Unmet healthcare needs among midlife adults with mental distress and multiple chronic conditions.

BACKGROUND: Limited attention has focused on midlife health. Yet, this is a time of great change, including onset of chronic conditions and changes in mental health. OBJECTIVE: To examine unmet healthcare needs among midlife adults (50-64 years) in the US with severe psychological distress (SPD) and/or multiple chronic conditions (MCC). METHODS: Nationally representative data for midlife adults (50-64 years) from NHIS 2014-2018 were examined (n = 39,329). Multimorbidity status: no MCC/SPD, MCC alone, SPD alone, or both. We used logistic regression to estimate adjusted odds ratios (AOR) of delayed or foregone care by multimorbidity status. RESULTS: Nearly 40% of midlife adults had MCC, SPD, or SPD/MCC. SPD with or without MCC had higher prevalence of social disadvantage, fair/poor health, activity limitations, and delayed/foregone healthcare. Compared to those with neither, adults with SPD/MCC were more likely to delay care due to limited office hours (AOR = 4.2, 95% CI 3.1-5.5) and had nearly three to four times higher odds of delays for all other reasons. Those with SPD/MCC had higher odds of needing but not getting mental healthcare (AOR = 6.4, 95% CI 4.5-9.1), prescriptions (AOR = 4.8, 95% CI 3.9-5.9), or follow-up care (AOR = 5.0, 95% CI 3.7-6.6), and three to four times higher odds of all other types of foregone care. CONCLUSIONS: Midlife adults with SPD/MCC have substantial unmet healthcare needs. Midlife is a critical time to manage both chronic conditions and mental illness. Coordinated efforts by policymakers and healthcare systems are crucial to address complex healthcare needs of this population at a critical stage of the life-course.

Do Hospitals with a Higher Level of Maternal Care Designation Have Better Maternal Outcomes?

BACKGROUND: A recent document by the American Congress of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine introduced the concept of uniform levels of maternal care (LMCs). OBJECTIVE: We assessed LMC across hospitals and measured their association with maternal morbidity, focusing on women with high-risk conditions. STUDY DESIGN: We collected data from hospitals from May to November 2015 and linked survey responses to Statewide Inpatient Databases (SID) hospital discharge data in a retrospective cross-sectional study of 247,383 births admitted to 236 hospitals. Generalized logistic regression models were used to examine the associations between hospitals' LMC and the risk of severe maternal morbidity. Stratified analyses were conducted among women with high-risk conditions. RESULTS: High-risk pregnancies were more likely to be managed in hospitals with higher LMC (p < 0.001). Women with cardiac conditions had lower odds of maternal morbidity when delivered in level I compared with level IV units (adjusted odds ratio: 0.29; 95% confidence interval: 0.08-0.99; p = 0.049). There were no other significant associations between the LMC and severe maternal morbidity. CONCLUSION: A higher proportion of high-risk pregnancies were managed within level IV units, although there was no overall evidence that these births had superior outcomes. Further prospective evaluation of LMC designation with patient outcomes is necessary to determine the impact of regionalization on maternal outcomes.

Paid Maternity Leave in the United States: Associations with Maternal and Infant Health.

Objectives The United States is one of only three countries worldwide with no national policy guaranteeing paid leave to employed women who give birth. While maternity leave has been linked to improved maternal and child outcomes in international contexts, up-to-date research evidence in the U.S. context is needed to inform current policy debates on paid family leave. Methods Using data from Listening to Mothers III, a national survey of women ages 18-45 who gave birth in 2011-2012, we conducted multivariate logistic regression to predict the likelihood of outcomes related to infant health, maternal physical and mental health, and maternal health behaviors by the use and duration of paid maternity leave. Results Use of paid and unpaid leave varied significantly by race/ethnicity and household income. Women who took paid maternity leave experienced a 47% decrease in the odds of re-hospitalizing their infants (95% CI 0.3, 1.0) and a 51% decrease in the odds of being re-hospitalized themselves (95% CI 0.3, 0.9) at 21 months postpartum, compared to women taking unpaid or no leave. They also had 1.8 times the odds of doing well with exercise (95% CI 1.1, 3.0) and stress management (95% CI 1.1, 2.8), compared to women taking only unpaid leave. Conclusions for Practice Paid maternity leave significantly predicts lower odds of maternal and infant re-hospitalization and higher odds of doing well with exercise and stress management. Policies aimed at expanding access to paid maternity and family leave may contribute toward reducing socio-demographic disparities in paid leave use and its associated health benefits.

