alone. All of the women disclosed concerns about neighborhood conditions, experiences of discrimination, and psychological distress either reported on the questionnaires, during the qualitative interviews, or both. The mixed-methods approach provided a rich source of data that brought into focus the depth of the perceptions around these constructs. CLINICAL IMPLICATIONS: Maternal-child nurses should assess perceptions of neighborhood environment, racial discrimination, and psychological distress, as these factors may increase the risk for adverse pregnancy and birth outcomes.

Skin Tone Matters: Racial Microaggressions and Delayed Prenatal Care.

INTRODUCTION: Literature posits that discrimination can be a barrier to racial and ethnic minorities' healthcare use. This study examines the relationship between perceived discrimination in the form of racial microaggressions and delayed prenatal care in African American women. It also investigates whether this relationship is modified by women's shade of skin color owing to societal attitudes and beliefs tied to colorism (also known as skin-tone bias). METHODS: Data were collected from a cohort of 1,410 black, African American women in metropolitan Detroit, Michigan, enrolled in 2009-2011 (analyzed between August 2017 and July 2018). Perceived racial microaggressions were assessed using the 20-item Daily Life Experiences of Racism and Bother scale. Logistic regression modeled the relationship between the Daily Life Experiences of Racism and Bother scale and delayed prenatal care, defined as third trimester or no prenatal care entry. RESULTS: Nearly a quarter (24.8%) of women had delayed prenatal care. Logistic regression models showed that a Daily Life Experiences of Racism and Bother score above the median was associated with delayed prenatal care (AOR=1.31, 95% CI=1.00, 1.71). This association was moderated by self-reported maternal skin tone (interaction p=0.03). A higher Daily Life Experiences of Racism and Bother score was associated with delayed prenatal care among African-American women at either end of the color continuum (light brown: AOR=1.64, 95% CI=1.02, 2.65; dark brown: AOR=2.30, 95% CI=1.20, 4.41) but not in the middle (medium brown women). CONCLUSIONS: Skin tone-based mistreatment in tandem with racial discrimination in the form of racial microaggressions may influence African American women's use of prenatal care. These findings have implications related to the engagement of women of color, particularly African American women, in healthcare systems and maternal and child health programs.

Neighborhood Tax Foreclosures, Educational Attainment, and Preterm Birth among Urban African American Women.

Ecological evidence suggests that neighborhoods with more tax foreclosures also have more adverse birth outcomes. However, whether neighborhood-level tax foreclosures impact individual-level risk for adverse birth outcomes is unknown. We assessed whether living in a neighborhood with high tax foreclosures is associated with a woman's preterm birth (PTB) risk and tested for effect modification by educational attainment, among urban African American women from the Life Influence on Fetal Environments Study (2009⁻2011; n = 686). We linked survey and medical record data to archival, block-group level tax foreclosure data from the county treasurer. We used Modified Poisson regression with robust error variance and included a foreclosure X education interaction in adjusted models. In the overall sample, neighborhood tax foreclosures did not predict PTB (adjusted relative risk: 0.93, CI: 0.74, 1.16), but the association was modified by educational attainment (interaction p = 0.01). Among women with lower education (n = 227), neighborhood tax foreclosures did not predict PTB risk. The association for women with higher education (n = 401) was statistically significant for a reduction in risk for PTB (adjusted relative risk: 0.74, CI: 0.55, 0.98) among those who lived in neighborhoods with high versus low tax foreclosures. Future studies should seek to identify the mechanisms of this association.

The Impact of Symptoms of Depression and Walking on Gestational Age at Birth in African American Women.

BACKGROUND: Symptoms of depression have been related to lower gestational age and preterm birth (<37 completed weeks gestation). Leisure time physical activity may have protective effects on preterm birth; however, less has been published with regard to other domains of physical activity such as walking for a purpose (e.g., for transportation) or the pathways by which symptoms of depression impact gestational age at birth. METHODS: This was a secondary analysis of available data of African American women. Women were interviewed within 3 days after birth. We proposed a model in which walking for a purpose during pregnancy mediated the effects of symptoms of depression (measured by the 20-item Center for Epidemiologic Studies-Depression [CES-D] scale) on gestational age at birth in a sample of 1,382 African American women. RESULTS: Using structural equation modeling, we found that the direct effect of CES-D scores of 23 or greater, which have been correlated with major depression diagnosis, on gestational age at birth was -4.23 (p < .001). These results indicate that symptoms of depression were associated with a decrease in gestational age at birth of 4.23 days. Walking for a purpose mediated the effect of CES-D scores of 23 or greater on gestational age at birth. CONCLUSIONS: Compared with African American women without symptoms of depression, African American women who had symptoms of depression walked less for a purpose during their pregnancy and delivered infants with lower gestational age at birth. If not medically contraindicated, clinicians should incorporate walking as part of prenatal care recommendations and reassure women about safety of walking during pregnancy.

