The effect of the COVID-19 pandemic on substance use patterns and physiological dysregulation in pregnant and postpartum women.

BACKGROUND: The SARS-CoV-2/COVID-19 pandemic has been associated with increased stress levels and higher alcohol use, including in pregnant and postpartum women. In the general population, alcohol use is associated with dysregulation in the autonomic nervous system (ANS), which is indexed by heart rate variability (HRV). The objectives of this study were to: (1) characterize changes in substance use during the SARS-CoV-2/COVID-19 pandemic via a baseline self-report survey followed by mobile ecological momentary assessment (mEMA) of substance use; and (2) examine the associations between momentary substance use and ambulatory HRV measures in pregnant and postpartum women. METHODS: Pregnant and postpartum women were identified from the ENRICH-2 prospective cohort study. Participants were administered a baseline structured phone interview that included the Coronavirus Perinatal Experiences (COPE) survey and ascertained the prevalence of substance use. Over a 14-day period, momentary substance use was assessed three times daily, and HRV measurements were captured via wearable electronics. Associations between momentary substance use and HRV measures (root mean square of successive differences [RMSSD] and low frequency/high frequency [LF/HF] ratio) were examined using a mixed effects model that included within-subject (WS) and between-subject (BS) effects and adjusted for pregnancy status and participant age. RESULTS: The sample included 49 pregnant and 22 postpartum women. From a combination of a baseline and 14-day mEMA surveys, 21.2% reported alcohol use, 16.9% reported marijuana use, and 8.5% reported nicotine use. WS effects for momentary alcohol use were associated with the RMSSD (ß = -0.14; p = 0.005) and LF/HF ratio (ß = 0.14; p = 0.01) when controlling for pregnancy status and maternal age. No significant associations were observed between HRV measures and instances of marijuana or nicotine use. CONCLUSIONS: These findings highlight the negative effect of the SARS-CoV-2/COVID-19 pandemic on the psychological health of pregnant and postpartum women associated with substance use, and in turn, ANS dysregulation, which potentially puts some women at risk of developing a substance use disorder.

Impulsivity and Alcohol Use during Pregnancy and Postpartum: Insights from Novel Methodological Approaches within the Context of the COVID-19 Pandemic.

Impaired emotion regulation and impulsivity have been linked to substance use. This study evaluated the association between emotion regulation difficulties-specifically impulsivity-and substance use within the context of the COVID-19 pandemic among pregnant (n = 49) and postpartum (n = 20) women. Participants from a prospective cohort ENRICH-2 completed a baseline phone survey of COVID-19-related experiences and impulsivity followed by a 14-day (3x/day) mobile ecological momentary assessment (mEMA) of impulsivity and substance use. Between-subject (BS) and within-subject (WS) associations for baseline impulsivity and momentary impulsivity with respect to substance use were examined using mixed effects models. At the BS level, momentary impulsivity scores that were higher than the overall group average were positively associated with subsequent momentary reports of marijuana use (ß = 1.25; p = 0.04) when controlling for pregnancy status and COVID-19-related stress. At the WS level, momentary impulsivity scores that were higher than an individual's average score were positively associated with subsequent reports of momentary alcohol use (ß = 0.08; p = 0.04). This research supports the idea that impulsivity varies based on individual situations, such as stress associated with the COVID-19 pandemic, and may be an important correlate of substance use in pregnant and postpartum women. Future research might consider investigation of additional factors, which may serve to moderate or mediate the relationship between impulsivity and substance use.

Effects of prenatal opioid and alcohol exposures on immune and serotonin factors in human placenta.