Using Obesity Research to Shape Obesity Policy in Minnesota: Stakeholder Insights and Feasibility of Recommendations.

OBJECTIVE: Preventing childhood obesity requires innovative, evidence-based policy approaches. This study examines the use of research evidence by obesity policy stakeholders in Minnesota and develops pilot tools for communicating timely evidence to policymakers. DESIGN, SETTING, AND PARTICIPANTS: From November 2012 to January 2013, semistructured interviews were conducted with 51 Minnesota stakeholders in childhood obesity prevention. Interviewees included 16 state legislators and staff; 16 personnel from the Minnesota Department of Education, Minnesota Department of Health, and Minnesota Department of Transportation; and 19 advocates for and against childhood obesity prevention legislation (response rate = 71%). MAIN OUTCOME MEASURES: Participants were asked their views on 3 themes: (1) Whether and how they used research evidence in their current decision-making processes; (2) barriers to using research evidence for policymaking; and (3) suggestions for improving the evidence translation process. All interviews were audio-recorded and transcribed. A team approach to qualitative analysis was used to summarize themes, compare findings across interviewees' professional roles, and highlight unexpected findings, areas of tension, or illuminating quotes. RESULTS: Stakeholders used research evidence to support policy decisions, educate the public, and overcome value-based arguments. Common challenges included the amount and complexity of research produced and limited relationships between researchers and decision makers. Responding to interviewee recommendations, we developed and assessed 2 pilot tools: a directory of research experts and a series of research webinars on topics related to childhood obesity. Stakeholders found these materials relevant and high-quality but expressed uncertainty about using them in making policy decisions. CONCLUSIONS: Stakeholders believe that research evidence should inform the design of programs and policies for childhood obesity prevention; however, many lack the time and resources to consult research consistently. Future efforts to facilitate evidence-informed policymaking should emphasize approaches to designing and presenting research that better meets the needs of policy and programmatic decision makers.

Women's Experiences with Neuraxial Labor Analgesia in the Listening to Mothers II Survey: A Content Analysis of Open-Ended Responses.

BACKGROUND: Most women who give birth in United States hospitals receive neuraxial analgesia to manage pain during labor. In this analysis, we examined themes of the patient experience of neuraxial analgesia among a national sample of U.S. mothers. METHODS: Data are from the Listening to Mothers II survey, conducted among a national sample of women who delivered a singleton baby in a U.S. hospital in 2005 (N = 1,573). Our study population consisted of women who experienced labor, did not deliver by planned cesarean, and who reported neuraxial analgesia use (n = 914). We analyzed open-ended responses about the best and worst parts of women's birth experiences for themes related to neuraxial analgesia using qualitative content analysis. RESULTS: Thirty-three percent of women (n = 300) mentioned neuraxial analgesia in their open-ended responses. We found that effective pain relief was frequently spontaneously mentioned as a key positive theme in women's experiences with neuraxial analgesia. However, some women perceived timing-related challenges with neuraxial analgesia, including waiting in pain for neuraxial analgesia, receiving neuraxial analgesia too late in labor, or feeling that the pain relief from neuraxial analgesia wore off too soon, as negative aspects. Other themes in women's experiences with neuraxial analgesia were information and consent, adverse effects of neuraxial analgesia, and plans and expectations. CONCLUSIONS: The findings from this analysis underscored the fact that women appreciate the effective pain relief that neuraxial analgesia provides during childbirth. Although pain control was 1 important facet of women's experiences with neuraxial analgesia, their experiences were also influenced by other factors. Anesthesiologists can work with obstetric clinicians, nurses, childbirth educators, and pregnant and laboring patients to help mitigate some of the challenges with timing, communication, neuraxial analgesia administration, or expectations that may have contributed to negative aspects of women's birth experiences.

