Social Transfers for Exclusive Breastfeeding (STEB) Intervention in Lao People's Democratic Republic: Protocol for a Randomized Controlled Trial.

BACKGROUND: Children in Lao People's Democratic Republic (Lao PDR) receive suboptimal nutrition because of low breastfeeding rates, undermining their developmental potential. While major public health campaigns have attempted to increase breastfeeding rates, they have been largely unsuccessful. One explanation for these unsuccessful interventions is the economic and financial constraints faced by mothers. A potential solution for alleviating these pressures is providing social transfers to support breastfeeding; defined as a cash or in-kind transfer. Capitalizing on key strategies used in previous social transfer programs, we will assess the effectiveness of social transfer intervention for increasing exclusive breastfeeding rates in Vientiane, Lao PDR. OBJECTIVE: This study aims to conduct a randomized controlled trial (RCT) designed to assess whether social transfers can increase exclusive breastfeeding rates in Vientiane Capital, Lao PDR. METHODS: A prospective, parallel cluster-RCT was conducted among 300 mothers who recently gave birth and initiated breastfeeding. Enrolling 100 participants for each intervention arm provided us with 80% power to detect an increase in exclusive breastfeeding from the anticipated 21% in the control arm to 40% in either of the 2 intervention arms. Mother-infant dyads were enrolled at approximately 1 month post partum. Follow-up visits will occur at 6 months, 1 year, 2 years, and 3 years post partum; with the ambition to extend the follow-up period. Mother-infant dyads were enrolled between August 2022 and April 2023 with follow-up until 3 years post partum (2026). A local study team comprised of 2 nurses and 2 laboratory technicians is responsible for enrollment and follow-up of participants. Participants were randomly assigned to one of three groups during the baseline, 1-month visit: (1) control group, no social transfer; (2) intervention group 1, an unconditional social transfer at 6 months post partum; and (3) intervention group 2, a social transfer at 6 months post partum conditional upon mothers exclusively breastfeeding. All groups received educational materials supporting mothers to exclusively breastfeed. The primary end point will be exclusive breastfeeding at 6 months post partum. Secondary end points will include exclusive and complementary breastfeeding duration, childhood wasting and stunting, child growth, maternal and infant stress, predictors of early breastfeeding cessation, intestinal inflammation, anemia, maternal weight loss, maternal blood pressure, maternal anxiety, and GRIT personality score. Questionnaires and physical examinations were used to collect information. RESULTS: As of November 2023, the study has enrolled 300 participants. Study participation is ongoing until December 2026 at minimum. Over the study lifetime, 93% have completed all visits. CONCLUSIONS: We see potential for a long-term program that may be implemented in other low- or lower-middle-income countries with only minor modifications. The RCT will be used as a basis for observational studies and to investigate the impact of human milk on child fecal microbiota and growth. TRIAL REGISTRATION: ClinicalTrials.gov NCT05665049; https://clinicaltrials.gov/study/NCT05665049. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54768.

Prenatal exposure to polybrominated diphenyl ether (PBDE) and child neurodevelopment: The role of breastfeeding duration.

BACKGROUND: Prenatal and early-life exposure to polybrominated diphenyl ethers (PBDEs) is associated with detrimental and irreversible neurodevelopmental health outcomes during childhood. Breastfeeding may be a child's largest sustained exposure to PBDE- potentially exacerbating their risk for adverse neurodevelopment outcomes. However, breastfeeding has also been associated with positive neurodevelopment. Our study investigates if breastfeeding mitigates or exacerbates the known adverse effects of prenatal exposure to PBDEs and child neurodevelopment. METHODS: Participants included 321 mother-infant dyads from the Center for the Health Assessment of Mothers and Children of Salinas (CHAMACOS), a longitudinal birth cohort in California. PBDE concentrations were measured in maternal serum blood samples collected during pregnancy or at delivery. Using generalized estimated equations (GEE), we estimated associations of PBDE concentrations with children's attention, executive function, and cognitive scores assessed longitudinally between 7 and 12 years of age, stratified by duration of exclusive and complementary breastfeeding. RESULTS: We observed that higher maternal prenatal PBDE concentrations were associated with poorer executive function among children who were complementary breastfed for a shorter duration compared to children breastfed for a longer duration; preservative errors (ß for 10-fold increase in complementary breastfeeding <7 months = -6.6; 95 % Confidence Interval (CI): -11.4, -1.8; ß ≥ 7 months = -5.1; 95 % CI: -10.2, 0.1) and global executive composition (ß for 10-fold increase <7 months = 4.3; 95 % CI: 0.4, 8.2; ß for 10-fold increase ≥7 months = 0.6; 95 % CI: -2.8, 3.9). CONCLUSIONS: Prolonged breastfeeding does not exacerbate but may mitigate some previously observed negative associations of prenatal PBDE exposure and child neurodevelopment.

