Prescribing Patterns for Postpartum Contraception Among Breastfeeding Patients Insured Under Medicaid in Rhode Island: A PRAMS Analysis.

INTRODUCTION: Disparities in contraceptive counseling are well documented in the United States. People of color, those of lower socio-economic status, and Medicaid insurance are more likely to receive contraception/sterilization counseling than White patients. Postpartum contraceptive choice is an important aspect for pregnant people, especially for those who plan to breastfeed. This study assessed postpartum contraception/sterilization prescription among breastfeeding people in Rhode Island insured under Medicaid compared to other insurance carriers. METHODS: Secondary analysis of data from the Rhode Island Pregnancy Risk Assessment Monitoring System (PRAMS) from 2016-2019. Participants who answered yes to 'having ever breastfed' were included and dichotomized based on insurance into 'Medicaid' or 'other insurance'. Primary outcome was postpartum contraception/sterilization prescription. Stata software version 15 was used to perform multivariable logistic regression accounting for complex survey design and weighting. RESULTS: Of 3686 participants, 868 (24.4%) were insured under Medicaid. Medicaid participants were younger, had higher BMIs and were more likely to identify as Black or mixed race or Hispanic ethnicity than those with other insurers. Those insured under Medicaid were 1.5 times more likely to be prescribed postpartum contraception than those with other insurers (95% CI 1.26,1.78). After adjusting for race/ethnicity, education level, marital status and preterm delivery, those with Medicaid were 1.28 times more likely to be prescribed contraception (95% CI 1.05,1.57). CONCLUSION: In this study, breastfeeding participants with Medicaid were more likely to be prescribed postpartum contraception than those with other insurances. Future research should be focused on assessing provider bias, contraception coercion, and initiatives to provide equitable and patient-centered counseling in this population.

Influenza vaccine during pregnancy, recommendations from healthcare providers, and race/ethnicity in the United States.

OBJECTIVES: We examined racial/ethnic differences in the association between influenza vaccine recommendations from healthcare providers and maternal vaccination uptake. METHODS: This cross-sectional study examined data from the Pregnancy Risk Assessment Monitoring System. We categorized respondents as non-Hispanic (NH) Whites, NH-Blacks, NH-Asians, American Indians/Alaska Natives, NH Other non-Whites, and Hispanics. We conducted multivariable logistical regression models to evaluate adjusted odds ratios (AOR) and 95% confidence intervals (CI). Covariates included maternal age, marital status, education, insurance status before pregnancy, the number of previous live births, the number of prenatal care visits, and smoking status during pregnancy. RESULTS: The prevalences of receiving influenza vaccine recommendations from healthcare providers and maternal vaccine were 80.01% and 50.42%, respectively. NH-Blacks are less likely to receive provider recommendations (AOR = 0.82; 95%CI 0.77-0.87) and be vaccinated (AOR = 0.76; 95%CI 0.72-0.80) than NH-Whites. Receiving provider recommendations was significantly associated with increased maternal influenza vaccine uptake (AOR = 15.50; 95% CI 14.51-16.55). The associations were significant for all racial/ethnic groups, with the highest among NH-Asians (AOR = 22.04; 95% CI 17.88-27.16) and the lowest among NH Other non-Whites (AOR = 11.07; 95% CI 8.25-14.86). Within NH-Asians, effectiveness among Chinese was highest (AOR = 29.39; 95% CI 18.10-47.71). CONCLUSIONS: Racial/ethnic disparities in maternal influenza vaccine uptake and receiving vaccine recommendations from healthcare providers persisted. Further studies on the racial/ethnic disparities in maternal vaccination were warranted and tailored strategies are required to reduce this health disparity.

Stress During Pregnancy Associated with Newborn Low Birth Weight: Experiences from the State of Rhode Island.

PURPOSE: Prenatal stress is a known risk for poor birth outcomes. This study specifically looked at reported stress during pregnancy and low birth weight (LBW) in Rhode Island. METHODS: Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2016 to 2018 for the state of Rhode Island was utilized. Stress during most recent pregnancy was dichotomized as: 'none to minimal' and 'moderate to high.' LBW was defined as less than 2,500 g. Multivariable regression analysis was performed, accounting for complex survey design. RESULTS: In this cohort, 24% of pregnant people reported moderate to high stress leading to an adjusted odds of 1.70 (95% CI 1.43-2.03) of having a LBW newborn compared to those with none to minimal stress. Primiparity, previous preterm birth, racism, smoking history, and history of chronic medical problems were also associated with LBW newborns. CONCLUSION: We recommend screening and provision of support services for stress in all settings where pregnant people access care.