Strategic messaging to promote taxation of sugar-sweetened beverages: lessons from recent political campaigns.

OBJECTIVES: This study explored the use of strategic messaging by proponents of sugar-sweetened beverage (SSB) taxation to influence public opinion and shape the policy process, emphasizing the experiences in El Monte and Richmond, California, with SSB tax proposals in 2012. METHODS: We conducted 18 semistructured interviews with key stakeholders about the use and perceived effectiveness of messages supporting and opposing SSB taxation, knowledge sharing among advocates, message dissemination, and lessons learned from their messaging experiences. RESULTS: The protax messages most frequently mentioned by respondents were reinvesting tax revenue into health-related programs and linking SSB consumption to health outcomes such as obesity and diabetes. The most frequently mentioned antitax messages addressed negative economic effects on businesses and government restriction of personal choice. Factors contributing to perceived messaging success included clearly defining "sugar-sweetened beverage" and earmarking funds for obesity prevention, incorporating cultural sensitivity into messaging, and providing education about the health effects of SSB consumption. CONCLUSIONS: Sugar-sweetened beverage taxation has faced significant challenges in gaining political and public support. Future campaigns can benefit from insights gained through the experiences of stakeholders involved in previous policy debates.

Delay and nonreceipt of needed healthcare in U.S. adults with household family members with serious health needs.

INTRODUCTION: Households may be primary settings for developing noncommunicable and infectious diseases due to shared lifestyle factors and ease of transmission, rendering multiple family members within a household in simultaneous need of health services. Limited resources may force families to prioritize healthcare for individuals with serious health needs over other family members; however, few studies have examined unmet healthcare needs within family contexts. This study examines the odds of U.S. adults' own unmet healthcare needs due to cost when living with a family member who has serious health needs. METHODS: In this cross-sectional analysis of 2018 National Health Interview Survey data, we use multivariate logistic regression models to estimate the odds of U.S. adults' own delay and nonreceipt of care when living with a spouse or partner, child under age 18, or parent/parent-in-law with a limiting chronic condition or high volume of past-year healthcare use. RESULTS: Of 56,165 adults surveyed, 51.7% were female, and 63.1% were non-Hispanic White. Adults who had a household family member with extensive health needs had 1.5-2.0 times the odds of experiencing delay or nonreceipt of their own needed care. Being female, uninsured, and having a household income ≤ 400% of the Federal Poverty Level was associated with higher risk of having unmet healthcare needs. DISCUSSION: Families with limited resources may be forced to prioritize some members' needed healthcare over others'. Policy and programmatic support for individuals with ongoing and acute health needs may help ensure adequate resources for all family members to seek needed care. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Tobacco Control as an LGBTQ+ Issue: Knowledge, Attitudes, and Recommendations from LGBTQ+ Community Leaders.

Tobacco companies use price discounts, including coupons and rebates, to market their products. Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) communities are targeted by these marketing strategies, contributing to inequitably high tobacco use. Some localities have adopted policies restricting tobacco price discounts; for successful implementation, community buy-in is crucial. From July-October 2018, Equality California staff conducted semi-structured interviews with seven participants in Los Angeles, CA. Themes included familiarity with tobacco price discounts, their perceived impact on tobacco use in LGBTQ+ communities, and attitudes toward potential policy restrictions. Interview notes were analyzed using a deductive approach to qualitative analysis. Awareness of tobacco price discounts varied; some interviewees were familiar, while others expressed surprise at their ubiquity. Price discounts were seen to disproportionately impact LGBTQ+ individuals, especially those who additionally identify with other vulnerable groups, including young people and communities of color. Support for policy restrictions was unanimous; however, interviewees expressed concern over political opposition and emphasized a need for culturally competent outreach to LGBTQ+ communities. Community organizations are essential in mobilizing support for policy reform. Understanding the perceptions and recommendations of community leaders provides tools for policy action, likely improving outcomes to reduce LGBTQ+ tobacco use through restricting tobacco price discounts.

