Group prenatal care and improved birth outcomes: Results from a type 1 hybrid effectiveness-implementation study.

To compare birth outcomes for patients receiving Expect With Me (EWM) group prenatal care or individual care only, we conducted a type 1 hybrid effectiveness-implementation trial (Detroit and Nashville, 2014-2016). Participants entered care <24 weeks gestation, had singleton pregnancy, and no prior preterm birth (N = 2402). Mean participant age was 27.1 (SD = 5.77); 49.5% were Black; 15.3% were Latina; 59.7% publicly insured. Average treatment effect of EWM compared to individual care only was estimated using augmented inverse probability weighting (AIPW). This doubly-robust analytic method produces estimates of causal association between treatment and outcome in the absence of randomization. AIPW was effective at creating equivalent groups for potential confounders. Compared to those receiving individual care only, EWM patients did significantly better on three of four primary outcomes: lower risk of infants born preterm (<37 weeks gestation; 6.4% vs. 15.1%, risk ratio (RR) 0.42, 95% Confidence Interval (CI) 0.29, 0.54), low birthweight (<2500 g; 4.3% vs. 11.6%, RR 0.37, 95% CI 0.24, 0.49), and admission to NICU (9.4% vs. 14.6%, RR 0.64, 95% CI 0.49, 0.78). There was no difference in small for gestational age (<10% percentile of weight for gestational age). EWM patients attended a mean of 5.9 group visits (SD = 2.7); 70% attended ≥5 group visits. Post-hoc analyses indicated EWM patients utilizing the integrated information technology platform had lower risk for low birthweight infants (RR 0.47, 95% CI 0.24, 0.86) than non-users. Future research is needed to understand mechanisms by which group prenatal care improves outcomes, best practices for implementation, and health systems savings. Trial registration: ClinicalTrials.govNCT02169024.

Features and Impact of Trust-Based Relationships Between Community Health Workers and Low-Resource Perinatal Women with Chronic Health Conditions.

OBJECTIVES: Community health worker (CHW) programs are a promising strategy to improve maternal and child health outcomes, particularly among low-resource women. Yet, little is known about which aspects of CHW-client relationships are most salient for promoting positive change. This paper examines features of the CHW-client relationship that perinatal women with chronic conditions reported as being beneficial for their experience of prenatal care and pregnancy. METHODS: Focus groups and interviews were conducted with 18 CHWs and 39 clients from three Merck for Mothers-funded programs in the Eastern United States. Data were analyzed using a grounded theory-informed thematic approach. RESULTS: CHWs built trust-based relationships through emotional attendance, authenticity, and prioritization of clients' needs. They provided instrumental, informational, and emotional support that clients reported facilitated greater engagement with the healthcare system, improved health behaviors, and reduced stress. CHWs and clients alike viewed their relationships as having long-lasting impacts, made possible by the trust-based bond between them. DISCUSSION: Strong, trusting relationships with CHWs may be one avenue through which to improve maternal and infant health for vulnerable perinatal women. Community health care programs should promote trust-building as an explicit program goal. Trust-based CHW-client relationships may serve as an exemplar for transforming traditional care relationships between providers and clients, leading to greater client engagement in care and improved health.

Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women.

AIMS: Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts. METHODS: Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span. RESULTS: Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research. CONCLUSIONS: This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.

Associations between intimate partner violence profiles and mental health among low-income, urban pregnant adolescents.