The association between maternal influenza vaccination during pregnancy and adverse birth outcomes in the United States: Pregnancy risk Assessment Monitoring System (PRAMS).

OBJECTIVE: Influenza vaccination during pregnancy is highly recommended. We examined the association between maternal influenza vaccination and adverse birth outcomes. METHODS: This cross-sectional study used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) during 2012-2017. The primary exposure was the receipt of influenza vaccination during pregnancy. Low birth weight (LBW), preterm birth (PTB), and small for gestational age (SGA) were the primary outcomes. We conducted multivariable logistic regression models to estimate the adjusted odds ratios (AOR) and 95% confidence intervals (CI). Covariates used to adjust confounding included maternal age, marital status, education, race and ethnicity, insurance status before pregnancy, and smoking status. For a subgroup in 2012-2015, we analyzed the association between influenza vaccination in each trimester and adverse birth outcomes. RESULTS: During 2012-2017, compared with unvaccinated women, women vaccinated during pregnancy had a lower risk of LBW and PTB. During 2012-2015, maternal influenza vaccination in the 1st and 3rd trimesters was associated with a reduced risk of LBW and PTB, and vaccination in the 3rd trimester had a greater protective effect than in the 1st trimester. Influenza vaccination was not associated with SGA regardless of trimester. CONCLUSIONS: Our findings suggest that influenza vaccination during pregnancy is a safe and effective way to protect newborns.

The Association of Antenatal Depression and Cesarean Delivery among First-Time Parturients: A Population-Based Study.

OBJECTIVE: Antenatal depression (AD) has been considered a risk factor for cesarean delivery (CD); however, the supporting data are inconsistent. We used a large, nationally representative dataset to evaluate whether there is an association between AD and CD among women delivering for the first time. STUDY DESIGN: We utilized the 2016 to 2019 Multistate Pregnancy Risk Assessment Monitoring System (PRAMS) from the Centers for Disease Control. First-time parturients who reported depression in the 3 months prior to or at any point during their recent pregnancy were compared with those who did not. The mode of delivery was obtained through the birth certificate. Maternal demographics, pregnancy characteristics, and delivery characteristics were compared by the report of AD using bivariable analyses. Population-weighted multivariable regression was performed, adjusting for maternal age, race/ethnicity, insurance, pregnancy complications, preterm birth, and body mass index (BMI). RESULTS: Of the 61,605 people who met the inclusion criteria, 18.3% (n = 11,896) reported AD and 29.8% (n = 19,892) underwent CD. Parturients with AD were younger, more likely to be non-Hispanic white, publicly insured, use tobacco in pregnancy, deliver earlier, have lower levels of education, higher BMIs, and more medical comorbidities (hypertension and diabetes). After adjustment for these differences, there was no difference in risk of CD between those with AD compared with those without (adjusted odds ratio: 1.04; 95% confidence interval: 0.97-1.13). CONCLUSION: In a large, population-weighted, nationally representative sample of first-time parturients, there was no association between AD and CD. KEY POINTS: · Antenatal depression is increasingly common and has multiple known morbidities.. · Prior data on antenatal depression and cesarean delivery are mixed.. · We found no association between depression and cesarean delivery..

The association between adverse birth outcomes and smoking cessation during pregnancy across the United States-43 States and New York City, 2012-2017.

PURPOSE: This cross-sectional study aimed to estimate the risks of adverse birth outcomes among pregnant smokers and the benefits of smoking cessation during pregnancy on birth outcomes across the United States. METHODS: We performed an analysis of 203,437 pregnant women using data collected by the Pregnancy Risk Assessment Monitoring System (PRAMS) from 2012 to 2017. PRAMS uses questionnaires and birth certificates to collect information about the socio-demographic characteristics of pregnant women, smoking status before and during pregnancy, and birth outcomes. We assessed the relationship between self-reported smoking status during pregnancy and preterm birth, low birth weight, and small-for-gestational-age using multivariable logistic regression models. RESULTS: In our study population, 80.43% of pregnant women never smoked, 10.55% of pregnant women quit smoking during pregnancy, and 9.02% continued smoking during pregnancy. Puerto Rico had the highest prevalence of non-smokers (94.12%), while West Virginia had the lowest prevalence of non-smokers (60.54%). Pregnant women who had a higher education level, were married, had less than 5 types of stress, and had government or private insurance before pregnancy had a higher prevalence of smokers who quit during pregnancy (quit smokers) than those that continued smoking (continuous smokers). Compared to non-smokers, continuous smokers had a significantly higher risk of low birth weight (AOR: 1.91, 95% CI 1.80, 2.03), preterm birth (AOR: 1.31, 95% CI 1.21, 1.41), and small-for-gestational-age (AOR: 2.22, 95% CI 2.07, 2.39). However, the relationships between quitting smoking and preterm birth and small-for-gestational-age were not significant. CONCLUSION: Our models suggest that smoking cessation during pregnancy can prevent adverse birth outcomes by significantly reducing the risk of preterm birth and small-for-gestational-age to almost comparable to not smoking.

