Racial disparities in emergency mental healthcare utilization among birthing people with preterm infants.

BACKGROUND: Birthing people of color are more likely to deliver low birthweight and preterm infants, populations at significant risk of morbidity and mortality. Birthing people of color are also at higher risk for mental health conditions and emergency mental healthcare utilization postpartum. Although this group has been identified as high risk in these contexts, it is not known whether racial and ethnic disparities exist in mental healthcare utilization among birthing people who have delivered preterm. OBJECTIVE: We sought to determine if racial and ethnic disparities exist in postpartum mental healthcare-associated emergency department visits or hospitalizations for birthing people with preterm infants in a large and diverse population. STUDY DESIGN: This population-based historic cohort study used a sample of Californian live-born infants born between 2011 and 2017 with linked birth certificates and emergency department visit and hospital admission records from the California Statewide Health Planning and Development database. The sample was restricted to preterm infants (<37 weeks' gestation). Self-reported race and ethnicity groups included Hispanic, non-Hispanic Black, non-Hispanic Asian, non-Hispanic White, and non-Hispanic others. Mental health diagnoses were identified from the International Classification of Diseases Ninth and Tenth revision codes recorded in emergency department and hospital discharge records. Logistic regression analysis was used to estimate the association between mental health-related emergency department visits and rehospitalizations by race or ethnicity compared with non-Hispanic White birthing people and controlling for the following characteristics and health condition covariates: age, parity, previous preterm birth, body mass index, smoking, alcohol use, hypertension, diabetes, previous mental health diagnosis, and prenatal care. RESULTS: Of 204,539 birthing people who delivered preterm infants in California, 1982 visited the emergency department and 836 were hospitalized in the first year after preterm birth for a mental health-related illness. Black birthing people were more likely to have a mental health-related emergency department visit and hospitalization (risk ratio, 1.8; 95% confidence interval, 1.5-2.0 and risk ratio, 1.9; 95% confidence interval, 1.5-2.3, respectively) within the first postpartum year than White birthing people. Hispanic and Asian birthing people were less likely to have mental health-related emergency department visits (adjusted risk ratio, 0.7; 95% confidence interval, 0.7-0.8 and adjusted risk ratio, 0.2; 95% confidence interval, 0.2-0.3, respectively) and hospitalizations (adjusted risk ratio, 0.6; 95% confidence interval, 0.5-0.7 and adjusted risk ratio, 0.2; 95% confidence interval, 0.1-0.3, respectively). When controlling for birthing people with a previous mental health diagnosis and those without, the disparities remained the same. CONCLUSION: Racial and ethnic disparities exist in emergency mental healthcare escalation among birthing people who have delivered preterm infants. Our findings highlight a need for further investigation into disparate mental health conditions, exacerbations, access to care, and targeted hospital and legislative policies to prevent emergency mental healthcare escalation and reduce disparities.

The association between preterm birth and postpartum mental healthcare utilization among California birthing people.

BACKGROUND: While mental health conditions such as postpartum depression are common, little is known about how mental healthcare utilization varies after term versus preterm delivery. OBJECTIVE: This study aimed to determine whether preterm birth is associated with postpartum inpatient and emergency mental healthcare utilization. STUDY DESIGN: The study sample was obtained from a database of live-born neonates delivered in California between the years of 2011 and 2017. The sample included all people giving birth to singleton infants between the gestational age of 20 and 44 weeks. Preterm birth was defined as <37 weeks' gestation. Emergency department visits and hospitalizations with a mental health diagnosis within 1 year after birth were identified using International Classification of Diseases codes. Logistic regression was used to compare relative risks of healthcare utilization among people giving birth to preterm infants vs term infants, adjusting for the following covariates: age, race or ethnicity, parity, previous preterm birth, body mass index, tobacco use, alcohol or drug use, hypertension, diabetes mellitus, adequacy of prenatal care, education, insurance payer, and the presence of a mental health diagnosis before birth. Results were then stratified by mental health diagnosis before birth to determine whether associations varied based on mental health history. RESULTS: Of our sample of 3,067,069 births, 6.7% were preterm. In fully adjusted models, compared with people giving birth to term infants, people giving birth to preterm infants had a 1.5 times (relative risk; 95% confidence interval, 1.4-1.7) and 1.3 times (relative risk; 95% confidence interval, 1.2-1.4) increased risk of being hospitalized with a mental health diagnosis within 3 months and 1 year after delivery, respectively. People giving birth to preterm infants also had 1.4 times (95% confidence interval, 1.3-1.5) and 1.3 times (95% confidence interval, 1.2-1.4) increased risk of visiting the emergency department for a mental health diagnosis within 3 months and 1 year after birth, respectively. Stratifying by preexisting mental health diagnosis, preterm birth was associated with an elevated risk of mental healthcare utilization for people with and without a previous mental health diagnosis. CONCLUSION: We found that preterm birth is an independent risk factor for postpartum mental healthcare utilization. Our findings suggest that screening for and providing mental health resources to birthing people after delivery are crucial, particularly among people giving birth to preterm infants, regardless of mental health history.

