Predictors of Breastfeeding Initiation and Maintenance in an Integrated Healthcare Setting.

BACKGROUND: The American Academy of Pediatrics recommends exclusive breastfeeding to age 6 months. Although breastfeeding rates in the United States have been increasing over time, further improvements are needed to meet Healthy People 2020 targets. Research aim: This study examined predictors of breastfeeding initiation and maintenance among a population of insured pregnant women. METHODS: Participants were 1,149 pregnant women enrolled in the Pregnancy and Influenza Project in two Kaiser Permanente regions in 2010-2011. Data were collected through interviews at enrollment and 1 month and 6 months postpartum and through participants' electronic medical records. RESULTS: Nearly all (99%) women reported initiating breastfeeding. Rates of exclusive breastfeeding were 70% and 54% at 1 month and 6 months, respectively; an additional 22% and 23% of women reported supplementing breastfeeding with formula. Of the women who supplemented, the mean ( SD) infant age at formula introduction was 53 (62) days. Of those who had stopped breastfeeding, the mean ( SD) infant age at cessation was 85 (59) days. Higher maternal education level, better maternal self-rated health, prenatal folic acid use, absence of chronic medical conditions, and infant full-term birth were significantly associated with breastfeeding maintenance. CONCLUSION: Although rates of breastfeeding in this population were higher than national rates, a significant number of women stopped breastfeeding or introduced formula earlier than recommended. Two to 3 months postpartum may be a critical period warranting additional encouragement or intervention by healthcare providers. Mothers' education attainment, maternal health factors, and gestational age at delivery may predict likelihood of breastfeeding maintenance.

Factors associated with seasonal influenza vaccination in pregnant women.

BACKGROUND: This observational study followed a cohort of pregnant women during the 2010-2011 influenza season to determine factors associated with vaccination. METHODS: Participants were 1105 pregnant women who completed a survey assessing health beliefs related to vaccination upon enrollment and were then followed to determine vaccination status by the end of the 2010-2011 influenza season. We conducted univariate and multivariate analyses to explore factors associated with vaccination status and a factor analysis of survey items to identify health beliefs associated with vaccination. RESULTS: Sixty-three percent (n=701) of the participants were vaccinated. In the univariate analyses, multiple factors were associated with vaccination status, including maternal age, race, marital status, educational level, and gravidity. Factor analysis identified two health belief factors associated with vaccination: participant's positive views (factor 1) and negative views (factor 2) of influenza vaccination. In a multivariate logistic regression model, factor 1 was associated with increased likelihood of vaccination (adjusted odds ratio [aOR]=2.18; 95% confidence interval [CI]=1.72-2.78), whereas factor 2 was associated with decreased likelihood of vaccination (aOR=0.36; 95% CI=0.28-0.46). After controlling for the two health belief factors in multivariate analyses, demographic factors significant in univariate analyses were no longer significant. Women who received a provider recommendation were about three times more likely to be vaccinated (aOR=3.14; 95% CI=1.99-4.96). CONCLUSION: Pregnant women's health beliefs about vaccination appear to be more important than demographic and maternal factors previously associated with vaccination status. Provider recommendation remains one of the most critical factors influencing vaccination during pregnancy.

Antidepressant medication use, depression, and the risk of preeclampsia.

OBJECTIVE: To assess the effects of depression and antidepressant medication use during pregnancy on the risk of preeclampsia. METHODS: We conducted a retrospective, population-based cohort study that linked automated clinical and pharmacy databases including comprehensive electronic medical records of 21,589 pregnant Kaiser Permanente Northern California members between 2010 and 2012. RESULTS: The overall risk of preeclampsia was 4.5%. The timing of antidepressant medication exposure was an important factor. A significant increase in the risk of preeclampsia emerged for women with a depression diagnosis who took antidepressant medications during the second trimester compared to women with untreated depression (adjusted relative risk [aRR]: 1.6, 95% CI: 1.06, 2.39) and to women without depression (aRR: 1.70, 95% CI: 1.30, 2.23). Similar associations existed for women who took antidepressant medications, but without depression. In contrast, depressed women with psychotherapy showed no increased risk of preeclampsia compared to women with untreated depression or no depression. There was also a statistically significant relationship between the duration of antidepressant medication use and preeclampsia. The observed association appeared stronger for selective serotonin reuptake inhibitor (SSRI) use, although a nonsignificant trend was also noted for use of norepinephrine-dopamine reuptake inhibitors (NDRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). CONCLUSION: Study findings suggest that antidepressant use during pregnancy may increase the risk of preeclampsia, especially use during the second trimester.

The association between influenza vaccination and other preventative health behaviors in a cohort of pregnant women.