Relationship Between Risks for Obstructive Sleep Apnea, Resistant Hypertension, and Aldosterone Among African American Adults in the Jackson Heart Study.

BACKGROUND: African Americans have a higher prevalence of resistant hypertension compared with Caucasians. Racial differences in obstructive sleep apnea (OSA) and increased aldosterone level may explain the racial disparity in resistant hypertension prevalence. Therefore, the purpose of this study is to investigate if aldosterone level and hypertension status differ by risks for OSA (e.g., obesity, loud snoring, and daytime sleepiness) and how aldosterone level varies with hypertension severity and control among African Americans. METHODS: A cross-sectional analysis was performed using baseline data on 5,052 African American adults in the Jackson Heart Study to investigate the relationships of interest using multivariable linear and multinomial logistic regression models adjusted for potential confounders. Risks for OSA were defined by a "risk score" consisting of the number of risks for OSA. RESULTS: Of the 5,052 participants, 623 had no risks for OSA. Body mass index was the highest among those with a risk score of 6. About 39% of the sample had no hypertension, 29% had controlled hypertension, 26% had uncontrolled hypertension, and 6% had resistant hypertension. Higher odds of having uncontrolled hypertension or resistant hypertension were present in those with a higher risk score compared with those without risks for OSA. Log-aldosterone level increased with each additional risk for OSA (P-trend <0.05). Similarly, log-aldosterone also increased with more severe hypertension (P-trend <0.001). The highest aldosterone level was found in those with resistant hypertension that was inadequately controlled with medications. CONCLUSIONS: Risks for OSA were positively associated with resistant hypertension and higher aldosterone level in African American adults.

Antenatal Depression and Cesarean Delivery Among Recently-Delivered Nulliparous Women in Rhode Island.

OBJECTIVE: Antenatal depression (AD) is frequently cited as a risk factor for cesarean delivery (CD) with limited supporting data. STUDY DESIGN: We utilized 2016-2018 data from the Pregnancy Risk Assessment Monitoring System (PRAMS) survey for the state of Rhode Island. Nulliparous women who reported AD (n=242) were compared to women who did not (n=1,081). Maternal demographics, pregnancy and delivery characteristics were compared by AD status using population-weighted bivariable analyses and multivariable logistic regression. RESULTS: 17.7% reported AD, and 34% underwent CD. There was no difference in CD based on reported AD status (aOR 1.04; 95% CI 0.69, 1.56). However, there were significant differences between those reporting AD compared to those who did not: less education, more public insurance, use of Women, Infants and Children (WIC) benefits, tobacco use, and pre-gestational hypertension/diabetes. CONCLUSION: In this large, population-based, state representative sample, we found no difference in CD among recently delivered nulliparous women with and without AD.

Do Unmet Health Needs Drive Pediatric Emergency Department Utilization?: A Population-Based Assessment.

OBJECTIVE: Lack of access to basic health services is thought to increase emergency department (ED) utilization. This study assessed the relationship between unmet health care needs and pediatric ED utilization in the United States. METHODS: The National Survey of Children's Health was used (2016-2017; n = 71,360). Parent/guardians reported number of ED visits and the presence of unmet health needs (medical, dental, mental health, vision, hearing, other) in the last 12 months. Associations were analyzed using multinomial logistic regression modeling and accounted for the weighting and complex survey design of the National Survey of Children's Health. RESULTS: Children with 2 or more unmet health needs had 3.72 times (95% confidence interval, 2.25-6.16) risk of ≥2 ED visits when compared with those with 0 unmet health needs. This risk became nonsignificant when adjusted for race, ethnicity, age, insurance, having asthma, current medication status, health description, number of preventative health visits, and place to go for preventative health (aRR, 1.77; 95% confidence interval, 0.96-3.27). The adjusted association was also nonsignificant for specific types of unmet needs. Race, insurance status, age 0 to 3 years, current medication status, having asthma, ≥2 preventative visits, and poorer health were associated with ≥2 ED visits. CONCLUSIONS: Unmet health needs were not found to be a significant driving force for ED utilization. Other factors were found to be more strongly associated with it. Future studies to understand the perception, motives, and complex interaction of various factors leading to ED use in high-risk populations may optimize care for these children.