BACKGROUND: Intimate partner violence (IPV) during pregnancy is associated with adverse maternal and child health outcomes, including poor mental health. Previous IPV research has largely focused on women's victimization experiences; however, evidence suggests young women may be more likely to engage in bilateral violence (report both victimization and perpetration) or perpetrate IPV (unilateral perpetration) during pregnancy than to report being victimized (unilateral victimization). This study examined prevalence of unilateral victimization, unilateral perpetration, and bilateral violence, and the association between these IPV profiles and mental health outcomes during pregnancy among young, low-income adolescents. METHODS: Survey data were collected from 930 adolescents (14-21 years; 95.4% Black and Latina) from fourteen Community Health Centers and hospitals in New York City during second and third trimester of pregnancy. Multivariable regression models tested the association between IPV profiles and prenatal depression, anxiety, and distress, adjusting for known predictors of psychological morbidity. RESULTS: Thirty-eight percent of adolescents experienced IPV during their third trimester of pregnancy. Of these, 13% were solely victims, 35% were solely perpetrators, and 52% were engaged in bilateral violence. All women with violent IPV profiles had significantly higher odds of having depression and anxiety compared to individuals reporting no IPV. Adolescents experiencing bilateral violence had nearly 4-fold higher odds of depression (OR = 3.52, 95% CI: 2.43, 5.09) and a nearly 5-fold increased likelihood of anxiety (OR = 4.98, 95% CI: 3.29, 7.55). Unilateral victims and unilateral perpetrators were also at risk for adverse mental health outcomes, with risk of depression and anxiety two- to three-fold higher, compared to pregnant adolescents who report no IPV. Prenatal distress was higher among adolescents who experienced bilateral violence (OR = 2.84, 95% CI: 1.94, 4.16) and those who were unilateral victims (OR = 2.21, 95% CI: 1.19, 4.12). CONCLUSIONS: All violent IPV profiles were associated with adverse mental health outcomes among pregnant adolescents, with bilateral violence having the most detrimental associations. Comprehensive IPV screening for both victimization and perpetration experiences during pregnancy is warranted. Clinical and community prevention efforts should target pregnant adolescents and their partners to reduce their vulnerability to violence and its adverse consequences. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00628771 . Registered 29 February 2008.

Acculturation and Syndemic Risk: Longitudinal Evaluation of Risk Factors Among Pregnant Latina Adolescents in New York City.

Background: Syndemics are co-occurring epidemics that synergistically contribute to specific risks or health outcomes. Although there is substantial evidence demonstrating their existence, little is known about their change over time in adolescents. Purpose: The objectives of this paper were to identify longitudinal changes in a syndemic of substance use, intimate partner violence, and depression and determine whether immigration/cultural factors moderate this syndemic over time. Methods: In a cohort of 772 pregnant Latina adolescents (ages 14-21) in New York City, we examined substance use, intimate partner violence, and depression as a syndemic. We used longitudinal mixed-effect modeling to evaluate whether higher syndemic score predicted higher syndemic severity, from pregnancy through 1 year postpartum. Interaction terms were used to determine whether immigrant generation and separated orientation were significant moderators of change over time. Results: We found a significant increasing linear effect for syndemic severity over time (ß = 0.0413, P = 0.005). Syndemic score significantly predicted syndemic severity (ß = -0.1390, P ≤ 0.0001), as did immigrant generation (ßImmigrant = -0.1348, P ≤ 0.0001; ß1stGen = -0.1932, P = 0.0005). Both immigrant generation (ßImmigrant = -0.1125, P = 0.0035; ß1stGen = -0.0135, P = 0.7279) and separated orientation (ß = 0.0946, P = 0.0299) were significantly associated with change in severity from pregnancy to 1 year postpartum. Conclusion: Pregnancy provides an opportunity for reducing syndemic risk among Latina adolescents. Future research should explore syndemic changes over time, particularly among high-risk adolescents. Prevention should target syndemic risk reduction in the postpartum period to ensure that risk factors do not increase after pregnancy.

The Prevention of Lower Urinary Tract Symptoms (PLUS) in girls and women: Developing a conceptual framework for a prevention research agenda.

AIMS: The Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium was established by the National Institutes of Health in 2015 to expand research beyond the detection and treatment of lower urinary tract symptoms (LUTS) to the promotion and preservation of bladder health and prevention of LUTS in girls and women. While many multi-disciplinary scientific networks focus on pelvic floor dysfunction and LUTS, the PLUS Consortium stands alone in its focus on prevention. This article describes the PLUS approach to developing a conceptual framework to guide the Consortium's initial prevention research agenda. METHODS: The conceptual framework was informed by traditional social ecological models of public health, biopsychosocial models of health, Glass and McAtee's Society-Behavior-Biology Nexus, and the World Health Organization's conceptual framework for action on the social determinants of health. RESULTS: The PLUS conceptual framework provides a foundation for developing prevention interventions that have the greatest likelihood of promoting and preserving bladder health among diverse populations. CONCLUSIONS: PLUS Consortium work is premised on the notion that programs, practices, and policies designed to promote health will have optimal impact if the conceptual foundation upon which efforts are based is comprehensive and informed by multiple disciplines. The PLUS conceptual framework is broadly applicable to domains of health that have historically focused on the treatment of illness and symptoms rather than the promotion of health. It is also applicable to domains of health that have been examined from a predominantly biological or social ecological perspective, without integration of both perspectives.