Plasma concentrations of per- and polyfluoroalkyl substances in pregnancy and breastfeeding duration in Project Viva.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) may disrupt mammary gland development and function; thereby inhibiting milk supply and breastfeeding duration. However, conclusions on the potential effects of PFAS and breastfeeding duration are limited by prior epidemiologic studies that inconsistently adjusted for past cumulative breastfeeding duration and by a lack of examination of the joint effects of PFAS mixtures. METHODS: In Project Viva, a longitudinal cohort that enrolled pregnant participants from 1999 to 2002 in the greater Boston, MA area, we studied 1079 women who ever attempted to lactate. We investigated associations of plasma concentrations of select PFAS in early pregnancy (mean: 10.1 weeks gestation) with breastfeeding termination by 9 months, after which women typically cite self-weaning as the reason for terminating breastfeeding. We used Cox regression for single-PFAS models and quantile g-computation for mixture models, adjusting for sociodemographics, prior breastfeeding duration, and weeks of gestation at the time of blood draw. RESULTS: We detected 6 PFAS [perfluorooctane sulfonate; perfluorooctanoate (PFOA); perfluorohexane sulfonate; perfluorononanoate; 2-(N-ethyl-perfluorooctane sulfonamido) acetate (EtFOSAA); 2-(N-methyl-perfluorooctane sulfonamide) acetate (MeFOSAA)] in >98 % of samples. Sixty percent of lactating women terminated breastfeeding by 9 months postpartum. Women with higher plasma concentrations of PFOA, EtFOSAA, and MeFOSAA had a greater hazard of terminating breastfeeding in the first 9 months postpartum [HR (95 % CI) per doubling concentration: 1.20 (1.04, 1.38) for PFOA; 1.10 (1.01, 1.20) for EtFOSAA; 1.18 (1.08, 1.30) for MeFOSAA]. In the quantile g-computation model, simultaneously increasing all PFAS in the mixture by one quartile was associated with 1.17 (95 % CI: 1.05, 1.31) greater hazard of terminating breastfeeding in the first 9 months. CONCLUSION: Our findings suggest that exposure to PFAS may be associated with reduced breastfeeding duration and draw further attention to environmental chemicals that may dysregulate human lactation.

Dynamics and consequences of nutrition-related microbial dysbiosis in early life: study protocol of the VITERBI GUT project.

Introduction: Early life under- and overnutrition (jointly termed malnutrition) is increasingly recognized as an important risk factor for adult obesity and metabolic syndrome, a diet-related cluster of conditions including high blood sugar, fat and cholesterol. Nevertheless, the exact factors linking early life malnutrition with metabolic syndrome remain poorly characterized. We hypothesize that the microbiota plays a crucial role in this trajectory and that the pathophysiological mechanisms underlying under- and overnutrition are, to some extent, shared. We further hypothesize that a "dysbiotic seed microbiota" is transmitted to children during the birth process, altering the children's microbiota composition and metabolic health. The overall objective of this project is to understand the precise causes and biological mechanisms linking prenatal or early life under- or overnutrition with the predisposition to develop overnutrition and/or metabolic disease in later life, as well as to investigate the possibility of a dysbiotic seed microbiota inheritance in the context of maternal malnutrition. Methods/design: VITERBI GUT is a prospective birth cohort allowing to study the link between early life malnutrition, the microbiota and metabolic health. VITERBI GUT will include 100 undernourished, 100 normally nourished and 100 overnourished pregnant women living in Vientiane, Lao People's Democratic Republic (PDR). Women will be recruited during their third trimester of pregnancy and followed with their child until its second birthday. Anthropometric, clinical, metabolic and nutritional data are collected from both the mother and the child. The microbiota composition of maternal and child's fecal and oral samples as well as maternal vaginal and breast milk samples will be determined using amplicon and shotgun metagenomic sequencing. Epigenetic modifications and lipid profiles will be assessed in the child's blood at 2 years of age. We will investigate for possible associations between metabolic health, epigenetics, and microbial changes. Discussion: We expect the VITERBI GUT project to contribute to the emerging literature linking the early life microbiota, epigenetic changes and growth/metabolic health. We also expect this project to give new (molecular) insights into the mechanisms linking malnutrition-induced early life dysbiosis and metabolic health in later life, opening new avenues for microbiota-engineering using microbiota-targeted interventions.