Sounding the Alarm on Sleep: A Negative Association Between Inadequate Sleep and Flourishing.

OBJECTIVE: To assess the national prevalence of inadequate sleep among school-age children and its relationship with childhood flourishing. STUDY DESIGN: This cross-sectional study analyzed 49 050 parental responses from the 2016-2017 National Survey of Children's Health for school-age children. Inadequate sleep duration was defined as <9 hours for 6- to 12-year-olds and <8 hours for 13- to 17-year-olds on an average weeknight. Five markers of flourishing were examined individually and as a combined measure. Logistic regression was used with complex survey design and applied weights. RESULTS: Inadequate sleep was found in 36.4% of 6- to 12-year-olds and in 31.9% of 13- to 17-year-olds. Compared with children with adequate sleep, 6- to 12-year-olds with inadequate sleep had increased odds of not showing interest and curiosity in learning (aOR, 1.61; 95% CI, 1.34-1.94), not caring about doing well in school (aOR, 1.45; 95% CI, 1.23-1.71), not doing homework (aOR, 1.44; 95% CI, 1.24-1.68), and not finishing tasks (aOR, 1.18; 95% CI, 1.03-1.35). Children aged 13-17 years with inadequate sleep had increased odds of not doing homework (aOR, 1.36; 95% CI, 1.17-1.58), not staying calm and in control when challenged (aOR, 1.34; 95% CI, 1.16-1.54), not showing interest and curiosity in learning (aOR, 1.34; 95% CI, 1.14-1.58), not finishing tasks (aOR, 1.20; 95% CI, 1.03-1.40), and not demonstrating the combined flourishing measure (aOR, 1.35; 95% CI, 1.17-1.56). CONCLUSIONS: Nationally representative data show that one-third of school-age children have inadequate sleep. Inadequate sleep is associated with decreased flourishing. These data will help inform sleep policies and optimize child development.

Frequent Emergency Department Use by Children.

OBJECTIVES: Frequent use of the emergency department (ED) is often targeted as a quality improvement metric. The objective of this study was to assess ED visit frequency by the demographic and health characteristics of children who visit the ED to better understand risk factors for high ED utilization. METHODS: The majority of pediatric ED services in Rhode Island are provided by a hospital network that includes the state's only children's hospital. Using 10 years of data (2005-2014) from this statewide hospital network, we examined ED use in this network for all children aged 0 to 17 years. Patients' home addresses were geocoded to assess their neighborhood characteristics. RESULTS: Between 2005 and 2014, 17,844 children visited 1 or more of the network EDs at least once. In their year of maximum use, 67.8% had only 1 ED visit, 20.1% had 2 visits, 6.9% had 3 visits, and 5.2% had 4 or more visits. In the adjusted multinomial logistic regression model, age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the ED were found to be significantly associated with increased visit frequency. CONCLUSIONS: Risk factors for frequent ED use by children include age, race/ethnicity, language, insurance coverage, medical complexity, neighborhood risk, and distance to the hospital. To decrease frequent pediatric ED use, improved medical management of complex medical problems is needed, but it is also essential to address modifiable social determinants of health care utilization in this population.

Children With ADHD Engage in Less Physical Activity.

Background: Children with ADHD should engage in physical activity, given its known role as a treatment adjunct. Objective: The main objective of this study is to assess the relationship between ADHD diagnosis and physical activity among children in the United States. Methods: This retrospective population-based cross-sectional study used data from the 2016 caregiver reported, National Survey of Children's Health (NSCH). Results: In the adjusted binary model, children with an ADHD diagnosis had 21% lower odds of engaging in daily physical activity than their nondiagnosed counterparts. In the adjusted multinomial model, children with ADHD were increasingly unlikely to report additional days of physical activity as compared to those without a diagnosis. Conclusion: Given the known benefits of physical activity for those with ADHD, this study underscores the need for enhanced access to an important treatment adjunct for this population.

