Maternal opioid use disorder and infant mortality in Wisconsin, United States, 2010-2018.

OBJECTIVE: The difference in infant health outcomes by maternal opioid use disorder (OUD) status is understudied. We measured the association between maternal OUD during pregnancy and infant mortality and investigated whether this association differs by infant neonatal opioid withdrawal syndrome (NOWS) or maternal receipt of medication for OUD (MOUD) during pregnancy. METHODS: We sampled 204,543 Medicaid-paid births from Wisconsin, United States (2010-2018). The primary exposure was any maternal OUD during pregnancy. We also stratified this exposure on NOWS diagnosis (no OUD; OUD without NOWS; OUD with NOWS) and on maternal MOUD receipt (no OUD; OUD without MOUD; OUD with <90 consecutive days of MOUD; OUD with 90+ consecutive days of MOUD). Our outcome was infant mortality (death at age <365 days). Demographic-adjusted logistic regressions measured associations with odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Maternal OUD was associated with increased odds of infant mortality (OR 1.43; 95% CI 1.02-2.02). After excluding infants who died <5 days post-birth (i.e., before the clinical presentation of NOWS), regression estimates of infant mortality did not significantly differ by NOWS diagnosis. Likewise, regression estimates did not significantly differ by maternal MOUD receipt in the full sample. CONCLUSIONS: Maternal OUD is associated with an elevated risk of infant mortality without evidence of modification by NOWS nor by maternal MOUD treatment. Future research should investigate potential mechanisms linking maternal OUD, NOWS, MOUD treatment, and infant mortality to better inform clinical intervention.

Spillover Effects of Prenatal Care Coordination on Older Siblings Beyond the Mother-Infant Dyad.

BACKGROUND: Pregnancy care coordination increases preventive care receipt for mothers and infants. Whether such services affect other family members' health care is unknown. OBJECTIVE: To estimate the spillover effect of maternal exposure to Wisconsin Medicaid's Prenatal Care Coordination (PNCC) program during pregnancy with a younger sibling on the preventive care receipt for an older child. RESEARCH DESIGN: Gain-score regressions-a sibling fixed effects strategy-estimated spillover effects while controlling for unobserved family-level confounders. SUBJECTS: Data came from a longitudinal cohort of linked Wisconsin birth records and Medicaid claims. We sampled 21,332 sibling pairs (one older; one younger) who were born during 2008-2015, who were <4 years apart in age, and whose births were Medicaid-covered. In all, 4773 (22.4%) mothers received PNCC during pregnancy with the younger sibling. MEASURES: The exposure was maternal PNCC receipt during pregnancy with the younger sibling (none; any). The outcome was the older sibling's number of preventive care visits or preventive care services in the younger sibling's first year of life. RESULTS: Overall, maternal exposure to PNCC during pregnancy with the younger sibling did not affect older siblings' preventive care. However, among siblings who were 3 to <4 years apart in age, there was a positive spillover on the older sibling's receipt of care by 0.26 visits (95% CI: 0.11, 0.40 visits) and by 0.34 services (95% CI: 0.12, 0.55 services). CONCLUSION: PNCC may only have spillover effects on siblings' preventive care in selected subpopulations but not in the broader population of Wisconsin families.

Serum Cotinine and Adverse Cardiovascular Outcomes: A Cross-sectional Secondary Analysis of the nuMoM2b Heart Health Study.