Inter-relationships between objective and subjective measures of the residential environment among urban African American women.

PURPOSE: The inter-relationships between objective (census based) and subjective (resident reported) measures of the residential environment is understudied in African American (AA) populations. METHODS: Using data from the Life Influences on Fetal Environments Study (2009-2011; n = 1387) of AA women, we quantified the area-level variation in subjective reports of residential healthy food availability, walkability, safety, and disorder that can be accounted for with an objective neighborhood disadvantage index (NDI). Two-level generalized linear models estimated associations between objective and subjective measures of the residential environment, accounting for individual-level covariates. RESULTS: In unconditional models, intraclass correlation coefficients for block-group variance in subjective reports ranged from 11% (healthy food availability) to 30% (safety). Models accounting for the NDI (vs. both NDI and individual-level covariates) accounted for more variance in healthy food availability (23% vs. 8%) and social disorder (40% vs. 38%). The NDI and individual-level variables accounted for 39% and 51% of the area-level variation in walkability and safety, respectively. Associations between subjective and objective measures of the residential environment were significant and in the expected direction. CONCLUSIONS: Future studies on neighborhood effects on health, especially among AAs, should include a wide range of residential environment measures, including subjective, objective, and spatial contextual variables.

Where we used to live: validating retrospective measures of childhood neighborhood context for life course epidemiologic studies.

Early life exposures influence numerous social determinants of health, as distal causes or confounders of later health outcomes. Although a growing literature is documenting how early life socioeconomic position affects later life health, few epidemiologic studies have tested measures for operationalizing early life neighborhood context, or examined their effects on later life health. In the Life-course Influences on Fetal Environments (LIFE) Study, a retrospective cohort study among Black women in Southfield, Michigan (71% response rate), we tested the validity and reliability of retrospectively-reported survey-based subjective measures of early life neighborhood context(N=693). We compared 3 subjective childhood neighborhood measures (disorder, informal social control, victimization), with 3 objective childhood neighborhood measures derived from 4 decades of historical census tract data 1970-2000, linked through geocoded residential histories (tract % poverty, tract % black, tract deprivation score derived from principal components analysis), as well as with 2 subjective neighborhood measures in adulthood. Our results documented that internal consistency reliability was high for the subjective childhood neighborhood scales (Cronbach's α =0.89, 0.93). Comparison of subjective with objective childhood neighborhood measures found moderate associations in hypothesized directions. Associations with objective variables were strongest for neighborhood disorder (rhos=.40), as opposed to with social control or victimization. Associations between subjective neighborhood context in childhood versus adulthood were moderate and stronger for residentially-stable populations. We lastly formally tested for, but found little evidence of, recall bias of the retrospective subjective reports of childhood context. These results provide evidence that retrospective reports of subjective neighborhood context may be a cost-effective, valid, and reliable method to operationalize early life context for health studies.

The impact of neighborhood quality, perceived stress, and social support on depressive symptoms during pregnancy in African American women.

Living in a lower-quality neighborhood is associated with higher levels of depressive symptoms in the general population as well as among pregnant and postpartum women. However, little is known of the important pathways by which this association occurs. We proposed a model in which perceived stress and social support mediated the effects of neighborhood quality on depressive symptoms during pregnancy (measured by the 20-item Center for Epidemiologic Studies-Depression, CES-D, scale) in a sample of 1383 African American women from the Detroit metropolitan area interviewed during their delivery hospitalization. Using structural equation modeling (SEM), we built a latent variable of neighborhood quality using 4 measures (neighborhood disorder, neighborhood safety/danger, walking environment, overall rating). We then tested two SEM mediation models. We found that lower neighborhood quality was associated with higher prevalence of depressive symptoms during pregnancy (standardized total effect = .16, p = .011). We found that perceived stress partially mediated the neighborhood quality association with depressive symptoms. Although the association of social support with depressive symptoms was negligible, social support mediated associations of neighborhood quality with perceived stress [standardized path coefficient = .38 (.02), p = .009]. Our results point to the need for public health, health care, as well as non-health related interventions (e.g. crime prevention programs) to decrease overall exposure to stressors, as well as stress levels of women living in poor quality neighborhoods. Interventions that increase the levels of social support of women during pregnancy are also needed for their potential to decrease stress and ultimately improve mental health at this important time in the life course.