Benefits of Oral Health Education at Women, Infant, and Children (WIC) Clinic Visits: Assessments of Parent's Oral Health Beliefs, Behaviors and Dental Access in O'ahu, Hawai'i.

Improving oral health outcomes in Hawai'i for children and families remains a high priority. Children in the state are leading the nation with the highest caries rates, while women before, during, and after pregnancy are failing to receive regular and necessary dental care resulting in poor health outcomes. To answer for this need, an educational intervention was conducted among families enrolled in the Kapi'olani Medical Center for Women and Children's Women, Infant, and Children program (WIC) in O'ahu. The project included the following activities: (1) identification the oral health beliefs and behaviors of families, (2) providing oral health education to families, and (3) reassessing beliefs and behaviors in 3-6 months to document the impact of theeducation session. Participants consisted of 81 families resulting in the data on 176 children and 4 pregnant women. Of the 81 families, 40 representing84 children completed the follow-up oral health questionnaire. Results of the assessment and education demonstrated a positive impact on the family's oral health behaviors. Parents were 6.61 times as likely to report using fluoride toothpaste in the follow-up visit compared to their initial visit (95% confidence interval [CI] = 3.12-14.00). Additionally, statistically significant changes were noted in the frequency of children's daily tooth brushing (odds ratio [OR] = 2.15, 95% CI = 1.33-3.46), as well as in the incidence of children receiving fluoride varnish application over time (OR = 2.66, 95% CI = 1.50-4.73). These results provide further evidence that initiating a simple educational intervention can have a positive impact on oral health behaviors in groups that are at highest risk for developing dental disease in Hawai'i.

Assessment, Education, and Access: Kona Hawai'i WIC Oral Health Pilot Project.

The Kona WIC oral health pilot project was developed to assess the oral health beliefs and behaviors of parents of children and pregnant women at the Kona WIC site and to demonstrate the ease of providing oral health education to families in order to improve oral health behaviors. Data were collected from 50 families about the oral health behaviors and dental care of a total of 73 children, including 5 pregnant women, four of whom had a child enrolled in WIC and one pregnant woman without any previous children. Data revealed that 68% of children with teeth had been seen by a dentist within 6 to 12 months of the study visit. Mothers were seen less often, with 55% stating that they had not been seen for a dental visit for over one year. Parental knowledge about the effects of fluoride on teeth was limited; however, 90% of the parents would allow fluoride varnish applied to their child's teeth, 88% would give daily fluoride drops/tablets to their child, and 78% would support water fluoridation if it would help to improve their children's oral health. Additionally, for children old enough to receive fluoride supplementation, 60% were not given a prescription by their health care providers, and 58% had not received any fluoride varnish applications. By offering oral health education in a WIC clinic and assisting clients to seek out comprehensive care within a dental home, children and caregivers can be provided essential education and resources early in a child's life or women's pregnancies to reduce poor oral health outcomes.

Oral Health Knowledge and Practices of Pediatric and Family Nurse Practitioners.

INTRODUCTION: The purpose of the study was to assess the relationship between oral health educational activities of NPs and their current oral health knowledge and practices. METHOD: An online survey was distributed to practicing NPs and members of the NAPNAP organization. RESULTS: The study results from n = 147 NPs indicated an association between oral health CE attendance and knowledge on the age to initiate fluoride toothpaste, age for an initial dental visit, as well as NPs comfort in educating about oral hygiene, diets to reduce caries, bacterial transmission and caries development, in addition to the NPs comfort in performing a risk assessment, oral exam, and identifying decay and other oral pathology compared to NPs that had not attended a CE course. DISCUSSION: The study findings demonstrate the importance of CE courses for NPs on the latest oral health guidelines and practices beyond their traditional academic education, in order to improve oral health outcomes among children.

The Association Between Socio-demographic Factors, Dental Problems, and Preterm Labor for Pregnant Women Residing in Hawai'i.