OBJECTIVE: We aimed to (1) compare serum cotinine with self-report for ascertaining smoking status among reproductive-aged women; (2) estimate the relative odds of adverse cardiovascular (CV) outcomes among women by smoking status; (3) assess whether the association between adverse pregnancy outcomes (APOs) and CV outcomes varies by smoking status. STUDY DESIGN: We conducted a cross-sectional study of the nuMoM2b Heart Health Study. Women attended a study visit 2 to 7 years after their first pregnancy. The exposure was smoking status, determined by self-report and by serum cotinine. Outcomes included incident chronic hypertension (HTN), metabolic syndrome (MetS), and dyslipidemia. Multivariable logistic regression estimated odds ratios (ORs) for each outcome by smoking status. RESULTS: Of 4,392 women with serum cotinine measured, 3,610 were categorized as nonsmokers, 62 as secondhand smoke exposure, and 720 as smokers. Of 3,144 women who denied tobacco smoke exposure, serum cotinine was consistent with secondhand smoke exposure in 48 (1.5%) and current smoking in 131 (4.2%) After adjustment for APOs, smoking defined by serum cotinine was associated with MetS (adjusted OR [aOR] = 1.52, 95% confidence interval [CI]: 1.21, 1.91) and dyslipidemia (aOR = 1.28, 95% CI: 1.01, 1.62). When stratified by nicotine exposure, nonsmokers with an APO in their index pregnancy had higher odds of stage 1 (aOR = 1.64, 95% CI: 1.32, 2.03) and stage 2 HTN (aOR = 2.92, 95% CI: 2.17, 3.93), MetS (aOR = 1.76, 95% CI: 1.42, 2.18), and dyslipidemia (aOR = 1.55, 95% CI: 1.25, 1.91) relative to women with no APO. Results were similar when smoking exposure was defined by self-report. CONCLUSION: Whether determined by serum cotinine or self-report, smoking is associated with subsequent CV outcomes in reproductive-aged women. APOs are also independently associated with CV outcomes in women. KEY POINTS: · Cotinine was detected in 5.7% of reported nonsmokers.. · Smoking and APOs were independently associated with CV health.. · Smoking was associated with MetS and dyslipidemia..

Factors Influencing Provider Behavior Around Delivery of Preconception Care.

OBJECTIVE: Despite growing consensus about the clinical value of preconception care (PCC), gaps and disparities remain in its delivery. This study aimed to examine the factors influencing behavior of health care providers around PCC in outpatient clinical settings in the United States. METHODS: Twenty health care providers who serve people of reproductive age were interviewed using semi-structured interviews. Data was coded based on a modified Theoretical Domains Framework and analyzed using deductive content analysis. RESULTS: We interviewed eight family medicine physicians, four obstetricians/gynecologists, seven nurse practitioners, and one nurse midwife. Overall, we found a wide variety in practices and attitudes towards PCC. Barriers and challenges to delivering PCC were shared across sites. We identified six themes that influenced provider behavior around PCC: (1) lack of knowledge of PCC guidelines, (2) perception of lack of preconception patient contact, (3) pessimism around patient "compliance," (4) opinion about scope of practice, (5) clinical site structure, and (6) reliance on the patient/provider relationship. CONCLUSIONS FOR PRACTICE: Overall, our findings call for improved provider understanding of PCC and creative incorporation into current health care culture and practice. Given that PCC-specific visits are perceived by some as outside the norm of clinical offerings, providers may need to incorporate PCC into other encounters, as many in this study reported doing. We amplify the call for providers to understand how structural inequities may influence patient behavior and the value of standardized screening, within and beyond PCC, as well as examination of implicit and explicit provider bias.

Birth outcomes affecting infants of mothers with intellectual and developmental disabilities.

BACKGROUND: Women with intellectual and developmental disabilities (IDD) face increased risk of adverse maternal pregnancy outcomes, yet less is known about infant outcomes. OBJECTIVES: To examine birth outcomes of infants born to mothers with IDD and assess associations with demographics and IDD-type. METHODS: We used data from the Big Data for Little Kids project, which links Wisconsin birth records to Medicaid claims for live births covered by Medicaid from 2007 to 2016. We identified IDD using maternal prepregnancy Medicaid claims and ran Poisson regression (with a log link function) with robust variance clustered by mother to compare prevalence of outcomes between singleton births with and without mothers with IDD. We adjusted the associations for demographic factors and estimated prevalence ratios (PR) as the effect measure. We assessed outcomes by IDD-type (intellectual disability, genetic conditions, cerebral palsy, and autism spectrum disorder) to explore differences by categories of IDD. RESULTS: Of 267,395 infants, 1696 (0.6%) had mothers with IDD. A greater percentage of infants with mothers with IDD were born preterm (12.8% vs 7.8%; PR 1.64, 95% confidence interval [CI] 1.42, 1.89), small for gestational age (8.5% vs 5.4%; PR 1.42, 95% CI 1.25, 1.61), and died within 12 months of birth (3.2% vs 0.7%; PR 4.93, 95% CI 3.73, 6.43) compared to infants of mothers without IDD. Prevalence ratios were robust to adjustment for demographics factors. Estimates did not meaningfully differ when comparing different IDD-types. CONCLUSIONS: A greater porportion of infants born to mothers with IDD who were covered by Medicaid had poor outcomes compared to other infants. Prevalence of poor infant outcomes was greater for mothers with IDD even after accounting for demographic differences. It is imperative to understand why infants of mothers with IDD are at greater risk so interventions and management can be developed.

