The pandemic preterm paradox: A test of competing explanations.

Epidemiologists have long argued that side effects of the stress response include preterm birth. Research reports that fear of lethal infection stressed pregnant persons at the outset of the COVID-19 pandemic and that "shutdowns" and "social distancing" impeded access to social support and prenatal care. The decline in preterm births in high-income countries, including the United States (US), during the early months of the pandemic therefore poses a paradox for science. Explanations of this "pandemic preterm paradox" remain untested. We apply time-series modeling to data describing 80 monthly conception cohorts begun in the US from July 2013 through February 2020 to determine which of 3 explanations most parsimoniously explains the paradox. We infer that "prior loss," or the argument that an increase in spontaneous abortions and stillbirths depleted the population of fetuses at risk of preterm birth, best explains data currently available. We describe the implications of these results for public health practice.

Changes in Racial and Ethnic Inequities in Pregnancy-Associated Death in the United States During the COVID-19 Pandemic.

Objectives. To examine changes in cause-specific pregnancy-associated deaths during the COVID-19 pandemic by race and ethnicity and assess changes in racial and ethnic inequities in pregnancy-associated deaths. Methods. We used US vital statistics mortality data from 2018 to 2021 to identify pregnancy-associated deaths among females aged 15 to 44 years. We calculated crude pregnancy-associated death rates (deaths per 100 000 live births) by year, cause, and race/ethnicity, percent change in death rate, and the inequity (difference) in rate for each racial or ethnic group compared with non-Hispanic White people. Results. The pregnancy-associated death rate for obstetric, drug-related, homicide, and other causes of death increased during 2020, and obstetric deaths continued to increase in 2021. Overall estimates mask 2021 increases in drug-related deaths among Hispanic, non-Hispanic American Indian and Alaska Native (AI/AN), and non-Hispanic Asian people; increases in homicide among most racial and ethnic groups; and increases in suicide among Hispanic, non-Hispanic AI/AN, and non-Hispanic Asian people. Conclusions. We found disproportionate increases in pregnancy-associated deaths from nonobstetric causes among minoritized racial and ethnic groups during the COVID-19 pandemic. (Am J Public Health. 2024;114(7):733-742. https://doi.org/10.2105/AJPH.2024.307651).

Food and nutrition information requirements of Australian primary school parents.

OBJECTIVE: To explore what Australian primary school parents want to learn about food and nutrition to improve their children's eating behaviours, as well as the associations between parents' personal and demographic characteristics and their views regarding their food and nutrition knowledge needs. DESIGN: An online nationwide cross-sectional survey was conducted in 2021 using a mixed-methods approach. Logistic regression analysis was utilised to examine the relationship between parents' demographics, personal values and their views. Content analysis was performed using Leximancer. SETTING: Australia. PARTICIPANTS: Seven hundred and eighty-seven parents. RESULTS: Fifty-one per cent wanted to learn more about food and nutrition to improve their children's healthy eating habits, and 77% of those preferred schools to provide that information. Online/printed newsletters and YouTube were the most preferred methods for receiving food and nutrition related information. Higher universalism-concern value (concern for the welfare of those in the larger society and world) scores were positively associated parents' preference for schools to provide food and nutrition-related information. Parents with non-English-speaking backgrounds and younger parents were more likely to want to learn about food and nutrition. Parents wanted to learn more about encouraging healthy eating, ideas for the lunchbox, food labels and age-specific portion sizes and recommendations. CONCLUSIONS: Findings can inform public health educators and assist them in designing future food and nutrition education programmes and resources targeting primary school parents.

The prevalence of food insecurity amongst refugees and asylum seekers during, and prior to, their early resettlement period in Australia: A cross-sectional analysis of the 'Building a New Life in Australia' data.