Periodontal disease during pregnancy has the potential to increase the risk of adverse perinatal outcomes including preterm labor (PTL), prematurity, and low birth weight (LBW). Despite professional recommendations on the importance and safety of dental assessments and treatments, the rate of dental care utilization during pregnancy remains low. The purpose of this study was to document the utilization of dental services and explore the relationships among socio-demographic factors, dental problems, and PTL in pregnant women residing in Hawai'i. Hawai'i Pregnancy Risk Assessment Monitoring System (PRAMS) survey results were analyzed from 4,309 women who experienced live births between the years 2009-2011. Results revealed that 2 in 5 women in Hawai'i had their teeth cleaned during pregnancy, while 1 in 5 reported seeing a dentist for a dental problem. Women who reported having a dental problem during pregnancy were more likely to experience PTL (OR=1.46, 95% CI=1.10-1.94, P=.008) compared to women without a dental problem. In addition, Native Hawaiian and Part-Hawaiian women were more likely to experience PTL (OR=1.73, 95% CI=1.22-2.46, P=.002) compared to Caucasian women. These findings document the underutilization of dental services in pregnant women in Hawai'i and reveal an association between poor dental care and PTL. Identification of groups at risk for maternal complications may assist in the development of programs that are sensitive to the diverse cultures and variability of community resources that exist throughout Hawai'i.

The ICN Leadership For Change™ Programme--20 years of growing influence.

AIM: The aim of this article was to present experiences from the field in the context of the International Council of Nurses' Leadership for Change™ programme, which celebrates 20 years of excellence in 2016 for developing the leadership and management capacity of nurses worldwide. BACKGROUND: The programme was launched in 1996 in order to boost nurse participation in the healthcare policy-making process, globally, and to foster within the nursing profession the requisite skills for nurses to lobby for and assume a greater responsibility in the leadership and management of health care services. INTRODUCTION: Over the course of two decades, the programme has been implemented in cooperation between ICN, national nurses associations, the World Health Organization, Ministries of Health and a variety of donor organizations such as the W.K. Kellogg Foundation and development agencies such as USAID and AUSAID. The programme has been implemented in more than 60 nations throughout Africa, Asia, Europe, the Middle East, Latin America and the Pacific Islands, to name a few regions. METHODS: This article offers an overview of the impact that certified ICN LFC nurse trainers and their colleagues have had in the United Arab Emirates, Vietnam and the United States of America and is affiliated islands and the North Pacific Islands. RESULTS: Twenty years of growth and empowerment are now the ongoing legacy of the ICN LFC Program, which has graduated and deployed nurse trainers around the world and achieved significant advances in the professional development of nurse leaders on an international scale. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Nurse leaders can improve the health and well-being of their nations in collaboration with consumers and other key stakeholders. Nurse leaders are critical in improving health systems, their work places and broader societal challenges through sound nursing practice, education, research and evidence-based health and social policy change.

Predictors of Dental Cleaning Over a Two-year Time Period Around Pregnancy Among Asian and Native Hawaiian or Other Pacific Islander Race Subgroups in Hawai'i, 2009-2011.

Oral health disease is linked to several chronic diseases including adverse health outcomes around pregnancy. Optimizing a woman's oral health before, during, and after pregnancy can impact her health and the health of her children. Preventive, diagnostic, and restorative dental services can be done safely and effectively including during pregnancy. We examined data from the 2009-2011 Hawai'i Pregnancy Risk Assessment Monitoring System (PRAMS) to assess the prevalence of dental cleanings over an approximately 2 year (Median: 2.0 years, Range:1.6-2.5 years) time period (12 months before pregnancy, during pregnancy, and in the first few months postpartum) among 4,735 mothers who recently had a live birth. Adjusted prevalence ratios (APR) of dental cleanings were calculated for both race and Medicaid/QUEST insurance status adjusting for maternal age and education. During a two-year span before, during, and after pregnancy an estimated 60.8% of women had dental cleanings. Native Hawaiian (APR=0.87; 95% CI=0.80-0.93), Other Pacific Islander (0.70; 0.58-0.83), Filipino (0.90; 0.82-0.97), and Chinese (0.76; 0.63-0.93) mothers were less likely to have had dental cleanings compared to white mothers. Additionally, mothers with Medicaid/QUEST health insurance (0.73; 0.68-0.79) were less likely to have had cleanings. More than one-third of recently pregnant mothers did not have dental cleanings in the approximately two-year time period. Native Hawaiian, Other Pacific Islander, Filipino, and Chinese mothers and those on Medicaid/QUEST health insurance were less likely to receive regular dental care. Identification of the reasons why these populations do not seek regular dental care can inform programmatic efforts to improve oral health outcomes for women and families.

HIV-infected mothers' experiences during their infants' HIV testing.