The Association Between Exposure to Maternal Depression During Year 2 of a Child's Life and Future Child Problem Behavior.

INTRODUCTION: We examined the association of exposure to maternal depression during year 2 of a child's life with future child problem behavior. We conducted a secondary analysis to investigate whether race/ethnicity is a moderator of this relationship. METHODS: We used Fragile Families and Child Well-Being Study data (age 3 N = 3288 and 49% Black, 26% Hispanic, 22% non-Hispanic White; age 5 N = 3001 and 51% Black, 25% Hispanic, 21% non-Hispanic White; age 9 N = 3630 and 50% Black, 25% Hispanic, 21% non-Hispanic White) and ordinal logistic regression to model problem behavior at ages 3, 5, and 9 on maternal depression status during year 2. RESULTS: At age 9, children whose mother was depressed during year 2 were significantly more likely to have higher internalizing (AOR = 1.92, 95% CI: 1.42,2.61) and externalizing (AOR = 1.65, 95% CI: 1.10,2.48) problem behavior scores. In our secondary analysis, race/ethnicity did not have moderating effects, potentially due to a limitation of the data that required use of maternal self-reported race/ethnicity as a proxy for child race/ethnicity. DISCUSSION: Exposure to maternal depression after the prenatal and perinatal periods may have a negative association with children's behavioral development through age 9. Interventions that directly target maternal depression during this time should be developed. Additional research is needed to further elucidate the role of race/ethnicity in the relationship between maternal depression and child problem behavior.

Associations of perceived prenatal stress and adverse pregnancy outcomes with perceived stress years after delivery.

Maternal stress is a risk factor for adverse pregnancy outcomes (APOs). This study evaluates the associations of prenatal stress and APOs with maternal stress years after pregnancy. The 10-item Perceived Stress Scale (PSS) (0-40 range) was completed in the first and third trimesters, and 2-7 years after delivery among a subsample (n = 4161) of nulliparous women enrolled at eight US medical centers between 2010 and 2013 in a prospective, observational cohort study. Demographics, medical history, and presence of APOs (gestational diabetes (GDM), hypertensive disorders of pregnancy (HDP), preeclampsia (PE), and medically indicated or spontaneous preterm birth (miPTB, sPTB)) were obtained. The associations of prenatal PSS and the presence of APOs with PSS scores years after delivery were estimated using multivariable linear regression. Mean PSS scores were 12.5 (95% CI 12.3, 12.7) and 11.3 (95% CI 11.1, 11.5) in the first and third trimesters respectively and 14.9 (95% CI 14.7, 15.1) 2-7 years later, an average increase of 2.4 points (95% CI 2.2, 2.6) from the start of pregnancy. Regressing PSS scores after delivery on first-trimester PSS and PSS increase through pregnancy showed positive associations, with coefficients (95% CI) of 2.8 (2.7, 3.0) and 1.5 (1.3, 1.7) per 5-point change, respectively. Adding APO indicator variables separately showed higher PSS scores for women with HDP (0.7 [0.1, 1.3]), PE (1.3 [0.6, 2.1]), and miPTB (1.3 [0.2, 2.4]), but not those with GDM or sPTB. In this geographically and demographically diverse sample, prenatal stress and some APOs were positively associated with stress levels 2-7 years after pregnancy.ClinicalTrials.gov Registration number NCT02231398.

Food Insecurity and Housing Instability Partially Mediate the Association Between Maternal Depression and Child Problem Behavior.