PURPOSE: Opioids and alcohol impact critical serotonin (5-HT) function in the developing placenta and fetus through the actions of immune proinflammatory factors. Yet, possible convergent effects of opioids and alcohol on human placental toll-like receptor 4 (TLR4) activation and subsequent 5-HT homeostasis remain entirely unknown. The purpose of this study was to examine the effect of prenatal exposure to opioids with or without prenatal alcohol exposure (PAE) on the expression of key placental immune and serotonin signaling factors in human placental tissue obtained from a well-characterized prospective cohort. METHODS: Data were collected from a subset of participants enrolled in the prospective pre-birth Ethanol, Neurodevelopment, Infant, and Child Health (ENRICH-1) cohort. Women were recruited and classified into four study groups: 1) PAE (n = 20); 2) those taking medications for opioid use disorder (MOUD; n = 28), 3) concurrent PAE and MOUD (n = 20); and 4) controls (HC; n = 20) based on prospective, repeated self-report, and biomarker analysis. Placenta samples underwent tissue processing to identify mRNA for TLR4, nucleotide-binding oligomerization domain (NOD)-like receptor protein 3 (NLRP3), interleukin-1ß (IL-1ß), tumor necrosis factor-α (TNF-α), serotonin transporter (SERT), tryptophan hydroxylase (TPH1), indoleamine 2,3-Dioxygenase 1 (IDO) as well as protein concentrations of TLR4, IL-1ß, TNF-α, SERT. To consider the association between study group and mRNA/protein expression of our targets, multivariable regression models were developed with inclusion of a priori selected covariates. RESULTS: There was a significant negative association between PAE and SERT mRNA (ß = -0.01; p < 0.01) and a positive association with TPH1 mRNA expression (ß = 0.78; p < 0.05). In addition, there was a negative association between MOUD and TNF-α protein expression (ß = -0.12; p < 0.05). CONCLUSIONS: This study provides the first evidence that PAE may inhibit SERT expression while simultaneously promoting increased TPH1 protein expression in human placenta. This may result in increased 5-HT in fetal circulation known to affect neurodevelopment. Our data suggest that opioids and alcohol may disturb the bidirectional, dynamic interaction between the placental immune and serotonin system. Given the implication for brain development and health across the life-span further investigation of these critical mechanisms in well-defined cohorts is required.

Holistic Admissions Review in Nursing Education: A Concept Analysis Using Rodgers' Evolutionary Method.

AIM: The aim of this study was to analyze holistic review within the context of collegiate nursing program admissions. BACKGROUND: Holistic review is the evaluation of individual qualifications for college admission based on a pattern of individualized factors, including standardized scores, personal characteristics, experiences, abilities, and educational/professional "fit." Medical schools regularly use holistic review, and more nursing schools may adopt holistic review in the future. METHOD: Rodgers' evolutionary method of concept analysis was used to examine usage in current praxis. RESULTS: Findings support a desire to enhance diversity in collegiate, health-related programs while increasing numbers of culturally competent, qualified providers representative of the US population. CONCLUSION: Holistic review promotes diversity of nursing students and future nurse providers. This concept analysis provides a unified definition of holistic review to promote educational and health-care-related equity through increased representativeness of nursing students and future nurses.

The Social Determinants of Perinatal Maternal Distress.

This pilot study examined associations between prenatal individual and socioenvironmental determinants of health and symptoms of perinatal maternal distress (PMD) in women enrolled in midwifery practice and living in a rural state. Pearson's correlations between prenatal predictors and PMD scores were calculated. Having experienced emotional abuse in one's lifetime, total number of past year stressors, and everyday discrimination score were all statistically significant predictors of PMD at study enrollment and follow-up. Result suggest shifting to a multi-symptom, life course assessment and intervention paradigm, tailored to the context of specific populations, may improve perinatal care and reduce disparities.

Perinatal Behavioral Health, the COVID-19 Pandemic, and a Social Determinants of Health Framework.