Association between mother's work status and child stunting in urban slums: a cross-sectional assessment of 346 child-mother dyads in Dhaka, Bangladesh (2020).

BACKGROUND: A growing literature highlights the increased risk of stunting among children growing up in informal or slum settlements. Despite relatively high rates of female labor force participation in slums, there is limited evidence on relationship between mother's work participation and nutritional outcomes of children in these settings. METHODS: We conducted a cross-sectional study in two large slums (Korail and Tongi) of Dhaka and Gazipur, Bangladesh to assess the association between maternal work and childhood stunting in a low-income urban context. Logistic regression models estimated unconditional and conditional associations between maternal work status and 1) child stunting, 2) child morbidity and dietary intake, and 3) health and hygiene behaviors. Subgroup analyses were done by type of child care support available. RESULTS: After adjusting for variations in individual and household level characteristics, we found that children of working mothers had nearly twice the odds of being stunted than children of non-working mothers (OR 1.84, 95%CI 1.05-3.23). Large differences in stunting were found by available care support: compared to children of non-working mothers, children of working mothers with nuclear-type family support had 4.5 times increased odds of stunting (OR 4.49, 95%CI 1.81-11.12), while no odds differential was found for children of working mothers with an extended-type family support (OR 0.69, 95%CI 0.30-1.59). CONCLUSIONS: Maternal employment is associated with a substantial increase in the odds of child stunting in the slum areas studied. Given that these effects only appear to arise in the absence of adequate family support, integrating appropriate childcare support measures for low-income urban working mothers might be an effective strategy to help reduce the prevalence of chronic undernutrition among slum children.

Housing Insecurity, Housing Conditions, and Breastfeeding Behaviors for Medicaid-Eligible Families in Urban Settings.

BACKGROUND: Research exploring associations between exposure to social determinants of health and breastfeeding is needed to identify breastfeeding barriers. Housing insecurity and household conditions (chaos and crowding) may affect breastfeeding by increasing maternal stress and discomfort and decreasing time available to breastfeed. RESEARCH AIM: We aimed to examine the relationships between housing insecurity, breastfeeding exclusivity intention during the early postnatal period, and breastfeeding exclusivity at 6 months postpartum among a sample "at risk" for suboptimal breastfeeding rates. METHODS: This study is a secondary data analysis of a longitudinal study at two time periods. Data were collected from English- and Spanish-speaking, Medicaid-eligible mother-infant dyads (N = 361) at near-birth and child aged 6 months, in New York City and Pittsburgh. Structural equation modeling was used to examine direct and indirect effects of housing insecurity on breastfeeding exclusivity at child aged 6 months. RESULTS: The path model showed that experiencing more markers of housing insecurity (i.e., foreclosure/eviction threat, history of homelessness, late rent) was predictive of significantly lower breastfeeding exclusivity at 6 months. This was partially mediated through less exclusive breastfeeding intention during the early postnatal period. Greater household crowding was associated with 6-month breastfeeding exclusivity when mediated by intention. Household crowding had differential effects by study site and participant race/ethnicity. CONCLUSION: Refinement of housing insecurity as a multi-dimensional construct can lead to the development of standardized data collection instruments, inform future methodological decisions in research addressing social determinants of health, and can inform the development of responsive individual- and structural-level interventions.The data used in this study were collected as part of the SMART Beginnings Randomized Controlled Trial (NCT02459327 registered at ClinicalTrials.gov).

Intestinal microbiota research from a global perspective.