Maternal depression is a risk factor for the development of problem behavior in children. Although food insecurity and housing instability are associated with adult depression and child behavior, how these economic factors mediate or moderate the relationship between maternal depression and child problem behavior is not understood. The purpose of this study was to determine whether food insecurity and housing instability are mediators and/or moderators of the relationship between maternal depression when children are age 3 and children's problem behaviors at age 9 and to determine whether these mechanisms differ by race/ethnicity. We used data from the Fragile Families and Child Wellbeing Study. Food insecurity and housing instability at age 5 were tested as potential mediators and moderators of the relationship between maternal depression status at age 3 and problem behavior at age 9. A path analysis confirmed our hypothesis that food insecurity and housing instability partially mediate the relationship between maternal depression when children are age 3 and problem behavior at age 9. However, housing instability was only a mediator for externalizing problem behavior and not internalizing problem behavior or overall problem behavior. Results of the moderation analysis suggest that neither food insecurity nor housing instability were moderators. None of the mechanisms explored differed by race/ethnicity. While our findings stress the continued need for interventions that address child food insecurity, they emphasize the importance of interventions that address maternal mental health throughout a child's life. Given the central role of maternal health in child development, additional efforts should be made to target maternal depression.

Gestational age, kindergarten-level literacy, and effect modification by maternal socio-economic and demographic factors.

BACKGROUND: Shorter gestational age at birth is associated with worse academic performance in childhood. Socio-economic and demographic factors that affect a child's development may modify the relationship between gestational age and later academic performance. OBJECTIVE: The purpose of this study was to investigate socio-economic and demographic effect modification of gestational age's association with kindergarten-level literacy skills in a longitudinal Wisconsin birth cohort. METHODS: We sampled 153 145 singleton births (2007-2010) that linked to Phonological Awareness Literacy Screening-Kindergarten (PALS-K) scores (2012-2016 school years). PALS-K outcomes included meeting the screening benchmark (≥28 points, range 0-102 points) and the standardised score. Multivariable linear regressions of PALS-K outcomes on gestational age (completed weeks) included individual interactions for five maternal attributes measured at delivery: Medicaid coverage, education, age, race/ethnicity, and marital status. RESULTS: Each additional completed gestational week was associated with a 0.5 percentage point increase in the probability of meeting the PALS-K literacy benchmark. The benefit of an additional week of gestational age was 0.5 percentage points (95% confidence interval 0.3, 0.7 percentage points) greater for Medicaid-covered births (0.8 percentage points) relative to non-Medicaid births (0.3 percentage points). Relative to only completing high school, having college education weakened this association by 0.3-0.6 percentage points, depending on years in college. Similar but modest relations emerged with standardised scores. CONCLUSIONS: Socio-economic advantage as indicated by non-Medicaid coverage or higher levels of completed maternal education may diminish the cost of preterm birth on a child's kindergarten-level literacy skills.

The Preconception Period analysis of Risks and Exposures Influencing health and Development (PrePARED) consortium.

BACKGROUND: Preconception health may have intergenerational influences. We have formed the PrePARED (Preconception Period Analysis of Risks and Exposures influencing health and Development) research consortium to address methodological, conceptual, and generalisability gaps in the literature. OBJECTIVES: The consortium will investigate the effects of preconception exposures on four sets of outcomes: (1) fertility and miscarriage; (2) pregnancy-related conditions; (3) perinatal and child health; and (4) adult health outcomes. POPULATION: A study is eligible if it has data measured for at least one preconception time point, has a minimum of selected core data, and is open to collaboration and data harmonisation. DESIGN: The included studies are a mix of studies following women or couples intending to conceive, general-health cohorts that cover the reproductive years, and pregnancy/child cohort studies that have been linked with preconception data. The majority of the participating studies are prospective cohorts, but a few are clinical trials or record linkages. METHODS: Data analysis will begin with harmonisation of data collected across cohorts. Initial areas of interest include nutrition and obesity; tobacco, marijuana, and other substance use; and cardiovascular risk factors. PRELIMINARY RESULTS: Twenty-three cohorts with data on almost 200 000 women have combined to form this consortium, begun in 2018. Twelve studies are of women or couples actively planning pregnancy, and six are general-population cohorts that cover the reproductive years; the remainder have some other design. The primary focus for four was cardiovascular health, eight was fertility, one was environmental exposures, three was child health, and the remainder general women's health. Among other cohorts assessed for inclusion, the most common reason for ineligibility was lack of prospectively collected preconception data. CONCLUSIONS: The consortium will serve as a resource for research in many subject areas related to preconception health, with implications for science, practice, and policy.