With over 100 million humanitarian migrants globally, there is increasing pressure on high-income countries to offer resettlement opportunities. Humanitarian migrants face many challenges during pre-settlement and resettlement. One challenge is food insecurity (FI). The Building a New Life in Australia (BNLA) longitudinal cohort study gathered data from migrating units, that is, a group of humanitarian migrants included on the same visa application (n = 1599). Data were gathered in five annual waves (2013-2018). Data included food security status in four pre-settlement situations and during resettlement. The results of this secondary analysis of BNLA Wave One indicate that FI was highest in refugee camps (71%), followed by bridging visas (30%), community detention (17%), immigration detention (11%), and during early resettlement (9%). During early resettlement, respondents who were male, those from Afghanistan or Iran, and those living in a single person household reported the highest prevalence of FI. An association was found between having spent time on a bridging visa and FI during early resettlement (p < 0.01). This study's results are an important step in understanding the scale of FI and which sub-groups are most vulnerable, so the resources and policies of high-income countries can better meet food security needs during resettlement.

Australian adults cooked more and tried new recipes during COVID-19 restrictions and lockdowns.

The lockdowns and restrictions due to COVID-19 caused changes in both food accessibility and availability for people around the globe resulting in changes in food habits and behaviours. To enable a better public health response to the next pandemic, lessons must be learnt from this most recent emergency. This study aimed to examine self-reported changes in food habits and behaviours, of Australian adults during COVID-19 restrictions in 2020. A cross-sectional, convenience, Australia-wide survey, with open-ended and closed-ended questions was conducted online. Respondents were asked to report their demographic characteristics, positive food habit development, worst food-related experiences, changes in food habits and behaviours and cooking and food preparation practices during the COVID-19 restriction period. Adult Australian residents, recruited through social media advertising of the survey. Respondents (n = 764) were mostly female (86%), over 55 years of age (57%, mean age (SD) 53.4 (18.1) years), and half (51%) were not in paid employment. Nearly two-thirds (63%) developed positive food habits, including trying new recipes (54%), eating less take-away (53%) and cooking from scratch (46%) during the COVID-19 restrictions. Furthermore, respondents reported including family members in food preparation and eating together as a family. Negative experiences included being unable to buy certain foods (due to lack of stock and store limits), cooking at home, and being unable to access some food outlets. Australians experienced both positive and negative food experiences during the COVID-19 pandemic and associated lockdown periods, with most experiencing positive changes such as cooking at home from scratch and trying new recipes and relying on less take-away. Females and those who experienced a change in employment status were more likely to develop positive new food habits.

Parents face several barriers in providing a healthy school lunch for their primary school children: A survey of Victorian (Australian) parents.

ISSUE ADDRESSED: This paper aims to explore Victoria parents' perceptions of their current practices and barriers in providing school lunches for their primary school children. METHODS: Respondents were asked via an online survey about their lunch provision practices, perceptions of the healthiness of school lunches, and barriers to providing healthy school lunches. Data were analysed using different statistical techniques: Chi-square test, Spearman correlation analysis, Mann-Whitney U test, and Kruskal-Wallis test. RESULTS: In total, 359 respondents completed the survey. Most respondents (84%) reported their child takes a home-packed lunch to school every day. Most respondents provided fruits (94%), vegetables (57%), and sandwiches (54%) every day for school lunches, whilst other core food items such as milk, meats, and legumes were provided less frequently. A substantial proportion of respondents provided some discretionary food items frequently (e.g., the proportion of respondents providing selected discretionary food items daily or 3-4 times/week: salty crackers-50%, sweet cookies/biscuits-40%, chips-20%). Respondents strongly agreed or agreed with several barriers; examples include not packing certain foods due to food spoilage concerns (50%) (school-related), the allocated time at their child's school is not enough to eat and enjoy school lunch (48%) (school-related), need more meal ideas (61%) (parent-related), healthy foods take more time to prepare (51%) (parent-related), and children request easy-to-eat food for school lunches (50%) (child-related). Core food score (an indicator of frequency of preparing/packing core food) was negatively correlated with parent-related and child-related barrier scores, whilst discretionary food score (an indicator of frequency of preparing/packing discretionary food) was positively correlated with these barrier scores. CONCLUSIONS: Overall, home-packed lunches remain the main option in primary schools in Victoria, and parents face several challenges in providing healthy lunches for their primary school children. SO WHAT?: The findings suggest the need for strategies from school leaders, education authorities, and policymakers to improve the quality of lunch content and address the barriers faced by parents.

Exposure to the early COVID-19 pandemic and early, moderate and overall preterm births in the United States: A conception cohort approach.