The intestinal microbiota plays a crucial role in health and changes in its composition are linked with major global human diseases. Fully understanding what shapes the human intestinal microbiota composition and knowing ways of modulating the composition are critical for promotion of life-course health, combating diseases, and reducing global health disparities. We aim to provide a foundation for understanding what shapes the human intestinal microbiota on an individual and global scale, and how interventions could utilize this information to promote life-course health and reduce global health disparities. We briefly review experiences within the first 1,000 days of life and how long-term exposures to environmental elements or geographic specific cultures have lasting impacts on the intestinal microbiota. We also discuss major public health threats linked to the intestinal microbiota, including antimicrobial resistance and disappearing microbial diversity due to globalization. In order to promote global health, we argue that the interplay of the larger ecosystem with intestinal microbiota research should be utilized for future research and urge for global efforts to conserve microbial diversity.

Evaluation of an Electronic Health Record Alert to Improve Screening and Management of Cardiovascular Disease and Stroke Factors in a High-Risk Population.

OBJECTIVES: Cardiovascular disease and stroke risk factor screening and management by primary care providers (PCPs) have a significant impact on their patients' health. The objective of this study was to investigate the effectiveness of an electronic health record (EHR) cardiovascular disease and stroke risk alert in improving the ability of PCPs to manage risk factors among women and men aged 45 years and older. METHODS: PCPs at a tertiary care hospital were randomized. The intervention group received an EHR alert, which calculated the individual patient risk and provided an order set incorporating the American Heart Association and American Stroke Association guidelines, whereas the control group used the EHR in the usual manner. Multilevel analysis compared the rate of prescriptions between the intervention and control groups. RESULTS: A total of 23 PCPs were randomized: 12 in the intervention group and 11 in the control group, attending to 7190 patients between September 2016 and January 2017. None of the providers in the intervention group used the programmed order set. Intervention group providers were significantly more likely to prescribe smoking cessation medication to women than to the control group (adjusted odds ratio 2.37, 95% confidence interval 1.23-4.57). There were no statistically significant differences between the intervention and control groups in the rate of other medication prescriptions. CONCLUSIONS: As measured by prescriptions for medications, other than those for smoking cessation, the EHR alert was not shown to be successful in increasing the management of high-risk patients. Physicians receiving numerous messages in the EHR may experience alert desensitization.

Breastmilk, Stool, and Meconium: Bacterial Communities in South Africa.

Human milk optimizes gut microbial richness and diversity, and is critical for proper immune development. Research has shown differing microbial composition based on geographic location, providing evidence that diverse biospecimen data is needed when studying human bacterial communities. Yet, limited research describes human milk and infant gut microbial communities in Africa. Our study uses breastmilk, stool, and meconium samples from a South African birth cohort to describe the microbial diversity, identify distinct taxonomic units, and determine correlations between bacterial abundance in breastmilk and stool samples. Mother-infant dyads (N = 20) were identified from a longitudinal birth cohort in the Vhembe district of Limpopo Province, South Africa. Breastmilk, meconium, and stool samples were analyzed using 16S ribosomal RNA sequencing of the V4-V5 gene region using the MiSeq platform for identification and relative quantification of bacterial taxa. A non-metric multidimensional scaling using Bray-Curtis distances of sample Z-scores showed that meconium, stool, and breastmilk microbial communities are distinct with varying genus. Breastmilk was mostly comprised of Streptococcus, Staphylococcus, Veillonella, and Corynebacterium. Stool samples showed the highest levels of Bifidobacterium, Faecalibacterium, Bacteroides, and Streptococcus. Alpha diversity measures found that stool samples have the highest Shannon index score compared to breastmilk and meconium. The abundance of Bifidobacterium (r = 0.57), Blautia (r = 0.59), and Haemophilus (r = 0.69) was correlated (p < 0.1) between breastmilk and stool samples. Despite the importance of breastmilk in seeding the infant gut microbiome, we found evidence of distinct bacterial communities between breastmilk and stool samples from South African mother-infant dyads.

Parental Cohabitation and Breastfeeding Outcomes Among United States Adolescent Mothers.