Poverty, urban-rural classification and term infant mortality: a population-based multilevel analysis.

BACKGROUND: U.S. mortality rate of term infants is higher than most other developed countries. Term infant mortality is associated with exogenous socio-environmental factors. Previous research links low socioeconomic status and rurality with high infant mortality, but does not examine the effect of individual level factors on this association. Separating out the effect of contextual factors from individual level factors has important implications for targeting interventions. Therefore, we aim to estimate the independent effect of poverty and urban-rural classification on term infant mortality. METHODS: We used linked 2013 period cohort birth-infant death files from the National Center for Health Statistics (NCHS). Counties were assigned to low, medium and high poverty groups using US Census Bureau county-level percent of children ≤18 years living in poverty, and were classified based on NCHS urban-rural classification. Bivariate and multilevel logistic regression models were used to estimate odds of term infant death, accounting for individual and county level variables. RESULTS: There were 2,551,828 term births in 2013, with an overall term mortality of 2.1 per 1000 births. Odds of term infant mortality increased from 1.4 (95% CI: 1.2, 1.6) to 1.8 (95% CI: 1.6, 2.0) comparing births over increasing county poverty to those in the lowest. The associations remained significant in the multivariable model, for highest poverty 1.3 (95% CI: 1.1, 1.5). Similarly, the odds of term infant mortality increased with increasing rurality, from 1.3 (95% CI: 1.2, 1.5) in medium metro counties to 1.7 (95% CI: 1.5, 2.0) in non-core counties compared to large fringe metro counties. However, only rural non-core counties remained statistically associated with increased risk of term infant mortality after adjusting for individual level maternal characteristics. CONCLUSIONS: High poverty and very rural counties remained associated with term infant mortality independent of individual maternal sociodemographic, health and obstetric factors. Interventions should focus on contextual factors such as economic environment and availability of health and social services in addition to individual factors to reduce term infant mortality.

Variable Uptake of Medicaid-Covered Prenatal Care Coordination: The Relevance of Treatment Level and Service Context.

Prenatal care coordination programs direct pregnant Medicaid beneficiaries to medical, social, and educational services to improve birth outcomes. Despite the relevance of service context and treatment level to investigations of program implementation and estimates of program effect, prior investigations have not consistently attended to these factors. This study examines the reach and uptake of Wisconsin's Prenatal Care Coordination (PNCC) program among Medicaid-covered, residence occurrence live births between 2008 and 2012. Data come from the Big Data for Little Kids project, which harmonizes birth records with multiple state administrative sources. Logistic regression analyses measured the association between county- and maternal-level factors and the odds of any PNCC use and the odds of PNCC uptake (> 2 PNCC services among those assessed). Among identified Medicaid-covered births (n = 136,057), approximately 24% (n = 33,249) received any PNCC and 17% (n = 22,680) took up PNCC services. Any PNCC receipt and PNCC uptake varied substantially across counties. A higher county assessment rate was associated with a higher odds of individual PNCC assessment but negatively associated with uptake. Mothers reporting clinical risk factors such as chronic hypertension and previous preterm birth were more likely to be assessed for PNCC and, once assessed, more likely to received continued PNCC services. However, most mothers reporting clinical risk factors were not assessed for services. Estimates of care coordination's effects on birth outcomes should account for service context and the treatment level into which participants select.

Patterns of leisure-time physical activity across pregnancy and adverse pregnancy outcomes.