Between Synergy and Travesty: A Sexual Risk Syndemic Among Pregnant Latina Immigrant and Non-immigrant Adolescents.

Substance use, intimate partner violence, and depression contribute to sexual risk individually, yet have not been evaluated as a syndemic for adolescents. Using data from 772 pregnant Latina adolescents, we evaluated these factors as a syndemic and tested the moderating role of immigration. Bivariate analyses showed syndemic score (OR = 1.40, p = 0.02) and severity (OR = 1.68, p = 0.006) were predictors for multiple sex partners, and syndemic score predicting STIs (OR = 1.15, p = 0.05). Syndemic severity remained significant in multivariate analyses for multiple sex partners (OR = 1.53, p = 0.04). Moderation analyses showed higher syndemic severity was associated with more condom use among immigrants (OR = 1.75, p = 0.04) and less condom use (OR = 0.07, p = 0.011) among those with separated orientation. Higher syndemic severity also predicted greater odds for multiple partners (OR = 2.40, p = 0.01) among immigrants. This evidence suggests a sexual risk syndemic exists among Latina adolescents. Research should continue exploring this phenomenon, particularly exploring the role immigration plays for sexual health.

Expect With Me: development and evaluation design for an innovative model of group prenatal care to improve perinatal outcomes.

BACKGROUND: Despite biomedical advances and intervention efforts, rates of preterm birth and other adverse outcomes in the United States have remained relatively intransigent. Evidence suggests that group prenatal care can reduce these risks, with implications for maternal and child health as well as substantial cost savings. However, widespread dissemination presents challenges, in part because training and health systems have not been designed to deliver care in a group setting. This manuscript describes the design and evaluation of Expect With Me, an innovative model of group prenatal care with a strong integrated information technology (IT) platform designed to be scalable nationally. METHODS/DESIGN: Expect With Me follows clinical guidelines from the American Congress of Obstetricians and Gynecologists. Expect With Me incorporates the best evidence-based features of existing models of group care with a novel integrated IT platform designed to improve patient engagement and support, enhance health behaviors and decision making, connect providers and patients, and improve health service delivery. A multisite prospective longitudinal cohort study is being conducted to examine the impact of Expect With Me on perinatal and postpartum outcomes, and to identify and address barriers to national scalability. Process and outcome evaluation will include quantitative and qualitative data collection at patient, provider, and organizational levels. Mixed-method data collection includes patient surveys, medical record reviews, patient focus groups; provider surveys, session evaluations, provider focus groups and in-depth interviews; an online tracking system; and clinical site visits. A two-to-one matched cohort of women receiving individual care from each site will provide a comparison group (n = 1,000 Expect With Me patients; n = 2,000 individual care patients) for outcome and cost analyses. DISCUSSION: By bundling prevention and care services into a high-touch, high-tech group prenatal care model, Expect With Me has the potential to result in fundamental changes to the health care system to meet the "triple aim:" better healthcare quality, improved outcomes, and lower costs. Findings from this study will be used to optimize the dissemination and effectiveness of this model. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02169024 . Retrospectively registered on June 18, 2014.

Group Prenatal Care Attendance: Determinants and Relationship with Care Satisfaction.

Objectives Group prenatal care results in improved birth outcomes in randomized controlled trials, and better attendance at group prenatal care visits is associated with stronger clinical effects. This paper's objectives are to identify determinants of group prenatal care attendance, and to examine the association between proportion of prenatal care received in a group context and satisfaction with care. Methods We conducted a secondary data analysis of pregnant adolescents (n = 547) receiving group prenatal care in New York City (2008-2012). Multivariable linear regression models were used to test associations between patient characteristics and percent of group care sessions attended, and between the proportion of prenatal care visits that occurred in a group context and care satisfaction. Results Sixty-seven groups were established. Group sizes ranged from 3 to 15 women (mean = 8.16, SD = 3.08); 87 % of groups enrolled at least five women. Women enrolled in group prenatal care supplemented group sessions with individual care visits. However, the percent of women who attended each group session was relatively consistent, ranging from 56 to 63 %. Being born outside of the United States was significantly associated with higher group session attendance rates [B(SE) = 11.46 (3.46), p = 0.001], and women who received a higher proportion of care in groups reported higher levels of care satisfaction [B(SE) = 0.11 (0.02), p < 0.001]. Conclusions Future research should explore alternative implementation structures to improve pregnant women's ability to receive as much prenatal care as possible in a group setting, as well as value-based reimbursement models and other incentives to encourage more widespread adoption of group prenatal care.