Partner support in a cohort of African American families and its influence on pregnancy outcomes and prenatal health behaviors.

BACKGROUND: We examined how two indicators of partner involvement, relationship type and paternal support, influenced the risk of pregnancy outcomes (preterm birth, low birth weight) and health behaviors (prenatal care, drug use, and smoking) among African American women. METHODS: Interview and medical record data were obtained from a study of 713 adult African American women delivering singletons between March 2001 and July 2004. Women were enrolled prenatally if they received care at one of three Johns Hopkins Medical Institution (JHMI) prenatal clinics or post-partum if they delivered at JHMI with late, no or intermittent prenatal care. Relationship type was classified as married, unmarried/cohabitating, or unmarried/non-cohabitating. Partner support was assessed using an 8-item scale and was dichotomized at the median. Differences in partner support by pregnancy outcome and health behaviors were assessed using linear regression. To assess measures of partner support as predictors of adverse pregnancy outcomes and health behaviors, Poisson regression was used to generate crude and adjusted prevalence ratios (PR) and 95% confidence intervals (CI). RESULTS: There were no statistically significant differences in pregnancy outcomes or health behaviors by relationship type or when partner support was examined as a continuous or categorical variable. Modeled as a dichotomous variable, partner support was not associated with the risk of preterm birth (PR = 0.81, 95% CI = 0.56, 1.56), low birth weight (PR = 0.77, 96% CI = 0.48, 1.26), or health behaviors. CONCLUSIONS: Paternal involvement was not associated with pregnancy outcomes or maternal health behaviors. Attention to measurement issues and other factors relevant for African American women are discussed.

The influence of personal and group racism on entry into prenatal care among African American women.

BACKGROUND: Racism has been hypothesized as a barrier to accessing health care. No quantitative study has directly assessed its influence on women's initiation of prenatal care (PNC). We examined the relationship between PNC entry and experiences of personal and group racism among low-income, African-American (AA) women. We also examined whether the use of denial of racism as a coping mechanism was associated with a delay in accessing PNC. METHODS: Using a prospective/retrospective cohort design we collected data from 872 AA women (prenatally, n = 484; postpartum, n = 388). Multinomial logistic regression was used to assess the relationship between the overall denial of racism index and PNC initiation. FINDINGS: PNC entry was not associated with personal experiences of racism (p = .33); it was significantly associated with group experiences (p < .01). CONCLUSION: Denial of racism experienced by other AAs was a barrier to early PNC among low-income, AA women. Delayed access to PNC may be rooted in the avoidance of racialized experiences among less empowered women when faced with discrimination. Our findings have important implication for the engagement of AA women into the PNC delivery system and the health care system postpartum.

Direct and proxy recall of childhood socio-economic position and health.

BACKGROUND: The utility of proxy reporting within the life course framework has not been adequately assessed; therefore we sought to assess the magnitude and type of agreement that exists between index and proxy reports for bodyweight, health, and socio-economic position (SEP) in childhood. METHODS: Participants were enrolled as part of an ongoing study of preterm birth in African American women in Metro Detroit. Post-partum women and their mothers (n = 333 pairs) provided retrospective reports about the woman's childhood bodyweight, health, and SEP. Agreement was assessed using kappa, weighted kappa (κ), and intraclass correlation coefficients (ICC). Log-linear models were used to describe the pattern of agreement for ordinal data. RESULTS: Birthweight and weight at age 18 was reported with a high level of agreement (ICC = 0.86 and 0.71, respectively). Kappa indicated moderate agreement for early and late childhood/adolescent weight. Log-linear models suggested that there was diagonal agreement plus linear by linear association for early childhood weight and linear by linear association in late childhood/adolescence. Reports of childhood medical problems and hospitalisations had only moderate agreement. Agreement for SEP in both early (κ = 0.14) and late childhood/adolescence (κ = 0.20) was poor. Log-linear models suggest a linear by linear association, indicating a positive association between the responses. CONCLUSIONS: Results suggest that proxy reports may be utilised in conjunction with an index report to provide an estimate of the accuracy of report or to more fully capture experiences over the life course. This may be particularly useful when multiple developmental periods are examined.