BACKGROUND: Although leisure-time physical activity (PA) contributes to overall health, including pregnancy health, patterns across pregnancy have not been related to birth outcomes. We hypothesized that women with sustained low leisure-time PA would have excess risk of adverse pregnancy outcomes, and that changing patterns across pregnancy (high to low and low to high) may also be related to risk of adverse pregnancy outcomes. METHODS: Nulliparous women (n = 10,038) were enrolled at 8 centers early in pregnancy (mean gestational age in weeks [SD] = 12.05 [1.51]. Frequency, duration, and intensity (metabolic equivalents) of up to three leisure activities reported in the first, second and third trimesters were analyzed. Growth mixture modeling was used to identify leisure-time PA patterns across pregnancy. Adverse pregnancy outcomes (preterm birth, [PTB, overall and spontaneous], hypertensive disorders of pregnancy [HDP], gestational diabetes [GDM] and small-for-gestational-age births [SGA]) were assessed via chart abstraction. RESULTS: Five patterns of leisure-time PA across pregnancy were identified: High (35%), low (18%), late decreasing (24%), early decreasing (10%), and early increasing (13%). Women with sustained low leisure-time PA were younger and more likely to be black or Hispanic, obese, or to have smoked prior to pregnancy. Women with low vs. high leisure-time PA patterns had higher rates of PTB (10.4 vs. 7.5), HDP (13.9 vs. 11.4), and GDM (5.7 vs. 3.1, all p < 0.05). After adjusting for maternal factors (age, race/ethnicity, BMI and smoking), the risk of GDM (Odds ratio 2.00 [95% CI 1.47, 2.73]) remained higher in women with low compared to high patterns. Early and late decreasing leisure-time PA patterns were also associated with higher rates of GDM. In contrast, women with early increasing patterns had rates of GDM similar to the group with high leisure-time PA (3.8% vs. 3.1%, adjusted OR 1.16 [0.81, 1.68]). Adjusted risk of overall PTB (1.31 [1.05, 1.63]) was higher in the low pattern group, but spontaneous PTB, HDP and SGA were not associated with leisure-time PA patterns. CONCLUSIONS: Sustained low leisure-time PA across pregnancy is associated with excess risk of GDM and overall PTB compared to high patterns in nulliparous women. Women with increased leisure-time PA early in pregnancy had low rates of GDM that were similar to women with high patterns, raising the possibility that early pregnancy increases in activity may be associated with improved pregnancy health. TRIAL REGISTRATION: Registration number NCT02231398 .

Health Care Barriers to Provision of Long-Acting Reversible Contraception in Wisconsin.

INTRODUCTION: Long-acting reversible contraceptives (LARC), specifically implants and intrauterine devices (IUD), are highly effective, low maintenance forms of birth control. Practice guidelines from the American College of Obstetricians and Gynecologists, American Academy of Family Physicians, and American Academy of Pediatrics recommend that LARC be considered first-line birth control for most women; however, uptake remains low. In this study, we sought to understand practices and barriers to provision of LARC in routine and immediate postpartum settings as they differ between specialties. METHODS: We surveyed 3,000 Wisconsin physicians and advanced-practice providers in obstetrics-gynecology/women's health (Ob-gyn), family medicine, pediatrics, and midwifery to assess practices and barriers (56.5% response rate). This analysis is comprised of contraceptive care providers (n=992); statistical significance was tested using chi-square and 2-sample proportions tests. RESULTS: More providers working Ob-gyn (94.3%) and midwifery (78.7%) were skilled providers of LARC methods than those in family medicine (42.5%) and pediatrics (6.6%) (P < .0001). Lack of insertion skill was the most-cited barrier to routine provision among family medicine (31.1%) and pediatric (72.1%) providers. Among prenatal/delivery providers, over 50% across all specialties reported lack of device availability on-site as a barrier to immediate postpartum LARC provision; organizational practices also were commonly reported barriers. CONCLUSIONS: Gaps in routine and immediate postpartum LARC practice were strongly related to specialty, and providers' experience heightened barriers to immediate postpartum compared to routine insertion. Skills training targeting family medicine and pediatric providers would enable broader access to LARC. Organizational barriers to immediate postpartum LARC provision impact many providers.

Pregnancy as a Window to Future Cardiovascular Health: Design and Implementation of the nuMoM2b Heart Health Study.