Childhood Obesity Is Associated with Poor Academic Skills and Coping Mechanisms.

OBJECTIVE: To assess the relationship between obesity and select childhood flourishing markers including academic skills and coping strategies. STUDY DESIGN: Cross-sectional study utilizing parental reported data for children aged 10-17 years (n = 22 914) from the 2016 National Survey of Children's Health. Multiple binary regressions assessed the association between body mass index-for-age and 5 school-related and behavioral childhood flourishing markers independently and combined, including completing homework, showing interest in learning, finishing tasks, staying calm when challenged, and caring about academics. Analyses were adjusted for age, sex, depression, sleep, digital media exposure, poverty, and parental education level. RESULTS: Only 28.9% of children with obesity were reported to have all 5 markers, compared with 38% with overweight, and 40.5% with normal body mass index. In an adjusted model, children with obesity had significantly decreased odds of demonstrating 4 of 5 markers: showing interest in learning (aOR, 0.78; 95% CI, 0.62-0.97), finishing tasks (aOR, 0.77; 95% CI, 0.63-0.94), staying calm when challenged (aOR, 0.73; 95% CI, 0.59-0.90), and caring about academics (aOR, 0.69; 95% CI, 0.55-0.86). Completing homework was not associated with obesity. Youth with obesity also had 23% decreased odds (aOR, 0.77; 95% CI, 0.61-0.98) of meeting the combined measure for flourishing markers. CONCLUSIONS: Childhood obesity is associated with poor academic skills and coping strategies which may lead to worse individual and public health outcomes. Further studies are needed to create validated flourishing measures and identify interventions that promote healthy youth behavior and academic success.

Transfusion, mortality and hemoglobin level: Associations among emergency department patients in Kigali, Rwanda.

BACKGROUND: Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda. METHODS: This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013-16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL. RESULTS: Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p = 0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51-3.21) as compared to those ≤5.0 mg/dL. CONCLUSIONS: No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice.

Higher education associated with better national tetanus vaccination coverage: A population-based assessment.

Vaccination coverage among United States (U.S.) adults for tetanus continues to be lower than the national goals. Education has demonstrated a positive impact on vaccination coverage. However, recently there have been outbreaks of vaccine preventable conditions in areas with high college completion rates. This study assessed the relationship between education and tetanus vaccination. Data from the 2016 Behavioral Risk Factor Surveillance System (BRFSS), a self-reported annual survey for non-institutionalized adults in the US from the Centers for Disease Control, was analyzed in 2019. The outcome was up-to-date tetanus vaccination if received within the last 10 years. Education was categorized into 1) grade 11 or less, 2) grade 12/GED, 3) college 1-3 years, and 4) college 4 or more years. Bivariate analyses and multivariable logistic regression were conducted on the analytic sample (n = 417,473) using Stata 15, accounting for weighting and the complex survey design. In 2016, 59.9% of U.S. adults had up-to-date tetanus vaccination. Higher education level was associated with increased odds of up-to-date tetanus vaccination. The highest odds were for those with 4 or more years of college education [aOR = 1.31; 95% (CI: 1.26-1.35)]. Female sex, Black (non-Hispanic), unemployed, not being married, not having insurance or a personal health care provider, and above 45 years of age had lower odds of up-to-date tetanus vaccination. Targeted community specific vaccination education programs for those without tertiary education may help enhance the knowledge and thus the overall vaccination status in the U.S.

Transfusion, mortality and hemoglobin level: associations among emergency department patients in Kigali, Rwanda

Background: Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda. Methods: This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013­16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL. Results: Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p=0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51­3.21) as compared to those ≤5.0 mg/dL. Conclusions: No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice

Assessing the Association Between Maternal Education and Access to Pediatric Specialty Care.

Background. Timely access to pediatric specialty care continues to be a pervasive issue. We aimed to identify factors associated with unmet pediatric specialty care needs by assessing the association with maternal level of education. Methods. A sample was extracted from the 2011-2012 National Survey of Children's Health, which identified a subset of patients with unmet specialty care needs. Logistic regression models determined the strength of association between our sample and maternal level of education. Results. An estimated 12.5% of US children had unmet specialty care needs. Independent of confounding variables, children with mothers educated at a level of high school or less were 41% more likely to have unmet specialty care needs compared to those with mothers who were educated at a level greater than high school. Conclusions. Maternal level of education can be used as a risk factor to assess whether a child will have unmet specialty care needs.