AbstractBackground: Adolescent mothers in the United States experience disproportionately lower rates of breastfeeding compared to older mothers. Evidence suggests that paternal support helps improve breastfeeding outcomes; however, support is difficult to quantify. Parental cohabitation is easy to identify and could be used to quantify paternal support. Research Aim: Our study is to investigate the association between parental cohabitation and breastfeeding initiation and duration among US adolescent mothers. Materials and Methods: Data from the 2011-2017 National Survey of Family Growth were used. Our study sample included primipara, adolescent mothers (aged 15-19 years) who gave birth to a singleton (n = 1,867). Multivariate logistic regression and Cox Proportional Hazards models were used to analyze the relationship between cohabitation and breastfeeding initiation and duration, respectively. All models were subsequently stratified by race/ethnicity due to evidence of effect modification. Results: After adjusting for all a priori confounders, cohabiting with the infant's father at birth was associated with increased odds of breastfeeding initiation compared to noncohabiting adolescent mothers (odds ratio [OR]: 1.5, 95% confidence interval [CI]: 1.08-2.16). After stratifying by race/ethnicity, both Hispanic and non-Hispanic white adolescent mothers were more likely to initiate breastfeeding if cohabiting with the infant's father (ORHispanic: 1.9, 95% CI: 1.10-3.35; ORNon-Hispanic white: 1.7, 95% CI: 1.05-2.87). We found no evidence of an association between parental cohabitation and breastfeeding duration. Conclusions: Our study found evidence that cohabitation status at birth increases the odds of breastfeeding initiation in adolescent mothers. Practitioners should consider cohabitation status when working with adolescent mothers.

Understanding urban inequalities in children's linear growth outcomes: a trend and decomposition analysis of 39,049 children in Bangladesh (2000-2018).

BACKGROUND: Despite significant progress in reducing child undernutrition, Bangladesh remains among the top six countries globally with the largest burden of child stunting and has disproportionately high stunting prevalence among the urban poor. We use population representative data to identify key predictors of child stunting in Bangladesh and assess their contributions to linear growth differences observed between urban poor and non-poor children. METHODS: We combined six rounds of Demographic and Health Survey data spanning 2000-2018 and used official poverty rates to classify the urban population into poor and non-poor households. We identified key stunting determinants using stepwise selection method. Regression-decomposition was used to quantify contributions of these key determinants to poverty-based intra-urban differences in child linear growth status. RESULTS: Key stunting determinants identified in our study predicted 84% of the linear growth difference between urban poor and non-poor children. Child's place of birth (27%), household wealth (22%), maternal education (18%), and maternal body mass index (11%) were the largest contributors to the intra-urban child linear growth gap. Difference in average height-for-age z score between urban poor and non-poor children declined by 0.31 standard deviations between 2000 and 2018. About one quarter of this observed decrease was explained by reduced differentials between urban poor and non-poor in levels of maternal education and maternal underweight status. CONCLUSIONS: Although the intra-urban disparity in child linear growth status declined over the 2000-2018 period, socioeconomic gaps remain significant. Increased nutrition-sensitive programs and investments targeting the urban poor to improve girls' education, household food security, and maternal and child health services could aid in further narrowing the remaining linear growth gap.

Urban-Rural Gaps in Breastfeeding Practices: Evidence From Lao People's Democratic Republic.

Objectives: Breastfeeding rates are decreasing rapidly in many low and middle-income countries, disproportionately affecting urban residences. We use data from Lao People's Democratic Republic to identify primary mechanisms underlying the urban-rural gap in breastfeeding practices. Methods: We used data from the 2017 Lao Social Indicator Survey II. Residence was categorized as large-urban (>1 million), small-urban (<1 Million), and rural. Multivariable logistic regression provided odds ratios and 95% confidence intervals (CI) to identify factors attributing to the urban-rural differences in complying with World Health Organization's breastfeeding recommendations for children <24 months. Results: Mothers in large-urban residences had 3.78 (95% confidence intervals: 1.19, 11.95) and 4.67 (95% CI: 2.30, 9.46) higher odds of non-compliance with exclusive and complementary breastfeeding recommendations, respectively, than mothers living in rural areas in bivariate models. Breastfeeding differentials between small urban and rural residences were largely explained by differences in maternal education and household wealth. Conclusion: Results of our paper suggest large disparities in breastfeeding practices between large-urban, small-urban, and rural residences.

Socio-cultural factors for breastfeeding cessation and their relationship with child diarrhoea in the rural high-altitude Peruvian Andes - a qualitative study.