The National Institute of Child Health and Human Development's Nulliparous Pregnancy Outcomes Study-Monitoring Mothers-to-Be (nuMoM2b) Heart Health Study (HHS) was designed to investigate the relationships between adverse pregnancy outcomes and modifiable risk factors for cardiovascular disease. The ongoing nuMoM2b-HHS, which started in 2013, is a prospective follow-up of the nuMoM2b cohort, which included 10,038 women recruited between 2010 and 2013 from 8 centers across the United States who were initially observed over the course of their first pregnancies. In this report, we detail the design and study procedures of the nuMoM2b-HHS. Women in the pregnancy cohort who consented to be contacted for participation in future studies were approached at 6-month intervals to ascertain health information and to maintain ongoing contact. Two to 5 years after completion of the pregnancy documented in the nuMoM2b, women in the nuMoM2b-HHS were invited to an in-person study visit. During this visit, they completed psychosocial and medical history questionnaires and had clinical measurements and biological specimens obtained. A subcohort of participants who had objective assessments of sleep-disordered breathing during pregnancy were asked to repeat this investigation. This unique prospective observational study includes a large, geographically and ethnically diverse cohort, rich depth of phenotypic information about adverse pregnancy outcomes, and clinical data and biospecimens from early in the index pregnancy onward. Data obtained from this cohort will provide mechanistic and clinical insights into how data on a first pregnancy can provide information about the potential development of subsequent risk factors for cardiovascular disease.

Surveillance of ventricular septal defects in Delaware.

BACKGROUND: The prevalence of ventricular septal defects (VSDs), a birth defect in which there is an opening in the wall that separates the left and right ventricles of the heart, seemed to be substantially higher in Delaware compared with the National Birth Defects Prevention Network (NBDPN). The Delaware Birth Defects Registry (BDR) noted their high prevalence of VSDs in comparison with other states. METHODS: A subset of children with a VSD born in 2007 through 2010 was identified from the complete reportable statewide defect list that the BDR creates each year. VSDs were categorized by type of VSD (muscular, perimembranous, conotruncal, or atrioventricular septal defect), by either isolated or complex, and then by spontaneously closed, surgically closed, open but clinically insignificant, lost to follow-up, fetal or neonatal death. RESULTS: The BDR team found a prevalence of VSD of 83.4 per 10,000 including fetal/neonatal deaths. Excluding fetal and neonatal deaths the prevalence was 78.7 per 10,000 live births. Excluding small muscular VSDs, the prevalence in Delaware falls to 25.7 per 10,000. CONCLUSION: The BDR team chose to include all babies with all types of VSDs. Using these criteria Delaware's prevalence of 78.7 was higher than that reported by other states (whose prevalence ranges from 1.6 to 70.0 per 10,000 live births) (National Birth Defects Prevention Network, ). Delaware's prevalence is similar to other states when small muscular VSDs are excluded. Birth Defects Research (Part A) 106:888-893, 2016. © 2016 Wiley Periodicals, Inc.

The impact of psychosocial stressors on postpartum weight retention.

Excessive gestational weight gain and postpartum weight retention are implicated in future morbidity in women. To understand whether psychosocial stressors contribute to weight retention, we used data collected in a cohort of postpartum women and analyzed measures of stress, depression, social support, and health-related quality of life. Depressive symptoms at delivery and worse health-related quality of life and lower stress at 3 months postpartum were associated with 3-month weight retention. Interventions targeting depression and improving quality of life may further reduce weight retained.

Differences in the Protective Effect of Exclusive Breastfeeding on Child Overweight and Obesity by Mother's Race.