The United States has greater prevalence of mental illness and substance use disorders than other developed countries, and pregnant women are disproportionately affected. The current global COVID-19 pandemic, through the exacerbation of psychological distress, unevenly affects the vulnerable population of pregnant women. Social distancing measures and widespread closures of businesses secondary to COVID-19 are likely to continue for the foreseeable future and to further magnify psychosocial risk factors. We propose the use of a social determinants of health framework to integrate behavioral health considerations into prenatal care and to guide the implementation of universal and comprehensive psychosocial assessment in pregnancy. As the most numerous and well-trusted health care professionals, nurses are ideally positioned to influence program and policy decisions at the community and regional levels and to advocate for the full integration of psychosocial screening and behavioral health into prenatal and postpartum care as core components.

Use of the Antenatal Risk Questionnaire to Assess Psychosocial Risk Factors Associated with Risk for Postpartum Depression: A Pilot Study.

INTRODUCTION: Postpartum depression is the most common complication of childbirth. The purpose of this pilot study was to examine use of the Antenatal Risk Questionnaire (ANRQ) to assess psychosocial risk factors associated with increased risk for the development of symptoms of postpartum depression. METHODS: This study was a prospective investigation of women during the third trimester of pregnancy. Women were recruited from a high-volume collaborative obstetric and midwifery practice in a large academic tertiary-care hospital. Participants were enrolled during their third trimesters of pregnancy and studied through 6 weeks postpartum. Surveys were completed for psychosocial risk (ANRQ), perceived stress, and symptoms of depression. Bivariate analysis was conducted and multiple regression analysis was performed to examine the effects of the predictor variables on the outcome variable, symptoms of depression at 6 weeks postpartum. RESULTS: Thirty-five women participated in the study. Prenatal ANRQ scores, Perceived Stress Scale (PSS) scores, and Edinburgh Postnatal Depression Scale (EPDS) scores were significantly correlated with EPDS scores at 6 weeks postpartum. In the multiple regression analysis, the prenatal ANRQ score was a significant predictor of the postpartum EPDS score, whereas the prenatal PSS and EPDS scores were not significant. This regression model explained 57% of the variance in symptoms of depression at 6 weeks postpartum. DISCUSSION: Key past and present psychosocial risk factors experienced by women (measured by the prenatal ANRQ) were a significant predictor of postpartum depressive symptoms. In light of our results, use of the ANRQ in clinical practice warrants further exploration.

Role development in midwifery education: A place for simulation.

OBJECTIVE: simulation-based learning is increasingly seen as an effective strategy to develop student nurse-midwives into effective healthcare team members. A gap exists concerning the use of simulation to promote role transition/development of the student midwife. The purpose of this paper is to describe an evolving simulation curriculum aimed at role development of the student midwife as well as technical skills training. SETTING: the University of New Mexico, College of Nursing and the Interprofessional Healthcare Simulation Center. PARTICIPANTS: this program involves students enrolled in the Masters in Nursing Program, Midwifery Concentration and students enrolled in the pre-licensure Bachelor of Science in Nursing program. FINDINGS: simulation allows for an opportunity to focus on communication skills with other team members, practicing the importance of clear delegation of responsibilities in high-stress situations. CONCLUSIONS: the value of practicing the necessary communication skills, as well as the opportunity to engage in simulated delegation of tasks, is an important aspect of midwifery role development.

Antepartum Services and Symptoms of Postpartum Depression in At-Risk Women.