BACKGROUND: The United States (US) data suggest fewer-than-expected preterm births in 2020, but no study has examined the impact of exposure to the early COVID-19 pandemic at different points in gestation on preterm birth. OBJECTIVE: Our objective was to determine-among cohorts exposed to the early COVID-19 pandemic-whether observed counts of overall, early and moderately preterm birth fell outside the expected range. METHODS: We used de-identified, cross-sectional, national birth certificate data from 2014 to 2020. We used month and year of birth and gestational age to estimate month of conception for birth. We calculated the count of overall (<37 weeks gestation), early (<33 weeks gestation) and moderately (33 to <37 weeks gestation) preterm birth by month of conception. We employed time series methods to estimate expected counts of preterm birth for exposed conception cohorts and identified cohorts for whom the observed counts of preterm birth fell outside the 95% detection interval of the expected value. RESULTS: Among the 23,731,146 births in our study, the mean prevalence of preterm birth among monthly conception cohorts was 9.7 per 100 live births. Gestations conceived in July, August or December of 2019-that is exposed to the early COVID-19 pandemic in the first or third trimester-yielded approximately 3245 fewer moderately preterm and 3627 fewer overall preterm births than the expected values for moderate and overall preterm. Gestations conceived in August and October of 2019-that is exposed to the early COVID-19 pandemic in the late second to third trimester-produced approximately 498 fewer early preterm births than the expected count for early preterm. CONCLUSIONS: Exposure to the early COVID-19 pandemic may have promoted longer gestation among close-to-term pregnancies, reduced risk of later preterm delivery among gestations exposed in the first trimester or induced selective loss of gestations.

Selection in utero against male twins in the United States early in the COVID-19 pandemic.

OBJECTIVES: We aim to contribute to the literature reporting tests of selection in utero. The theory of reproductive suppression predicts that natural selection would conserve mechanisms, referred to collectively as selection in utero, that spontaneously abort fetuses unlikely to thrive as infants in the prevailing environment. Tests of this prediction include reports that women give birth to fewer than expected male twins, historically among the frailest of infants, during stressful times. The onset of the COVID-19 pandemic in the United States in Spring 2020 demonstrably stressed the population. We test the hypothesis that conception cohorts in gestation at the onset of the pandemic in the United States yielded fewer than expected live male twin births. METHODS: We retrieved deidentified data on the universe of live births in the United States from the National Center for Health Statistics birth certificate records. We applied Box-Jenkins time-series methods to the twin secondary sex ratio computed for 77 monthly conception cohorts spanning August 2013 to December 2019 to detect outlying cohorts in gestation at the onset of the pandemic. RESULTS: The twin secondary sex ratio fell below expected values in three conception cohorts (i.e., July, September, and October 2019, all p < .05) exposed in utero to the onset of the pandemic. CONCLUSIONS: Our results add to prior findings consistent with selection in utero. The role of selection in utero in shaping the characteristics of live births cohorts, especially during the COVID-19 pandemic, warrants further scrutiny.

Parental support for free school lunches in Australian primary schools: associated factors and perceived barriers.

OBJECTIVE: (1) To explore the feasibility of such programmes in Australia, this study examined parents' views on free school lunch provision. (2) To examine the associations between parents' demographic and personal characteristics and their support for free universal school lunches. DESIGN: An online cross-sectional survey of parents. SETTING: Australia, April 2021. PARTICIPANTS: Seven hundred and eighty-seven parents took the survey. They had a mean age of 40. The respondents were predominantly female (95 %) and had a university degree (72 %). RESULTS: Fifty-three percentage of the respondents agreed that all students should have access to healthy and well-balanced, free school lunches. Parents were concerned about healthiness, catering, allergies and cost of school-provided school lunches. Ethnic background, universalism values and education levels were significantly associated with support for free school lunch provision. Non-native English-speaking parents were almost three times more likely to support free universal lunches in primary schools than their native English-speaking counterparts. Parents with higher universalism-concern values were more likely to endorse free lunches in primary school. However, the level of education was negatively associated with parents' support for free school lunches. CONCLUSIONS: The survey results highlight the complexity of parental views on free school lunch provision. Parents' concerns regarding lunches should be considered in developing school lunch programmes that meet the needs and preferences of diverse communities. These findings can be used to guide future primary school lunch provision initiatives.