Psychological Distress and Access to Care Among Midlife Women.

Objective: The objective of this study is to examine unmet health care needs among midlife women (ages 50-64 years) in the United States by level of psychological distress. Method: Using data for a nationally representative sample of midlife women (N = 8,838) from the 2015-2016 National Health Interview Survey, we estimated odds ratios of reasons for delayed care and types of care foregone by level of psychological distress-none, moderate (moderate psychological distress [MPD], and severe (severe psychological distress [SPD]). Findings: More than one in five midlife women had MPD (15.3%) or SPD (5.2%). Women with MPD or SPD had 2 to 5 times higher odds of delayed and 2 to 20 times higher odds of foregone care. Conclusions: Midlife women with psychological distress have poorer health than those with no distress, yet they are less likely to get needed health care. There is a missed window of opportunity to address mental health needs and manage comorbid chronic conditions to facilitate healthy aging.

Health Care Disparities Among U.S. Women of Reproductive Age by Level of Psychological Distress.

Background: Reproductive-age women have a high rate of contact with the health care system for reproductive health care. Yet, beyond pregnancy, little is known about psychological distress and unmet health care needs among these women. We examined reasons for delayed medical care and types of foregone care by level of psychological distress. Materials and Methods: We used a nationally representative sample of U.S. women aged 18-49, from the 2015-2016 National Health Interview Survey. Using the K6 screening tool for nonspecific psychological distress, we examined differences in reasons for delayed care and types of care foregone due to cost by level of psychological distress (none, moderate psychological distress [MPD], and severe psychological distress [SPD]). Results: Overall, 20% of U.S. women aged 18-49 had MPD (16%) or SPD (4%), equating to nearly 13 million women of reproductive age living with psychological distress. Women with SPD or MPD are more likely to have delayed and foregone care. Notably, women with SPD have higher odds of needing but not receiving mental health care (adjusted odds ratios [AOR] = 12.4, 95% confidence interval [CI] 8.4-18.4), specialist care (AOR = 3.6, 95% CI 2.6-5.1), and follow-up care (AOR = 3.5, 95% CI 2.4-5.1) due to cost than women with no psychological distress. Cost is the greatest barrier to timely medical care for women with MPD and SPD. Conclusions: Women of reproductive age with psychological distress face considerable structural and cost-related barriers to accessing health care, which may be exacerbated by their psychological state. Despite recent policy advances such as the Affordable Care Act, additional efforts by policymakers and providers are crucial to address the needs of this population.

Quality of Life for Late Life Patients: Mixed-Methods Evaluation of a Whole-Person Approach for Patients With Chronic Illnesses.

Quality of life (QOL) for patients with serious illness in late life is important for patients and policy makers and has implications for improved care delivery. This mixed-methods evaluation examined the effectiveness of a new whole-person approach to late life care-the LifeCourse-which provides patients with ongoing, across-setting assistance from lay health care workers, supported by a clinical team. We investigated whether participation in LifeCourse improves QOL for intervention patients, compared with usual care controls. QOL was assessed using baseline and 6 months Functional Assessment of Chronic Illness Therapy-Palliative version tool ( n = 181 patients and 126 controls). LifeCourse had a significant positive effect on overall QOL for patients when compared with controls. Interview data revealed that participants adjusted expectations when assessing QOL and actively sought out ways to maintain QOL with meaningful activities and needed services. LifeCourse offers a promising model for improving QOL for late life patients.

Perceived Benefits of Using Complementary and Alternative Medicine by Race/Ethnicity Among Midlife and Older Adults in the United States.

Objective: To describe, for a national sample of midlife and older adults, the types of complementary and alternative medicine (CAM) used for health and wellness and the perceived benefits of CAM use by race/ethnicity. Method: Using data from the 2012 National Health Interview Survey, we ran multiple logistic regression models to estimate the odds of each perceived benefit among adults ages 50 and older. Results: More than 38% of midlife and older adults used CAM in the past year. For six of seven perceived benefits examined, we found significant differences by race/ethnicity, with each group having higher odds of two or more perceived benefits compared with non-Hispanic Whites. Discussion: Although racial/ethnic minority groups are less likely to use CAM compared with non-Hispanic Whites, those who use CAM perceive great benefit. Future research should examine the potential contribution of evidence-based CAM to promoting health and well-being in a diverse aging population.