The consequences of foreclosure for depressive symptomatology.

PURPOSE: We tested whether experiencing the stressful event of a home mortgage foreclosure was associated with depressive symptomatology. METHODS: Data derive from a cohort study of 662 new mothers in the Life-course Influences on Fetal Environment (LIFE) Study. Eligibility included black/African-American mothers, ages 18 to 45 years, who had just given birth to a singleton baby. Mothers enrolled June 2009 to December 2010 were interviewed immediately after giving birth. Our outcome measure was depressive symptoms based on the Center for Epidemiologic Studies-Depression Scale, dichotomized to measure severe depressive symptomatology during the week prior to the interview. RESULTS: A total of 8% of the sample experienced foreclosure in the past 2 years. Covariate-adjusted Poisson regression models showed that women experiencing a recent foreclosure had 1.76 times greater risk for severe depressive symptoms during the week prior to birth compared to women not experiencing foreclosure (95% confidence interval 1.25-2.47, p = .001); foreclosure was also associated with higher excess absolute risk for depressive symptoms (adjusted risk difference 0.173, 95% confidence interval 0.044-0.301, p = .008). CONCLUSIONS: Women who have recently experienced foreclosure are at risk for severe depressive symptoms. The mental health needs of pregnant women experiencing foreclosure or other housing stressors should be considered in clinical practice.

Women's perceived control of their birth outcomes in the Central Pennsylvania Women's Health Study: implications for the use of preconception care.

PURPOSE: This study examines nonpregnant women's beliefs about whether or not they can influence their future birth outcomes with respect to the baby's health and factors associated with internal locus of control for birth outcomes. Perceived internal control of birth outcomes could be a predisposing factor for use of preconception care, which is recommended for all women of childbearing age by the Centers for Disease Control and Prevention. The overall hypothesis is that internal control of birth outcomes is a function of prior pregnancy experiences, current health status and stress levels, access to health care, and sociodemographics. METHODS: Data are from the Central Pennsylvania Women's Health Study random digit dial telephone survey of 2,002 women ages 18-45; the analytic sample is 614 nonpregnant women with current reproductive capacity who reported that they are considering a future pregnancy. Internal control of birth outcomes is measured using 1) a 4-item Internal Control of Birth Outcomes Scale, 2) a single-item measure of Preconceptional Control, and 3) a score reflecting high internal control on both of these measures. FINDINGS: In multiple logistic regression analyses, internal control of birth outcomes is positively associated with older age (35-45 vs. 18-34 years), higher education (some college or more), marital status (currently married or living with a partner), and higher self-rated physical health status on the SF-12v2 (but not mental health status or psychosocial stress). Previous adverse pregnancy outcomes and current access to health care have no association with internal control for birth outcomes. CONCLUSION: Variables associated with internal control of birth outcomes among women contemplating a future pregnancy are primarily sociodemographic and physical health related. Educational and social marketing efforts to increase women's use of preconception care may be particularly important for women who are likely to have lower internal control, including younger, less educated, unmarried, and less healthy women.

Achieving safe motherhood: applying a life course and multiple determinants perinatal health framework in public health.

Safe motherhood has begun to be identified as a priority for the health of American women. We argue that safe motherhood can be achieved through application of a life course and multiple determinants framework. This framework, with its focus on the preconception period, poses a dilemma in that it links together periods of life and domains of activities that have traditionally not been linked with maternal health. The interests of women and children have often been juxtaposed in the making of policy. Further, the domains of women's health, maternal and child health, and family planning have often clashed over policy priorities and funds. This framework shows that the research literature now links them inextricably to better health outcomes, albeit indirectly; there are no intervention studies that have demonstrated the empirical efficacy of this approach. Thus, although this framework creates a strong rationale for the linkages described, it also demands attention to a set of implementation strategies that will overcome existing barriers. Through a focus on one maternal factor, obesity, we discuss how a range of strategies grounded in the framework can be undertaken to address maternal morbidity and mortality. We then examine selected strategies at each level of the multiple determinants life course framework and emphasize how public policies and public and private sector professional practice can be reexamined to improve outcomes for women in all time periods and aspects of reproductive potential, which in turn might enhance outcomes for their offspring, both at birth and beyond. Our intent is to influence how policy makers, public health professionals, clinicians, and researchers approach safe motherhood.