OBJECTIVES: Although pregnant women are a high-priority group for seasonal influenza vaccination, vaccination rates in this population remain below target levels. Previous studies have identified sociodemographic predictors of vaccine choice, but relationships between preconception heath behaviors and seasonal influenza vaccination are poorly understood. This prospective cohort study followed pregnant women during the 2010-2011 influenza season to determine if certain health behaviors were associated with vaccination status. METHOD: Participants were pregnant women receiving prenatal care from Kaiser Permanente Northwest and Kaiser Permanente Northern California. Women were surveyed about preconception smoking, alcohol consumption, and vitamin/supplement use. Vaccination data were obtained from health plan databases and state immunization records. RESULTS: Data from 1,204 women were included in this analysis. Most participants (1,204; 66.4%) received a seasonal influenza vaccine during the study period. Women vaccinated prior to pregnancy were more likely to use a supplement containing folic acid (80%) or vitamin D (30%) compared with women who were vaccinated during pregnancy (72% and 15%, respectively) or unvaccinated women (62% and 12%, respectively, p < .001). Women vaccinated prior to or during pregnancy were more likely (75%) to have never smoked compared with women who were not vaccinated (70%, p = .005). There were no significant differences in alcohol use or household cigarette smoke exposure by vaccination group. CONCLUSIONS: Women who engaged in specific preconception health behaviors were more likely to receive seasonal influenza vaccination. Failure to participate in these health behaviors could alert health care practitioners to patients' increased risk of remaining unvaccinated during pregnancy.

Volume and type of alcohol during early pregnancy and the risk of miscarriage.

BACKGROUND: Research on alcohol consumption during pregnancy and miscarriage spans over three decades, yet the relationship is still not well-understood. OBJECTIVES: To assess the relationship between volume and type of alcohol consumed during pregnancy in relation to miscarriage. METHODS: We utilized data from a population-based cohort study of pregnant women (n = 1061) of which 172 (16%) women had a miscarriage. Upon study entry, participants were asked about their alcohol consumption during pregnancy. Based on the average number of drinks per week, women were categorized into one of three categories: four or more drinks per week (n = 32, 3%), less than four drinks per week (n = 403, 38%), and no alcohol intake (n = 626, 59%). In addition, women were categorized by the type of alcohol beverage they consumed: beer only (n = 47, 4%), spirits only (n = 56, 5%), wine only (n = 160, 15%), or a combination of two or more types of alcohol (n = 172, 16%). RESULTS: A significant increased risk of miscarriage (adjusted hazard ratio (aHR): 2.65; 95% confidence interval (CI): 1.38, 5.10) was found for women who drank four or more drinks a week. Our findings also suggest the relationship between alcohol intake during pregnancy and miscarriage is strongest for miscarriage occurring prior to 10 weeks of gestation. In addition, women who drank only spirits had more than a two-fold increased risk of miscarriage compared to women who abstained (aHR: 2.24; 95% CI: 1.32, 3.81). Conclusions/Importance: Future research assessing the factors that may contribute to an increased risk of miscarriage should consider the type of alcohol consumed.

Alcohol, tobacco and drug use as reasons for abortion.

AIMS: Concern about the effects of alcohol and drug use during pregnancy is intertwined with debates about abortion. There is concern that alcohol abstinence recommendations lead women using low levels of alcohol to terminate otherwise wanted pregnancies. This study examines how women describe alcohol, tobacco and/or drug use (ATOD) as reasons for deciding to have abortions and assesses the differences between women reporting and not reporting ATOD as reasons for deciding to have an abortion. METHODS: Data come from the UCSF Turnaway Study which recruited 956 women seeking an abortion at one of 30 US clinics between 2008 and 2010. Mixed methods were used and data were analyzed through thematic coding and logistic regression. RESULTS: Nearly 5% reported ATOD as a reason for abortion. Women worried that their ATOD had affected their baby's health and that their or their partner's ATOD would influence parenting. Most women (84%) who reported alcohol as a reason binge drank or had an alcohol-problem symptom in the month before discovering their pregnancy. Sixty-one percent who reported drugs as a reason used drugs, with 88% using more than once/week. Although two-thirds smoked tobacco, no woman reported tobacco alone as a reason. Ninety-eight percent of women reporting ATOD as a reason had unintended pregnancies. CONCLUSION: Women reporting ATOD as a reason drink at levels exceeding a low threshold and do not appear to be terminating otherwise wanted pregnancies. Thus, findings are inconsistent with hypotheses that abstinence recommendations and punitive policies lead women using low levels of alcohol or using drugs to terminate otherwise wanted pregnancies.

Formal and informal substance use treatment utilization and alcohol abstinence over seven years: is the relationship different for blacks and whites?