Access to Workplace Accommodations to Support Breastfeeding after Passage of the Affordable Care Act.

OBJECTIVES: This study examines access to workplace accommodations for breastfeeding, as mandated by the Affordable Care Act, and its associations with breastfeeding initiation and duration. We hypothesize that women with access to reasonable break time and private space to express breast milk would be more likely to breastfeed exclusively at 6 months and to continue breastfeeding for a longer duration. METHODS: Data are from Listening to Mothers III, a national survey of women ages 18 to 45 who gave birth in 2011 and 2012. The study population included women who were employed full or part time at the time of survey. Using two-way tabulation, logistic regression, and survival analysis, we characterized women with access to breastfeeding accommodations and assessed the associations between these accommodations and breastfeeding outcomes. RESULTS: Only 40% of women had access to both break time and private space. Women with both adequate break time and private space were 2.3 times (95% CI, 1.03-4.95) as likely to be breastfeeding exclusively at 6 months and 1.5 times (95% CI, 1.08-2.06) as likely to continue breastfeeding exclusively with each passing month compared with women without access to these accommodations. CONCLUSIONS: Employed women face unique barriers to breastfeeding and have lower rates of breastfeeding initiation and shorter durations, despite compelling evidence of associated health benefits. Expanded access to workplace accommodations for breastfeeding will likely entail collaborative efforts between public health agencies, employers, insurers, and clinicians to ensure effective workplace policies and improved breastfeeding outcomes.

Complementary and Alternative Medicine Use among Women of Reproductive Age in the United States.

BACKGROUND: The purpose of this study was to examine the prevalence of complementary and alternative medicine (CAM) use, types of CAM used, and reasons for CAM use among reproductive-age women in the United States. METHODS: Data are from the 2007 National Health Interview Survey. We examined a nationally representative sample of U.S. women ages 18 to 44 (n = 5,764 respondents). Primary outcomes were past year CAM use, reasons for CAM use, and conditions treated with CAM by pregnancy status (currently pregnant, gave birth in past year, neither). Multivariate logistic regression was used to estimate the odds of CAM use by pregnancy status. FINDINGS: Overall, 67% of reproductive-age U.S. women reported using any CAM in the past year. Excluding vitamins, 42% reported using CAM. Significant differences in use of biologically based (p = .03) and mind-body therapies (p = .012) by pregnancy status were found. Back pain (17.1%), neck pain (7.7%), and anxiety (3.7%) were the most commonly reported conditions treated with CAM among reproductive-age women. However, 20% of pregnant and postpartum women used CAM for pregnancy-related reasons, making pregnancy the most common reason for CAM use among pregnant and postpartum women. CONCLUSIONS: CAM use during the childbearing year is prevalent, with one-fifth of currently or recently pregnant women reporting CAM use for pregnancy-related reasons. Policymakers should consider how public resources may be used to support appropriate, effective use of alternative approaches to managing health during pregnancy and postpartum. Providers should be aware of the changing needs and personal health practices of reproductive age women.

Complementary health approaches for health and wellness in midlife and older US adults.