Psychological and relational correlates of intimate partner violence profiles among pregnant adolescent couples.

We sought to identify relationship and individual psychological factors that related to four profiles of intimate partner violence (IPV) among pregnant adolescent couples: no IPV, male IPV victim only, female IPV victim only, mutual IPV, and how associations differ by sex. Using data from a longitudinal study of pregnant adolescents and partners (n = 291 couples), we used a multivariate profile analysis using multivariate analysis of covariance with between and within-subjects effects to compare IPV groups and sex on relationship and psychological factors. Analyses were conducted at the couple level, with IPV groups as a between-subjects couple level variable and sex as a within-subjects variable that allowed us to model and compare the outcomes of both partners while controlling for the correlated nature of the data. Analyses controlled for age, race, income, relationship duration, and gestational age. Among couples, 64% had no IPV; 23% male IPV victim only; 7% mutual IPV; 5% female IPV victim only. Relationship (F = 3.61, P < .001) and psychological (F = 3.17, P < .001) factors differed by IPV group, overall. Attachment anxiety, attachment avoidance, relationship equity, perceived partner infidelity, depression, stress, and hostility each differed by IPV profile (all P < .01). Attachment anxiety, equity, depression and stress had a significant IPV profile by sex interaction (all P < .05). Couples with mutual IPV had the least healthy relationship and psychological characteristics; couples with no IPV had the healthiest characteristics. Females in mutually violent relationships were at particularly high risk. Couple-level interventions focused on relational issues might protect young families from developing IPV behaviors. Aggr. Behav. 43:26-36, 2017. © 2016 Wiley Periodicals, Inc.

Cluster Randomized Controlled Trial of Group Prenatal Care: Perinatal Outcomes Among Adolescents in New York City Health Centers.

OBJECTIVES: We compared an evidence-based model of group prenatal care to traditional individual prenatal care on birth, neonatal, and reproductive health outcomes. METHODS: We performed a multisite cluster randomized controlled trial in 14 health centers in New York City (2008-2012). We analyzed 1148 pregnant women aged 14 to 21 years, at less than 24 weeks of gestation, and not at high obstetrical risk. We assessed outcomes via medical records and surveys. RESULTS: In intention-to-treat analyses, women at intervention sites were significantly less likely to have infants small for gestational age (< 10th percentile; 11.0% vs 15.8%; odds ratio = 0.66; 95% confidence interval = 0.44, 0.99). In as-treated analyses, women with more group visits had better outcomes, including small for gestational age, gestational age, birth weight, days in neonatal intensive care unit, rapid repeat pregnancy, condom use, and unprotected sex (P = .030 to < .001). There were no associated risks. CONCLUSIONS: CenteringPregnancy Plus group prenatal care resulted in more favorable birth, neonatal, and reproductive outcomes. Successful translation of clinical innovations to enhance care, improve outcomes, and reduce cost requires strategies that facilitate patient adherence and support organizational change.

Changes in experiences with discrimination across pregnancy and postpartum: age differences and consequences for mental health.

OBJECTIVES: We aimed to contribute to growing research and theory suggesting the importance of examining patterns of change over time and critical life periods to fully understand the effects of discrimination on health, with a focus on the period of pregnancy and postpartum and mental health outcomes. METHODS: We used hierarchical linear modeling to examine changes across pregnancy and postpartum in everyday discrimination and the resulting consequences for mental health among predominantly Black and Latina, socioeconomically disadvantaged young women who were receiving prenatal care in New York City. RESULTS: Patterns of change in experiences with discrimination varied according to age. Among the youngest participants, discrimination increased from the second to third trimesters and then decreased to lower than the baseline level by 1 year postpartum; among the oldest participants, discrimination decreased from the second trimester to 6 months postpartum and then returned to the baseline level by 1 year postpartum. Within-subjects changes in discrimination over time predicted changes in depressive and anxiety symptoms at subsequent points. Discrimination more strongly predicted anxiety symptoms among participants reporting food insecurity. CONCLUSIONS: Our results support a life course approach to understanding the impact of experiences with discrimination on health and when to intervene.

Housing instability and birth weight among young urban mothers.