Food literacy and diet quality in young vegans, lacto-ovo vegetarians, pescatarians, flexitarians and omnivores.

OBJECTIVE: To investigate whether food literacy competencies and diet quality vary between 16-to-24-year-olds vegans, lacto-ovo vegetarians, pescatarians, flexitarians and omnivores and to assess whether food literacy is associated with diet quality. DESIGN: Cross-sectional study. Food literacy (general nutrition knowledge, critical nutrition literacy and food skills) and diet quality were measured using an electronic questionnaire. SETTING: Southern Norway, September 2021 - March 2022. PARTICIPANTS: Healthy 16-24-year-olds (n 165). RESULTS: Overall, the mean general nutrition knowledge score was moderate (48·0 out of 67·0); the lowest mean score was found in omnivores and the highest in flexitarians (45·6 v. 51·5) (P = 0·034). The mean score of critical nutrition literacy was also moderate (3·7 out of 5·0); vegans showed higher scores compared to other dietary practices (P = 0·018). No difference was observed in food skills between the different dietary practices. The overall median diet quality score was 46·0 out of 80·0, lowest in omnivores and highest in vegans (42·0 v. 56·0) (P =< 0·001). In multivariate regression analyses, general nutrition knowledge, food skills and vegan dietary practice were significantly associated with higher diet quality. CONCLUSIONS: We found moderate levels of food literacy across all dietary practices. The food literacy competencies, general nutrition knowledge and food skills were associated with higher diet quality in our sample. Omnivores showed both the lowest general nutrition knowledge level and lowest diet quality scores. In contrast, both flexitarians and vegans scored highest on general nutrition knowledge and diet quality scores, despite being one of the less restrictive and one of the strictest plant-based dietary practices, respectively.

Associations of a current Australian model of dietetic care for women diagnosed with gestational diabetes and maternal and neonatal health outcomes.

BACKGROUND: Gestational diabetes mellitus (GDM) is a significant public health burden in Australia. Subsequent strain on healthcare systems is widespread and current models of care may not be adequate to provide optimal healthcare delivery. This study aimed to assess a current model of dietetic care with maternal and neonatal outcomes. METHODS: Hospital medical record data from The Women's Hospital, Melbourne, for women with GDM (n = 1,185) (July 2105-May 2017) was retrospectively analysed. Adjusted linear and logistic regression were used to analyse associations between the number of dietitian consultations and maternal and neonatal health outcomes. RESULTS: Half of all women (50%) received two consultations with a dietitian. 19% of women received three or more consultations and of these women, almost twice as many were managed by medical nutrition therapy (MNT) and pharmacotherapy (66%) compared with MNT alone (34%). Higher odds of any maternal complication among women receiving 3 + consultations compared to those receiving zero (OR = 2.33 [95% CI: 1.23, 4.41], p = 0.009), one (OR = 1.80 [95% CI: 1.09, 2.98], p = 0.02), or two (OR = 1.65 [95% CI: 1.04, 2.60], p = 0.03) consultations were observed. Lower odds of infant admission to the Neonatal Intensive Care Unit (NICU) were observed among women receiving one (OR = 0.38 [95% CI: 0.18, 0.78], p = 0.008), two (OR = 0.37 [95% CI: 15 0.19, 0.71], p = 0.003), or three + consultations (OR = 0.43 [95% CI: 0.21, 0.88], p = 0.02), compared to no consultations. CONCLUSION: The optimal schedule of dietitian consultations for women with GDM in Australia remains largely unclear. Alternate delivery of education for women with GDM such as telehealth and utilisation of digital platforms may assist relieving pressures on the healthcare system and ensure optimal care for women during pregnancy.

Patterned Outcomes, Unpatterned Counterfactuals, and Spurious Results: Perinatal Health Outcomes Following COVID-19.