OBJECTIVES: To characterize the use of complementary health approaches (CHA) and examine the perceived benefits of using CHA by reason for use among midlife and older adults. STUDY DESIGN: Analysis of 2012 National Health Interview Survey data, a nationally representative US sample using cross-tabulations with design-based F-tests and multiple logistic regression. The analytic sample included adults aged over 50 years (N=14,849). MAIN OUTCOME MEASURES: The proposed benefits of using CHA included: (1) better control over health, (2) reduced stress/relaxation, (3) better sleep, (4) feeling better emotionally, (5) coping with health problems, (6) improved health/feeling better, and (7) improved relationships. RESULTS: Overall, 31% of this sample of midlife and older US adults had used CHA in the past year. Among users, 15% had used CHA for treatment only, 40% for wellness only, and 45% for combined wellness and treatment. Herbs (60%), chiropractic (28%), massage (22%), and yoga (19%) were the most common CHA. Wellness-only and combined users had significantly higher odds of reporting that CHA conferred benefit compared with treatment-only users. CONCLUSIONS: CHA are used by nearly a third of midlife and older adults and are perceived to provide substantial benefit. Integrating CHA as part of a healthy lifestyle has the potential to contribute to healthy aging among midlife and older adults.

Workplace Accommodations for Pregnant Employees: Associations With Women's Access to Health Insurance Coverage After Childbirth.

OBJECTIVE: This study evaluates the associations between workplace accommodations for pregnancy, including paid and unpaid maternity leave, and changes in women's health insurance coverage postpartum. METHODS: Secondary analysis using Listening to Mothers III, a national survey of women ages 18 to 45 years who gave birth in U.S. hospitals during 2011 to 2012 (N = 700). RESULTS: Compared with women without access to paid maternity leave, women with access to paid leave were 0.4 times as likely to lose private health insurance coverage, 0.3 times as likely to lose public health coverage, and 0.3 times as likely to become uninsured after giving birth. CONCLUSION: Workplace accommodations for pregnant employees are associated with health insurance coverage via work continuity postpartum. Expanding protections for employees during pregnancy and after childbirth may help reduce employee turnover, loss of health insurance coverage, and discontinuity of care.

Patient-Perceived Pressure from Clinicians for Labor Induction and Cesarean Delivery: A Population-Based Survey of U.S. Women.

OBJECTIVE: To determine whether patient-perceived pressure from clinicians for labor induction or cesarean delivery is significantly associated with having these procedures. DATA SOURCES/STUDY SETTING: Listening to Mothers III, a nationally representative survey of women 18-45 years who delivered a singleton infant in a U.S. hospital July 2011-June 2012 (N = 2,400). STUDY DESIGN: Multivariate logistic regression analysis of factors associated with perceived pressure and estimation of odds of induction and cesarean given perceived pressure. PRINCIPAL FINDINGS: Overall, 14.8 percent of respondents perceived pressure from a clinician for labor induction and 13.3 percent for cesarean delivery. Women who perceived pressure for labor induction had higher odds of induction overall (adjusted odds ratio [aOR]: 3.51; 95 percent confidence interval [CI]: 2.5-5.0) and without medical reason (aOR: 2.13; 95 percent CI: 1.3-3.4) compared with women who did not perceive pressure. Those perceiving pressure for cesarean delivery had higher odds of cesarean overall (aOR: 5.17; 95 percent CI: 3.2-8.4), without medical reason (aOR: 6.13; 95 percent CI: 3.4-11.1), and unplanned cesarean (aOR: 6.70; 95 percent CI: 4.0-11.3). CONCLUSIONS: Patient-perceived pressure from clinicians significantly predicts labor induction and cesarean delivery. Efforts to reduce provider-patient miscommunication and minimize potentially unnecessary procedures may be warranted.

Medically complex pregnancies and early breastfeeding behaviors: a retrospective analysis.