Housing instability is an understudied social condition that may be a severe stressor during pregnancy. Aims of this study are to identify correlates of housing instability and to explore the association between housing instability and birth weight among pregnant teens and young mothers. Participants included pregnant women ages 14-21 from seven community hospitals and health centers in New York City (N = 623). Data were collected via structured surveys during the second trimester of pregnancy (14 to 24 weeks gestation, M = 19.35, SD = 3.20). Birth weight was obtained through labor and delivery logs. Housing instability was operationalized as two or more moves within the past year. More than one in four (28.5 %) pregnant teens and young women in this sample reported housing instability. Women who reported housing instability were less likely to be enrolled in school, have parents as main source of financial support, live in a single-family home or apartment, or be food secure; they were more likely to smoke (all p < 0.05). After adjusting for important clinical, behavioral, and demographic factors typically associated with lower birth weight, housing instability remained a significant predictor of lower birth weight (B (SE) = -83.96(35.47), p = 0.018). Results highlight the importance of housing stability during pregnancy for infant health. Future interventions and policies should ensure that women are housing stable before, during, and after pregnancy.

Postpartum intimate partner violence and health risks among young mothers in the United States: a prospective study.

The study assessed the relationship between postpartum intimate partner violence (IPV) and postpartum health risks among young mothers over time. Data were collected from 2001 to 2005 on young women aged 14-25 attending obstetrics and gynecology clinics in two US cities. Postpartum IPV (i.e., emotional, physical, sexual) was assessed at 6 and 12 months after childbirth (n = 734). Four types of postpartum IPV patterns were examined: emerged IPV, dissipated IPV, repeated IPV, and no IPV. Emerged IPV occurred at 12 months postpartum, not 6 months postpartum. Dissipated IPV occurred at 6 months postpartum, not 12 months postpartum. Repeated IPV was reported at 6 months and 12 months postpartum. Postpartum health risks studied at both time points were perceived stress, depression, fear of condom negotiation, condom use, infant sleeping problems, and parental stress. Repeated measures analysis of covariance was used. The proportion of young mothers reporting IPV after childbirth increased from 17.9 % at 6 months postpartum to 25.3 % at 12 months postpartum (P < 0.001). Emerged and/or repeated postpartum IPV were associated with increased perceived stress, depression, fear of condom negotiation, and infant sleeping problems as well as decreased condom use (P < 0.05). Dissipated postpartum IPV was associated with decreased depression (P < 0.05). IPV screening and prevention programs for young mothers may reduce health risks observed in this group during the postpartum period.

Perceived Stress and Depressive Symptoms Are Associated With Emotional Eating but Not Nutritional Intake During Pregnancy: A Prospective Cohort Study.

INTRODUCTION: Pregnancy is a major life event during which women may experience increased psychological distress and changes in eating behaviors. However, few studies have investigated the influence of psychological distress on pregnant women's eating behaviors. The primary objective of this prospective study was to examine the associations of changes in perceived stress and depressive symptoms with emotional eating and nutritional intake during pregnancy. In addition, we examined the direct and moderating effects of perceived social support. METHODS: Participants were racially diverse pregnant women (14-42 years) from 4 clinical sites in Detroit, MI, and Nashville, TN (N = 678). We used multiple linear and logistic regression models to determine if changes in stress and depressive symptoms across pregnancy were associated with changes in emotional eating and nutritional intake. We examined residualized change in stress and depressive symptoms from second to third trimester of pregnancy; positive residualized change scores indicated increased stress and depressive symptoms. RESULTS: Participants showed significant improvement in emotional eating and nutritional intake from second to third trimester of pregnancy (P < .001 for both). At second trimester, higher depressive symptoms were associated with a greater likelihood of emotional eating (P < .001) and worse nutritional intake (P = .044) at third trimester. Increased stress and depressive symptoms during pregnancy were both associated with increased risk, whereas increased perceived social support reduced risk of emotional eating at third trimester (stress: adjusted odds ratio [AOR], 1.17; 95% CI, 1.08-1.26; depressive symptoms: AOR, 1.05; 95% CI, 1.01-1.08; social support: AOR, 0.93; 95% CI, 0.88-0.99). None were associated with changes in nutritional intake. Perceived social support did not show any moderating effects. DISCUSSION: Increased psychological distress during pregnancy may increase emotional eating. Efforts to promote healthy eating behaviors among pregnant women should consider and address mental health.

Discrimination and perinatal depressive symptoms: The protective role of social support and resilience.