OBJECTIVE: To examine which psychosocial risk factors are predictors of symptoms of postpartum depression (PPD) and whether home visit services are associated with decreased reports of symptoms of PPD. DESIGN: Secondary analysis of observational data from the 2012 to 2013 Pregnancy Risk Assessment Monitoring System (PRAMS). PARTICIPANTS: A national sample with data from more than 30,000 births from 41 states. METHODS: To account for unequal probabilities of selection, PRAMS-produced survey weights were incorporated in all percentage estimates, all chi-square tests, and an overall logistic regression model for maternal characteristics as predictors of symptoms of PPD. The effect of interventions on PPD was assessed using statistical techniques that adjusted for the likelihood of receiving the intervention. RESULTS: Stressors (odds ratio [OR] = 2.6 for three to five stressors; OR = 3.1 for six or more stressors), physical abuse (OR = 1.8), and history of depression (OR = 3.0) were associated with PPD in the logistic regression model. Using propensity score analysis, the average treatment effect of home visiting on PPD, during or after pregnancy, was nonsignificant. However, the propensity score analysis did identify a group of high-risk women for whom receiving a home visit was associated with nearly 40% lower odds (OR = 0.6) of experiencing PPD symptoms. CONCLUSION: Findings highlight the effect home visits during pregnancy may have on the odds of at-risk women developing symptoms of PPD. Future research is indicated to assess the extent to which targeted interventions during these home visits can enhance effectiveness by mitigating psychosocial stress in pregnancy to prevent PPD.

Prepregnancy Obesity and a Biobehavioral Predictive Model for Postpartum Depression.

OBJECTIVE: To test a predictive model of the associations among prepregnancy body mass index (BMI), third-trimester biological and behavioral variables, and symptoms of depression at 4 weeks postpartum. DESIGN: Secondary data analysis from a longitudinal, biobehavioral repeated-measures study of women during the third trimester of pregnancy through 6 months postpartum. SETTING: Communities surrounding a Midwestern and a Western U.S. city. PARTICIPANTS: Participants were 111 women enrolled during their third trimesters of pregnancy who were studied through 4 weeks postpartum. METHODS: Whole blood and saliva were used for biological measures, and validated questionnaires were used for behavioral measures. Principal component analysis and path analysis with principal component variables were used to iteratively test the model. RESULTS: There were three statistically significant direct effects in the model: the path from prepregnancy BMI to inflammation, the path from prepregnancy BMI to stress, and the path from stress to symptoms of depression at 4 weeks postpartum. Indirect effects of prepregnancy BMI on postpartum depression through intervening variables were not statistically significant, nor was the model-based total effect of prepregnancy BMI on postpartum depression. CONCLUSION: Stress was significantly linked to prepregnancy BMI and postpartum depression. This finding highlights continuing possibilities for improving outcomes for mothers, infants, and families through stress-mitigating preventive strategies.

Concept analysis: prenatal obesity, a psychoneuroimmunology perspective.

PURPOSE: To analyze the concept of prenatal obesity within a psychoneuroimmunology framework. CONCLUSION: By considering the psychosocial, neurological, endocrine, and immunological contributions, a psychoneuroimmunology framework maintains a holistic focus. Identifying the multidirectional mechanisms linking these systems will provide valuable insight into the mechanisms by which prenatal obesity increases the rate of adverse pregnancy outcomes. PRACTICE IMPLICATIONS: Utilization of the concept of prenatal obesity within a psychoneuroimmunology framework will facilitate multidisciplinary research to identify underlying mechanisms by which prenatal obesity leads to adverse pregnancy outcomes, as well as the development of interventions to treat obesity before, during, and after pregnancy.

A profile of Colorado nurse--midwives: implications for health care.

Nurse-midwives provide significant health care to underserved and vulnerable women, yet there is limited information about the nature of nurse-midwifery practices and compensation for services. This study reports the results of a Colorado statewide survey of nurse-midwives (N = 217). Electronic survey was utilized to detail practice in seven areas: demographics, type of practice, compensation, leadership, legislative priorities,teaching involvement, and practice satisfaction. Responses (N = 114) were analyzed using SPSS 13.0. Results found wide variation in compensation and practice types. Respondents largely worked in urban settings, cared for low to moderate risk patients, and were generally older and White. Restriction from medical staff membership, prescriptive authority constraints, and liability issues were practice limitations. While teaching a wide variety of learners, nurse-midwives do limited mentoring of nurse-midwifery students, a finding which is concerning given the decreasing numbers of nurse-midwives. Findings are compared to known national data, with implications for the provision of health care services detailed.