BACKGROUND: Breastfeeding is beneficial for women and infants, and medical contraindications are rare. Prenatal and labor-related complications may hinder breastfeeding, but supportive hospital practices may encourage women who intend to breastfeed. We measured the relationship between having a complex pregnancy (entering pregnancy with hypertension, diabetes, or obesity) and early infant feeding, accounting for breastfeeding intentions and supportive hospital practices. METHODS: We performed a retrospective analysis of data from a nationally-representative survey of women who gave birth in 2011-2012 in a US hospital (N = 2400). We used logistic regression to examine the relationship between pregnancy complexity and breastfeeding. Self-reported prepregnancy diabetes or hypertension, gestational diabetes, or obesity indicated a complex pregnancy. The outcome was feeding status 1 week postpartum; any breastfeeding was evaluated among women intending to breastfeed (N = 1990), and exclusive breastfeeding among women who intended to exclusively breastfeed (N = 1418). We also tested whether breastfeeding intentions or supportive hospital practices mediated the relationship between pregnancy complexity and infant feeding status. RESULTS: More than 33% of women had a complex pregnancy; these women had 30% lower odds of intending to breastfeed (AOR = 0.71; 95% CI, 0.52-0.98). Rates of intention to exclusively breastfeed were similar for women with and without complex pregnancies. Women who intended to breastfeed had similar rates of any breastfeeding 1 week postpartum regardless of pregnancy complexity, but complexity was associated with >30% lower odds of exclusive breastfeeding 1 week among women who intended to exclusively breastfeed (AOR = 0.68; 95% CI, 0.47-0.98). Supportive hospital practices were strongly associated with higher odds of any or exclusive breastfeeding 1 week postpartum (AOR = 4.03; 95% CI, 1.81-8.94; and AOR = 2.68; 95% CI, 1.70-4.23, respectively). CONCLUSIONS: Improving clinical and hospital support for women with complex pregnancies may increase breastfeeding rates and the benefits of breastfeeding for women and infants.

Potential benefits of increased access to doula support during childbirth.

OBJECTIVES: The annual costs of US maternity-related hospitalizations exceed $27 billion. Continuous labor support from a trained doula is associated with improved outcomes and potential cost savings. This study aimed to document the relationship between doula support, desire for doula support, and cesarean delivery, distinguishing cesarean deliveries without a definitive medical indication. STUDY DESIGN: Retrospective analysis of a nationally representative survey of women who delivered a singleton baby in a US hospital in 2011- 2012 (N = 2400). METHODS: Multivariable logistic regression analysis of characteristics associated with doula support and desire for doula support; similar models examine the relationship between doula support, desire for doula support, and 1) any cesarean or 2) nonindicated cesarean. RESULTS: Six percent of women reported doula care during childbirth. Characteristics associated with desiring but not having doula support were black race (vs white; adjusted odds ratio [AOR] = 1.77; 95% CI,1.03-3.03), and publicly insured or uninsured (vs privately insured; AOR = 1.83, CI, 1.17-2.85; AOR = 2.01, CI, 1.07-3.77, respectively). Doula-supported women had lower odds of cesarean compared without doula support and those who desired but did not have doula support (AOR = 0.41, CI, 0.18-0.96; and AOR = 0.31, CI, 0.13-0.74). The odds of nonindicated cesarean were 80-90% lower among doula-supported women (AOR= 0.17, CI, 0.07-0.39; and AOR= 0.11, CI, 0.03-0.36). CONCLUSIONS: Women with doula support have lower odds of nonindicated cesareans than those who did not have a doula as well as those who desired but did not have doula support. Increasing awareness of doula care and access to support from a doula may facilitate decreases in nonindicated cesarean rates.

International application of sugar-sweetened beverage (SSB) taxation in obesity reduction: factors that may influence policy effectiveness in country-specific contexts.

Sugar-sweetened beverage (SSB) taxation is becoming of increasing interest as a policy aimed at addressing the rising prevalence of obesity in many countries. Preliminary evidence indicates its potential to not only reduce obesity prevalence, but also generate public revenue. However, differences in country-specific contexts create uncertainties in its possible outcomes. This paper urges careful consideration of country-specific characteristics by suggesting three points in particular that may influence the effectiveness of a volume-based soft drink excise tax: population obesity prevalence, soft drink consumption levels, and existing baseline tax rates. Data from 19 countries are compared with regard to each point. The authors suggest that SSB or soft drink taxation policy may be more effective in reducing obesity prevalence where existing obesity prevalence and soft drink consumption levels are high. Conversely, in countries where the baseline tax rate is already considered high, SSB taxation may not have a noticeable impact on consumption patterns or obesity prevalence, and may incur negative feedback from the beverage industry or the general public. Thorough evaluation of these points is recommended prior to adopting SSB or soft drink taxation as an obesity reduction measure in any given country.