The epidemiologic literature estimating the indirect or secondary effects of the coronavirus disease 2019 (COVID-19) pandemic on pregnant people and gestation continues to grow. Our assessment of this scholarship, however, leads us to suspect that the methods most commonly used may lead researchers to spurious inferences. This suspicion arises because the methods do not account for temporal patterning in perinatal outcomes when deriving counterfactuals, or estimates of the outcomes had the pandemic not occurred. We illustrate the problem in 2 ways. First, using monthly data from US birth certificates, we describe temporal patterning in 5 commonly used perinatal outcomes. Notably, for all but 1 outcome, temporal patterns appear more complex than much of the emerging literature assumes. Second, using data from France, we show that using counterfactuals that ignore this complexity produces spurious results. We recommend that subsequent investigations on COVID-19 and other perturbations use widely available time-series methods to derive counterfactuals that account for strong temporal patterning in perinatal outcomes.

Impacts of the Affordable Care Act's Medicaid Expansion on Live Births.

BACKGROUND: We hypothesize that the Affordable Care Act's (ACA) Medicaid expansion, which extended health insurance coverage to preconception, between-conception, and postconception periods for women meeting income eligibility guidelines, impacted the number of live births in the United States by increasing access to contraception and financial well-being. These impacts may differ by maternal socioeconomic and demographic characteristics. METHODS: Using data from birth certificates aggregated to the state-year level and a difference-in-differences design, we estimated the association between Medicaid expansion and count of live births. We also examined whether associations differed by socioeconomic and demographic characteristics. RESULTS: Overall, Medicaid expansion was not meaningfully associated with the count of births (difference-in-differences ß = 0.002; 95% confidence interval [CI] = -0.010, 0.015). However, among certain groups, Medicaid expansion was associated with meaningful changes in the count of live births, though all confidence intervals included the null value. The estimate of the relation between Medicaid expansion and the count of live births was -0.025 (95% CI = -0.052, 0.001) for those ages 18-24 years; -0.078 (95% CI = -0.231, 0.075) for those who were married, and -0.035 (95% CI = -0.104, 0.034) for those who were unmarried. CONCLUSIONS: Despite its potential to impact live births, our results indicate that the ACA's Medicaid expansion was not, in general, associated with live births of US residents of reproductive age. However, for younger, married, and unmarried women, the magnitude of estimates supports the hypothesis of a potentially meaningful effect of Medicaid expansions on live births.

Food sources of iodine in schoolchildren and relationship with 24-h urinary iodine excretion in Victoria, Australia.

Dietary recalls have been used previously to identify food sources of iodine in Australian schoolchildren. Dietary assessment can provide information on the relative contributions of individual food groups which can be related to a robust objective measure of daily intake (24-h urinary iodine excretion (UIE)). In Australia, the government has mandated the use of iodised salt in breadmaking to address iodine deficiency. The aim of this study was to determine the dietary intake and food sources of iodine to assess their contribution to iodine excretion (UIE) in a sample of Australian schoolchildren. In 2011-2013, UIE was assessed using a single 24-h urine sample and dietary intake was assessed using one 24-h dietary recall in a convenience sample of primary schoolchildren from schools in Victoria, Australia. Of the 454 children with a valid recall and urine sample, 55 % were male (average age 10·1 (1·3 (sd) years). Mean UIE and dietary iodine intake were 108 (sd 54) and 172 (sd 74) µg/d, respectively. Dietary assessment indicated that bread and milk were the main food sources of iodine, contributing 27 and 25 %, respectively, to dietary iodine. Milk but not bread intake was positively associated with UIE. Multiple regression (adjusted for school cluster, age and sex) indicated that for every 100 g increase in milk consumption, there was a 3 µg/d increase in UIE (ß = 4·0 (se 0·9), P < 0·001). In conclusion, both bread and milk were important contributors to dietary iodine intake; however, consumption of bread was not associated with daily iodine excretion in this group of Australian schoolchildren.

Changes in preterm birth and caesarean deliveries in the United States during the SARS-CoV-2 pandemic.