BACKGROUND: In some areas of the world, breast milk is seen as a potential source of child diarrhoea. While this belief has been explored in African and Southeast Asian countries, it remains vastly understudied in Latin American contexts. We investigate socio-cultural factors contributing to breastfeeding cessation in rural high-altitude populations of the Peruvian Andes. The role of socio- cultural factors in the local explanatory model of child diarrhoea, and whether these perceptions were integrated in the local healthcare system were assessed. METHODS: Within the framework of a randomised controlled trial, we conducted semi-structured interviews with 40 mothers and 15 health personnel from local healthcare centres involved in the trial. RESULTS: Cultural beliefs on breastfeeding cessation included the perception that breast milk turned into "blood" after six months and that breastfeeding caused child diarrhoea. We identified eight local types of child diarrhoea, and women linked six of them with breastfeeding practices. "Infection" was the only diarrhoea mothers linked to hygiene and the germ disease concept and perceived as treatable through drug therapy. Women believed that other types of diarrhoea could not be treated within the formal healthcare sector. Interviews with health personnel revealed no protocol for, or consensus about, the integration of the local explanatory model of child diarrhoea in local healthcare and service provision. CONCLUSIONS: The local explanatory model in rural Andean Peru connected breastfeeding with child diarrhoeas. Cultural beliefs regarding diarrhoea management may increase home treatments, even in cases of severe diarrhoeal episodes. Future national breastfeeding support programmes should promote peer-counselling approaches to reduce negative attitudes towards breastfeeding and health practitioners. Local explanatory models should be incorporated into provincial and regional strategies for child diarrhoea management to promote equity in health and improve provider-patient relationships.

RESUMEN: ANTECEDENTES: En diferentes partes del mundo, la leche materna es percibida como una fuente potencial de diarreas infantiles. Mientras que estas creencias se han estudiado en África o el Sudeste Asiático, su análisis en el contexto latinoamericano es limitado. Esta investigación se centra en el estudio de los factores culturales que contribuyen al cese de la lactancia materna en poblaciones rurales de los Andes peruanos. Al mismo tiempo, también se analiza el papel de estos factores culturales en el modelo explicativo local de diarreas infantiles y la integración de las creencias en los servicios locales de salud. MéTODOS: Dentro de un ensayo clínico aleatorizado, se llevaron a cabo entrevistas semi-estructuradas con 40 mujeres y 15 trabajadores de salud de centros participantes en el ensayo. RESULTADOS: Las creencias culturales en torno a la lactancia maternal incluían la percepción de que la leche materna se convierten en "sangre" a los seis meses del parto y que la leche materna causaba diarreas en los niños lactantes. Identificamos ocho tipos de diarreas locales, seis de las cuales fueron asociadas con la lactancia por las madres participantes. "Infección" resultó ser el único tipo de diarrea que las madres asociaron con los principios de la higiene y la teoría microbiana de la enfermedad y percibían como curable por medio de medicamentos. Las mujeres creían que el resto de diarreas locales no podían ser tratadas dentro del sistema de salud. Las entrevistas con el personal sanitario indicaron una falta de protocolos y consenso sobre cómo integrar el sistema de creencias locales en torno a las diarreas infantiles en los servicios de salud. CONCLUSIONES: El modelo explicativo local en zonas rurales de los Andes peruanos asocia la lactancia con las diarreas infantiles. Estas creencias culturales dan lugar a prácticas de manejo de diarreas infantiles que pueden incrementar los tratamientos domiciliarios, incluso en episodios de diarrea severos. Futuros programas nacionales de apoyo a la lactancia materna deben promover la consejería y apoyo de pares y profesionales de salud con la finalidad de reducir las actitudes negativas hacia la lactancia materna y el personal de salud. Los modelos explicativos locales de las diarreas infantiles deberían incorporarse a las estrategias provinciales y regionales con la finalidad de promover la equidad en salud y mejorar las relaciones médico-paciente.

The additive effect of interpregnancy interval and maternal body mass index on pregnancy induced hypertension in the U.S.

OBJECTIVES: The incidence of pregnancy induced hypertension (PIH), one of the most frequent causes of maternal and neonatal morbidity, has increased significantly in the U.S. in last two decades. However, reasons for this rise are not well explored. The interrelationship between interpregnancy interval (IPI), prepregnancy body mass index (BMI), and PIH might play a role in this rise. This study aims to investigate the additive effect of IPI and prepregnancy BMI on PIH. STUDY DESIGN: The 2018 Vital Statistics Natality Data was analyzed (N = 1,046,350) for this cross-sectional study. A combined variable was created using IPI and prepregnancy BMI. Adjusted odds ratios and 95% confidence intervals were generated for IPI, prepregnancy BMI, and PIH using multiple logistic regression models. MAIN OUTCOME MEASURE: PIH was defined using the birth certificate variable 'Gestational hypertension- (PIH, preeclampsia)' in the dataset. RESULTS: IPI and prepregnancy BMI were statistically significantly associated with PIH, both independently and in combination, after adjusting for potential confounders. The largest effect size was observed among women with long IPI and obesity (Adjusted OR = 4.01, 95% CI = 3.84, 4.25). Further, short IPI in combination with underweight BMI was found to be inversely associated with PIH (AOR = 0.64, 95% CI = 0.53, 0.78). CONCLUSIONS: When combined, IPI and BMI are crucial risk factors for PIH. The highest risk of PIH is in women with long IPI in combination with high BMI categories. Healthcare professionals should be cognizant of the additional increased risk of PIH for the overweight and obese women with long IPI.