BACKGROUND: This study examines whether the effects of formal substance use treatment utilization and Alcoholics Anonymous (AA) on 30-day abstinence vary for black versus white Americans. METHODS: The current analysis utilizes data from a longitudinal sample of 1013 black and white, dependent and problem drinkers across a 7-year period. Participants were identified through a probability survey in the general population and consecutive intakes in chemical dependency treatment programs in a California County. Generalized Estimating Equations assessing interactions between race and treatment utilization incorporated variables from four post-baseline interviews, controlling for baseline variables. RESULTS: Formal treatment utilization was associated with 30-day abstinence (OR:1.6, 95%CI: 1.3, 2.1), yet this relationship did not differ for blacks and whites. In contrast, there was a significant interaction between AA utilization, race and 30-day abstinence. While both whites and blacks who attended AA were more likely to report 30-day abstinence compared to their non-AA attending counterparts (white OR:4.0, 95%CI: 3.2-5.1 and black OR:2.2, 95%CI: 1.5-3.2), the relationship was stronger for whites. Among those who did not attend AA, blacks were more likely than whites to be abstinent. Post hoc analyses suggest that these latter findings may be related to greater religiosity and "drier" social networks among black Americans. CONCLUSIONS: While utilization of formal treatment may yield similar benefits for blacks and whites, AA utilization may be more important for maintaining abstinence among whites than blacks. Future research should investigate racial differences in social network drinking patterns and religious reinforcement of sobriety, and the role these may play in AA outcomes.

Does lack of multinutrient supplementation during early pregnancy increase vulnerability to alcohol-related preterm or small-for-gestational-age births?

The objective of this study was to assess whether women who do not take multinutrient supplements during early pregnancy are more susceptible to the effects of low-to-moderate alcohol consumption on preterm birth and small-for-gestational-age birth (SGA) compared to women who do take multinutrients. This analysis included 800 singleton live births to mothers from a cohort of pregnant women recruited for a population-based cohort study conducted in the Kaiser Permanente Medical Care Program in Northern California. Participants were recruited in their first trimester of pregnancy and information about their alcohol use and supplement intake during pregnancy was collected. Preterm birth (n=53, 7%) was defined as a delivery prior to 37 completed weeks of gestation and SGA birth (n=124, 16%) was defined as birth weight less than the 10th percentile for the infant's gestational age and sex compared to US singleton live births. A twofold increase in the odds of SGA birth attributed to low-to-moderate alcohol intake was found among multinutrient supplement non-users (95% CI: 1.1, 5.3). Yet, among multinutrient supplement users, there was no increased risk of an SGA birth for women who drank low-to-moderately compared to women who abstained (aOR: 0.97, 95% CI: 0.6, 1.6). Similar results emerged for preterm birth. Our findings provide marginal evidence that multinutrient supplementation during early pregnancy may modify the risk of SGA births and preterm birth associated with alcohol consumption during pregnancy and may have important implications for pregnant women and women of child-bearing age. However, future research needs to be conducted.

Stress, substance use and sexual risk behaviors among primary care patients in Cape Town, South Africa.

We assessed the relationship between stress, substance use and sexual risk behaviors in a primary care population in Cape Town, South Africa. A random sample of participants (and over-sampled 18-24-year-olds) from 14 of the 49 clinics in Cape Town's public health sector using stratified random sampling (n = 2,618), was selected. We evaluated current hazardous drug and alcohol use and three domains of stressors (Personal Threats, Lacking Basic Needs, and Interpersonal Problems). Several personal threat stressors and an interpersonal problem stressor were related to sexual risk behaviors. With stressors included in the model, hazardous alcohol use, but not hazardous drug use, was related to higher rates of sexual risk behaviors. Our findings suggest a positive screening for hazardous alcohol use should alert providers about possible sexual risk behaviors and vice versa. Additionally, it is important to address a broad scope of social problems and incorporate stress and substance use in HIV prevention campaigns.

7-year trajectories of Alcoholics Anonymous attendance and associations with treatment.

Although many members of Alcoholics Anonymous (AA) are introduced to AA during treatment, the relationship between treatment and AA attendance over time is unknown. This paper describes four latent classes of AA attendance among 586 dependent alcoholics interviewed by telephone 1, 3, 5 and 7 years after baseline, and models the relationship between treatment exposure and AA attendance in each class. There was a low AA group (averaging fewer than 5 meetings at most follow-ups), a medium AA group (about 50 meetings a year at each follow-up), a descending AA group (about 150 meetings year 1, then decreasing steeply), and a high AA group (about 200 meetings at 1 year, then decreasing gradually by year 7). Declines in meeting attendance were not always accompanied by decreases in abstinence. After accounting for the effect of time on AA attendance (i.e., the "ups-and-downs" that occur over time), treatment exposure was minimally related to AA attendance in all but the descending AA group, where it was negatively associated (p<0.001). Considering AA patterns over time highlights a different role for treatment in AA attendance than what is gleaned from analyses at single timepoints.