BACKGROUND: Preliminary studies suggest that the SARS-CoV-2 pandemic and associated social, economic and clinical disruptions have affected pregnancy decision-making and outcomes. Whilst a few US-based studies have examined regional changes in birth outcomes during the pandemic's first months, much remains unknown of how the pandemic impacted perinatal health indicators at the national-level throughout 2020, including during the 'second wave' of infections that occurred later in the year. OBJECTIVES: To describe changes in monthly rates of perinatal health indicators during the 2020 pandemic for the entire US. METHODS: For the years 2015 to 2020, we obtained national monthly rates (per 100 births) for four perinatal indicators: preterm (<37 weeks' gestation), early preterm (<34 weeks' gestation), late preterm (34-36 weeks' gestation) and caesarean delivery. We used an interrupted time-series approach to compare the outcomes observed after the pandemic began (March 2020) to those expected had the pandemic not occurred for March through December of 2020. RESULTS: Observed rates of preterm birth fell below expectation across several months of the 2020 pandemic. These declines were largest in magnitude in early and late 2020, with a 5%-6% relative difference between observed and expected occurring in March and November. For example, in March 2020, the observed preterm birth rate of 9.8 per 100 live births fell below the 95% prediction interval (PI) of the rate predicted from history, which was 10.5 preterm births per 100 live births (95% PI 10.2, 10.7). We detected no changes from expectation in the rate of caesarean deliveries. CONCLUSIONS: Our findings provide nationwide evidence of unexpected reductions in preterm delivery during the 2020 SARS-CoV-2 pandemic in the US. Observed declines below expectation were differed by both timing of delivery and birth month, suggesting that several mechanisms, which require further study, may explain these patterns.

How young adults in Australia classify foods as healthy and unhealthy.

Young Australian adults exhibit poor food behaviour however, there is limited research as to why young adults choose to eat healthy or unhealthy foods. This study aimed to explore how young adults' (18-30 years) in Australia classify foods as healthy and unhealthy. Through a social-constructivist approach, 38 young adults (76% females and 21% males; mean age = 24.1 years) were interviewed Australia-wide. Data were thematically analysed. Participants were classified into three groups based on their living arrangements namely, parental, shared and independent households. Four themes emerged, food preparation; food groups; nutrient composition and perceived impact. Food classification criteria based on nutrients were the most frequently used criterion to classify foods as unhealthy. A strong emphasis was placed on avoiding less healthy nutrients and there were limited discussions about beneficial nutrients. Participants belonging to the different household groups defined 'moderation' in several ways to justify their consumption of unhealthy foods. Reading food labels was a key criterion for evaluating healthiness amongst the participants of the parental and independent household groups, not among the shared household group. Findings reveal how living arrangements influenced young adults' perceptions of healthiness. Future public health policy could incorporate the language of young adults identified in this study in the transfer of nutritional knowledge to young adults.

Enough time for lunch? The duration and governance of lunch eating times in Australian primary schools: A mixed-methods study.

Developing healthy eating behaviours is important to assist children in maintaining good health and decrease the risk of chronic health conditions. Recent nutrition promotion efforts in Australian primary schools have mainly focused on canteen guideline compliance and obesity prevention interventions. The aim of this study was to investigate the primary school food environment, specifically, allocated lunch eating duration and the governance of children's lunch breaks. Parents (n = 402) and teachers (n = 123) were asked via an online survey, about school allocated lunch eating duration and its adequacy. Respondents were asked about the supervision, monitoring and feedback of children's lunches, as well as how they felt about these practices. Parents (n = 308) and teachers (n = 102) also responded to the open-ended question "What could be done to improve the school food environment at your school?". Ten minutes was the allocated lunch eating duration reported by most parents and teachers and 58% of those parents and 30% of those teachers rated this as inadequate. Increasing the allocated lunch eating duration was frequently cited as a way to improve the school food environment. A similar proportion of parents and teachers agreed with teachers monitoring food intake, not providing feedback on food brought to school, and that parents should decide what children eat. More parents (44%) than teachers (23%) believed that teachers should eat their own lunch with the children. These findings provide an insight into the primary school lunch environment and the views of two key stakeholder groups. School food policies should consider these findings in future revisions, particularly with regards to eating times.

Impacts of Medicaid Expansion Before Conception on Prepregnancy Health, Pregnancy Health, and Outcomes.