Breastfeeding, Physical Growth, and Cognitive Development.

BACKGROUND AND OBJECTIVES: Breastfeeding is an evidence-based recommendation for all countries, but breastfeeding rates have been declining in many middle-income settings. One reason behind this decline is the perception that breastfeeding may not be necessary in modern urban settings, where clean water is available and alternative foods are abundant. We investigate the importance of breastfeeding for early childhood development in the modern urban context of São Paulo, Brazil. METHODS: In our study, we used data from the ongoing prospective Western Region Birth cohort in São Paulo, Brazil. Children were recruited at birth and managed for 3 years. Durations of exclusive and mixed breastfeeding were our primary independent variables. Our secondary independent variable was an indicator for compliance with World Health Organization (WHO) breastfeeding recommendations. Our primary outcomes of interest were indicators of children's physical, cognitive, language, and social-emotional development at 3 years of age. Adjusted estimates and 95% confidence intervals were calculated by using linear and logistic regression. RESULTS: Complying with WHO recommendations to exclusively breastfeed for 6 months followed by complementary feeding until 2 years of age was associated with a 0.4-SD increase in overall child development (ß: .38; confidence limit = 0.23 to 0.53), a 0.6-SD increase in height-for-age z score (ß: .55; confidence limit = 0.31 to 0.79), and a 67% decrease in the odds of stunting (odds ratio = 0.33; 95% confidence interval = 0.20 to 0.54). CONCLUSIONS: Our results suggest that even in settings with easy access to complementary foods, complying with WHO breastfeeding recommendations is important for healthy physical growth and cognitive development.

Female genital mutilation and contraceptive use: findings from the 2014 Egypt demographic health survey.

OBJECTIVES: Female genital mutilation (FGM) includes procedures that remove partial or total external female genitalia, or causes other injury to female genital organs with no medical reason. Physical and psychological trauma associated with FGM may interfere with a woman's ability and intent to utilize contraception. Our study examines the association between FGM and utilization of contraception methods among sexually active reproductive-aged women in Egypt. METHODS: Data from the 2014 Egypt Demographic and Health Survey were analyzed (n = 20,055). Multinomial logistic regression was used to obtain odds ratios (OR) and 95% confidence intervals. RESULTS: Our study found that FGM was performed on over 90% of Egyptian women and almost half (45%) of women did not use contraception. Women with FGM had significantly lower odds (OR = 0.6) of using barrier/natural contraceptive methods (e.g., condoms) than intrauterine devices (IUDs). However, women with FGM were more likely to use hormonal methods (OR = 1.2) than IUDs compared to those who had not experienced FGM. CONCLUSIONS: In order to promote women's health and support use of effective contraception methods, a large reduction in FGM practice is essential.

Prenatal Depression Severity and Postpartum Care Utilization in a Medicaid Population.

Background: Postpartum visits are a necessary continuum of medical care for women who are diagnosed with depression during pregnancy. However, postpartum care utilization is typically lower in populations who face adverse events and it is unclear to what extent having depression during pregnancy may compromise postpartum visit follow-up. Our study examined the association between severity of prenatal depression and postpartum care utilization among women on Medicaid. Materials and Methods: Data from a university-based, nonprofit managed care organization (2008-2012) were analyzed (N = 846). Prenatal depression severity and postpartum care utilization were determined using the International Classification of Diseases, Ninth Revision (ICD-9) codes, from medical claims records. Bivariate and multivariable logistic regression was conducted. Odds ratios and 95% confidence intervals (CIs) were calculated. Results: The majority (64.2%) of women received a mild/moderate prenatal depression diagnosis and 52.5% of the total sample attended their postpartum care visit. After adjusting for confounders, we found decreased odds of postpartum care utilization among women with less severe diagnoses. Women with a mild/moderate prenatal depression diagnosis were 12% less likely to attend the postpartum care visit compared with women with a severe prenatal depression diagnosis (adjusted odds ratio = 0.88, 95% CI = 0.65-1.19). However, this finding was not statistically significant. Conclusions: Our study did not yield evidence of a statistically significant relationship between prenatal depression severity and postpartum visit attendance among a sample of Medicaid beneficiaries. Additional research is needed to assess the association between prenatal depression severity and postpartum care use to enhance continuity of services for Medicaid-insured women into the postpartum period.