BACKGROUND: Discrimination is an important social determinant of perinatal depression; however, evidence is limited regarding modifiable social and psychological factors that may moderate this association. We examined whether social support and resilience could protect against the adverse effects of discrimination on perinatal depressive symptoms. METHODS: Pregnant people (N = 589) receiving Expect With Me group prenatal care in Nashville, TN and Detroit, MI completed surveys during third trimester of pregnancy and six months postpartum. Linear regression models tested the association between discrimination and depressive symptoms, and the moderating effects of social support and resilience, during pregnancy and postpartum. RESULTS: The sample was predominantly Black (60.6 %), Hispanic (15.8 %) and publicly insured (71 %). In multivariable analyses, discrimination was positively associated with depressive symptoms during pregnancy (B = 4.44, SE = 0.37, p ≤0.001) and postpartum (B = 3.78, SE = 0.36, p < 0.001). Higher social support and resilience were associated with less depressive symptoms during pregnancy (B = -0.49, SE = 0.08, p < 0.001 and B = -0.67, SE = 0.10, p < 0.001, respectively) and postpartum (B = -0.32, SE = 0.07, p < 0.001 and B = -0.56, SE = 0.08, p < 0.001, respectively). Social support was protective against discrimination (pregnancy interaction B = -0.23, SE = 0.09, p = 0.011; postpartum interaction B = -0.35, SE = 0.07, p < 0.001). There was no interaction between discrimination and resilience at either time. LIMITATIONS: The study relied on self-reported measures and only included pregnant people who received group prenatal care in two urban regions, limiting generalizability. CONCLUSIONS: Social support and resilience may protect against perinatal depressive symptoms. Social support may also buffer the adverse effects of discrimination on perinatal depressive symptoms, particularly during the postpartum period.

Group prenatal care successes, challenges, and frameworks for scaling up: a case study in adopting health care innovations.

BACKGROUND: Group prenatal care enhances quality of care, improves outcomes, and lowers costs. However, this healthcare innovation is not widely available. Using a case-study approach, our objectives were to (1) examine organizational characteristics that support implementation of Expect With Me group prenatal care and (2) identify key factors influencing adoption and sustainability. METHODS: We studied five clinical sites implementing group prenatal care, collecting qualitative data including focus group discussions with clinicians (n = 4 focus groups, 41 clinicians), key informant interviews (n = 9), and administrative data. We utilized a comparative qualitative case-study approach to characterize clinical sites and explain organizational traits that fostered implementation success. We characterized adopting and non-adopting (unable to sustain group prenatal care) sites in terms of fit for five criteria specified in the Framework for Transformational Change: (1) impetus to transform, (2) leadership commitment to quality, (3) improvement initiatives that engage staff, (4) alignment to achieve organization-wide goals, and (5) integration. RESULTS: Two sites were classified as adopters and three as non-adopters based on duration, frequency, and consistency of group prenatal care implementation. Adopters had better fit with the five criteria for transformational change. Adopting organizations were more successful implementing group prenatal care due to alignment between organizational goals and resources, dedicated healthcare providers coordinating group care, space for group prenatal care sessions, and strong commitment from organization leadership. CONCLUSIONS: Adopting sites were more likely to integrate group prenatal care when stakeholders achieved alignment across staff on organizational change goals, leadership buy-in, and committed institutional support and dedicated resources to sustain it. TRIAL REGISTRATION: The Expect With Me intervention's design and hypotheses were preregistered: https://clinicaltrials.gov/study/NCT02169024 . Date: June 19, 2014.

Maternal experiences with everyday discrimination and infant birth weight: a test of mediators and moderators among young, urban women of color.

BACKGROUND: Racial/ethnic disparities in birth weight persist within the USA. PURPOSE: The purpose of this study is to examine the association between maternal everyday discrimination and infant birth weight among young, urban women of color as well as mediators (depressive symptoms, pregnancy distress, and pregnancy symptoms) and moderators (age, race/ethnicity, and attributions of discrimination) of this association. METHODS: A total of 420 women participated (14-21 years old; 62 % Latina, 38 % Black), completing measures of everyday discrimination and moderators during their second trimester of pregnancy and mediators during their third trimester. Birth weight was primarily recorded from medical record review. RESULTS: Path analysis demonstrated that everyday discrimination was associated with lower birth weight. Depressive symptoms mediated this relationship, and no tested factors moderated this relationship. CONCLUSIONS: Given the association between birth weight and health across the lifespan, it is critical to reduce discrimination directed at young, urban women of color so that all children can begin life with greater promise for health.