Objectives To examine the relationship between infant feeding and risk of child overweight and obesity across race and ethnicity in a diverse community-based cohort. Methods 2172 mother baby dyads were drawn from a prospective cohort constructed using data from electronic medical records linked to birth records. The primary exposure was exclusive breastfeeding at 2 months of age; outcome was BMI Z-score and BMI ≥ 85th percentile (overweight and obese) at 4 years of age. Regression models were adjusted for confounding using covariance balanced propensity score and inverse probability weighting. Results At age 4, exclusively breast fed children had lower BMI Z-score (-0.109, SE = 0.048) and a decreased odds of a BMI ≥ 85th percentile (0.832; 95 % CI 0.792, 0.994), when compared to those exclusively formula-fed or had mixed feeding. Race and ethnicity significantly moderated these associations. Sub-population analysis showed the effect was significant for BMI Z-score (p = 0.0002) and BMI ≥ 85th percentile (p < 0.0001) only for children of NH white mothers. For children of NH black mothers exclusive breastfeeding was not associated with a significant difference in BMI Z-score, however there was an increased odds of overweight or obesity (p = 0.0145). Conclusions The protective effect of breastfeeding against early childhood overweight and obesity may differ by race and ethnicity. This suggests that programs aiming to reduce obesity by increasing rates of breastfeeding may have limited impact for some groups and should be coupled with other racially and ethnically focused efforts to encourage healthy feeding practices in infancy and early childhood.

Preventive Effects on Birth Outcomes: Buffering Impact of Maternal Stress, Depression, and Anxiety.

OBJECTIVE: Although maternal stress, anxiety, and depression have been linked to negative birth outcomes, few studies have investigated preventive interventions targeting maternal mental health as a means of reducing such problems. This randomized controlled study examines whether Family Foundations (FF)-a transition to parenthood program for couples focused on promoting coparenting quality, with previously documented impact on maternal stress, depression, and anxiety-can buffer the negative effects of maternal mental health problems. METHODS: To assess the effects of FF, we used a randomized block design with a sample of 259 expectant mothers assigned to FF or a control condition and analyzed using propensity score models. We examine two-way interactions of condition (intervention vs. control) with maternal mental health problems (financial stress, depression, and anxiety) on birth outcomes (birth weight, days in hospital for mothers and infants). For birth weight, we assess whether intervention effects depend on length of gestation by including a third interaction term. RESULTS: FF buffered (p < 0.05) the negative impact of maternal mental health problems on birth weight and both mother and infant length of post-partum hospital stay. For birth weight, assignment to FF was associated with higher birth weight for infants born before term. CONCLUSIONS: These results demonstrate that a psycho-educational program for couples focused on enhancing mutual coparental support, with preventive effects on maternal mental health, can reduce incidence of birth problems among women at elevated risk. Such improvements in birth outcomes could translate into substantial reductions in public and personal healthcare costs. Future work should assess mediating mechanisms of intervention impact and cost-benefit ratio of the intervention. CLINICAL TRIALS REGISTRATION: The Family Foundations follow-up intervention study is currently registered with www.clinicaltrials.gov . The study identifier is NCT01907412.

Couple-Focused Prevention at the Transition to Parenthood, a Randomized Trial: Effects on Coparenting, Parenting, Family Violence, and Parent and Child Adjustment.

The transition to parenthood is a stressful period for most parents as individuals and as couples, with variability in parent mental health and couple relationship functioning linked to children's long-term emotional, mental health, and academic outcomes. Few couple-focused prevention programs targeting this period have been shown to be effective. The purpose of this study was to test the short-term efficacy of a brief, universal, transition-to-parenthood intervention (Family Foundations) and report the results of this randomized trial at 10 months postpartum. This was a randomized controlled trial; 399 couples expecting their first child were randomly assigned to intervention or control conditions after pretest. Intervention couples received a manualized nine-session (five prenatal and four postnatal classes) psychoeducational program delivered in small groups. Intent-to-treat analyses indicated that intervention couples demonstrated better posttest levels than control couples on more than two thirds of measures of coparenting, parent mental health, parenting, child adjustment, and family violence. Program effects on family violence were particularly large. Of eight outcome variables that did not demonstrate main effects, seven showed moderated intervention impact; such that, intervention couples at higher levels of risk during pregnancy showed better outcomes than control couples at similar levels of risk. These findings replicate a prior smaller study of Family Foundations, indicating that the Family Foundations approach to supporting couples making the transition to parenthood can have broad impact for parents, family relationships, and children's adjustment. Program effects are consistent and benefit all families, with particularly notable effects for families at elevated prenatal risk.