Importance of Familial Opinions on Breastfeeding Practices: Differences Between Father, Mother, and Mother-in-Law.

Background: Multiple types of individuals compose a mother's social support network. Women may value opinions of individuals' within their support network differently. Our study examined the relationship between breastfeeding opinions from individuals within the social support network and breastfeeding initiation and duration. Materials and Methods: Data from the Infant Feeding Practices Survey II were analyzed. The importance of individuals' opinions on a mother's breastfeeding decision was investigated for the baby's father, the participant's mother and mother-in-law, the infant's pediatrician, and the participant's obstetrician. The main outcomes were breastfeeding initiation (yes; no) and breastfeeding duration (weeks). Logistic regression provided the odds of never breastfeeding, while Cox proportional hazard models were used to assess the risk of breastfeeding cessation. Results: Women who stated that the father's opinion was not at all important were more likely to never breastfeed and prematurely cease breastfeeding compared to women who stated that the father's opinion was very important for their breastfeeding decisions. Conversely, women had lower odds of never breastfeeding and a decreased risk of breastfeeding cessation if they reported that the mother-in-law's opinion was not at all important or not very important compared to women who reported that the mother-in-law was very important. No statistically significant relationship was found between the participant's mother and breastfeeding initiation and cessation. Conclusion: This study found a hierarchical association between individuals in a social support network and breastfeeding initiation and duration. Inverse relationships were found between the importance of fathers' and mother-in-laws' opinions. Interventions aimed at increasing breastfeeding initiation, and duration rates should include a wider range of individuals within a social support network.

Marital Status Disruptions and Internalizing Disorders of Children.

Marital disruption (i.e., separation or divorce) impacts an estimated 40-50% of married couples. Previous research has shown that marital disruption results in negative health outcomes for children and adolescents. Our study aims to investigate the relationship between marital disruptions and internalizing disorders of children in a prospective cohort. Comparisons between marital status groups at each time point showed a significant difference in CBCL score between children in married and unmarried families at 3 years of age, with children in unmarried families having a 0.10 higher standardized CBCL score (95% CI: 0.09-0.12; p<.0001). Differences in CBCL score by marital status were not significant at 5 and 9 years after adjusting for confounders. Parental marital status is associated with an increased CBCL internalizing behavior score at 3 years of age, but the association disappears at later time points.

Interracial couples and breastfeeding initiation in the United States.

In the past decade, the prevalence of interracial couples has steadily increased. Recent reports state that nearly one in five marriages are between spouses of different races. Interracial couples receive less social support and are more likely to separate. As a result, children born to these couples may be at an increased risk of poor health outcomes. This study aims to investigate the relationship between interracial couples and breastfeeding initiation. Data from the 2014 Vital Statistics Natality Birth database were analyzed. Data were restricted to singleton births and infants with no congenital malformations. Racial composition of parents was categorized as non-Hispanic (NH) white, NH black; Hispanic; NH white/NH black; NH white/Hispanic; and NH black/Hispanic. Breastfeeding initiation (yes; no) was categorized according to information from the child's birth certificate file. Multiple logistic regression was used to generate crude and adjusted odds ratios and 99% confidence intervals. After adjusting for confounders, all interracial couples with at least one Hispanic parent had increased odds of breastfeeding initiation. Interracial white and black parents had 18% lower odds of breastfeeding initiation. The lowest odds of breastfeeding initiation were observed among intraracial black parents, who had 43% lower odds of breastfeeding initiation compared to intraracial white parents. Breastfeeding non-initiation continues to pose the greatest risk for infants with at least one black parent. Nurses, midwives, physicians, and other medical staff should discuss potential barriers that may be unique to interracial couples and provide additional breastfeeding education and support.