Preconception health care is heralded as an essential method of improving pregnancy health and outcomes. However, access to health care for low-income US women of reproductive age has been limited because of a lack of health insurance. Expansions of Medicaid program eligibility under the Affordable Care Act (as well as prior expansions in some states) have changed this circumstance and expanded health insurance coverage for low-income women. These Medicaid expansions provide an opportunity to assess whether obtaining health insurance coverage improves prepregnancy and pregnancy health and reduces prevalence of adverse pregnancy outcomes. We tested this hypothesis using vital statistics data from 2011-2017 on singleton births to female US residents aged 15-44 years. We examined associations between preconception exposure to Medicaid expansion and measures of prepregnancy health, pregnancy health, and pregnancy outcomes using a difference-in-differences empirical approach. Increased Medicaid eligibility was not associated with improvements in prepregnancy or pregnancy health measures and did not reduce the prevalence of adverse birth outcomes (e.g., prevalence of preterm birth increased by 0.1 percentage point (95% confidence interval: -0.2, 0.3)). Increasing Medicaid eligibility alone may be insufficient to improve prepregnancy or pregnancy health and birth outcomes. Preconception programming in combination with attention to other structural determinants of pregnancy health is needed.

Racial inequity in preterm delivery among college-educated women: The role of racism.

BACKGROUND: Non-Hispanic Black (NHB) women face a 50% increased risk of delivering preterm compared to non-Hispanic White (NHW) women in the United States. Sociodemographic and pregnancy risk factors do not fully explain this inequity. This inequity exists even among women with a college education, although recent empirical analysis on racial inequities in preterm delivery (PTD) among college-educated women is lacking. Furthermore, the contribution of preconception risk factors to the racial inequity in PTD has not been examined. OBJECTIVES: To determine whether: (i) there is a NHB-NHW inequity in PTD among college-educated women; (ii) the prevalence of known, measured sociodemographic, pregnancy, and preconception PTD risk factors differs between NHB and NHW college-educated women; (iii) equalising the distribution of risk factors between college-educated NHB and NHW women reduces or eliminates the racial inequity in PTD. METHODS: We analysed US natality data from 2015 to 2016 among women with a college degree or higher (n = 2 326 512). We calculated frequencies of sociodemographic, pregnancy, and preconception risk factors among all women and separately by race/ethnicity. We used modified Poisson regression models to estimate the association between race/ethnicity and PTD controlling for known, measured sociodemographic, pregnancy, and preconception factors. RESULTS: The largest percentage point differences in risk factors between NHW and NHB women were observed for marital status, trimester of care initiation, body mass index, and birth interval. Among college-educated women, the unadjusted risk of PTD for NHB women was 1.77 (95% CI 1.74, 1.79) times the risk for NHW women. After controlling for sociodemographic, pregnancy, and preconception factors, this attenuated to RR 1.47 (95% CI 1.45, 1.49). CONCLUSIONS: A racial inequity in PTD persists among college-educated women. Racism contributes to the NHB-NHW inequity in PTD, in part, through its influence on known sociodemographic, pregnancy, and preconception risk factors for PTD and, in part, through unmeasured pathways.

Parents' and teachers' views of the promotion of healthy eating in Australian primary schools.

BACKGROUND: Primary schools have long been identified as appropriate settings for improving the healthy eating behaviours of children and helping them develop food skills. This qualitative study explored the views of Australian primary school parents and teachers about schools' strengths and weaknesses in promoting healthy eating and equipping children with food skills. METHODS: Nineteen parents and 17 teachers from Victoria participated in semi-structured interviews. Audio recordings were transcribed and underwent thematic analysis using Nvivo. RESULTS: This study demonstrated that parents and teachers believed that several facilitators helped promote children's healthy eating. These included food and nutrition education (FNE) programs, the community-based nature of schools, and teacher role modelling and the authority schools possess over children. Time scarcity, lack of teacher expertise, lack of leadership and funding were reported as barriers. School food environments such as canteens, lunch orders, fundraising events and school fairs were identified as both weaknesses and strengths by parents and teachers, which indicated inconsistent implementation of school nutrition policies across schools. CONCLUSIONS: Australian primary schools demonstrate some useful efforts to promote healthy eating among children. However, there are numerous facilitators and barriers which impact on the promotion of healthy eating. These factors need to be addressed in order to develop healthy eating habits further among elementary students. These results provide directions for policymakers and school managers, as they point to the areas that need to be improved to assist the design of schools that better promote healthy eating among children.