Both survival with HIV and rates of perinatal HIV infection have significantly declined during the past decade, due to antiretroviral therapies that interrupt HIV transmission to the fetus and newborn. Although HIV is no longer routinely fatal to mothers or transmitted to fetuses, and the testing of newborns for HIV has been improved, evidence about HIV-infected mothers' experiences during the months of their infants' HIV testing predates these improvements. This qualitative study on 16 mothers was an analysis of interviews conducted several weeks after testing was completed and all infants had been determined to be uninfected. Mothers reported that their experiences evolved during the months of testing. Initial reactions included maternal trauma and guilt associated with infant testing. They then reported learning to cope with the roller coaster ride of repeated testing with the help of information from clinicians. By the end of the testing period, ambiguity began to resolve as they engaged in tentative maternal-infant attachment and expressed desire for a sense of normalcy. Need for support and fear of stigma persisted throughout. These findings expand current knowledge about this experience and suggest clinical strategies to guide HIV-infected women during this stressful period.

STI screening and treatment in pregnancy.

Nurse practitioners provide care for pregnant women with sexually transmitted infections. This article discusses the latest guidelines for treatment of sexually transmitted infections in pregnant women and provides recommendations for screening, treatment, prophylaxis, and follow-up.

Polycystic ovary syndrome: a common but often unrecognized condition.

Polycystic ovary syndrome (PCOS) affects 5% to 10% of women of reproductive age, with symptoms often presenting during adolescence and young adulthood. It is a condition characterized by (1) hyperandrogenism, (2) oligomenorrhea or amenorrhea, and (3) polycystic ovaries. This syndrome is associated with significant endocrine, metabolic, cardiovascular, reproductive, and psychiatric morbidities. Although the diagnosis of PCOS is based on the presence of at least 2 of the 3 criteria that characterize the condition, the syndrome has a broad spectrum of clinical features that may signal its presence. Evidence suggests that many women with clinical features of PCOS remain undiagnosed, placing them at an increased risk for developing complications associated with the syndrome. This review presents current information about the pathophysiology, clinical features, diagnosis, and recommended treatments for PCOS.

Unhealthy substance-use behaviors as symptom-related self-care in persons with HIV/AIDS.

Unhealthy substance-use behaviors, including a heavy alcohol intake, illicit drug use, and cigarette smoking, are engaged in by many HIV-positive individuals, often as a way to manage their disease-related symptoms. This study, based on data from a larger randomized controlled trial of an HIV/AIDS symptom management manual, examines the prevalence and characteristics of unhealthy behaviors in relation to HIV/AIDS symptoms. The mean age of the sample (n = 775) was 42.8 years and 38.5% of the sample was female. The mean number of years living with HIV was 9.1 years. The specific self-reported unhealthy substance-use behaviors were the use of marijuana, cigarettes, a large amount of alcohol, and illicit drugs. A subset of individuals who identified high levels of specific symptoms also reported significantly higher substance-use behaviors, including amphetamine and injection drug use, heavy alcohol use, cigarette smoking, and marijuana use. The implications for clinical practice include the assessment of self-care behaviors, screening for substance abuse, and education of persons regarding the self-management of HIV.

Prevalence, self-care behaviors, and self-care activities for peripheral neuropathy symptoms of HIV/AIDS.

As part of a larger randomized controlled trial examining the efficacy of an HIV/AIDS symptom management manual (n = 775), this study examined the prevalence of peripheral neuropathy in HIV-infected individuals at 12 sites in the USA, Puerto Rico, and Africa. Neuropathy was reported by 44% of the sample; however, only 29.4% reported initiating self-care behaviors to address the neuropathy symptoms. Antiretroviral therapy was found to increase the frequency of neuropathy symptoms, with an increased mean intensity of 28%. A principal axis factor analysis with Promax rotation was used to assess the relationships in the frequency of use of the 18 self-care activities for neuropathy, revealing three distinct factors: (i) an interactive self-care factor; (ii) a complementary medicine factor; and (iii) a third factor consisting of the negative health items of smoking, alcohol, and street drugs. The study's results suggest that peripheral neuropathy is a common symptom and the presence of neuropathy is associated with self-care behaviors to ameliorate HIV symptoms. The implications for nursing practice include the assessment and evaluation of nursing interventions related to management strategies for neuropathy.

Assisted reproduction for couples affected by human immunodeficiency virus in California.

Survey results demonstrate that the majority of fertility clinics in California are willing to care for couples affected by human immunodeficiency virus (HIV) if legal restrictions are removed. In response to scientific advances and evolving clinical standards, California reversed the limitations placed on the provision of assisted reproduction for HIV-positive men in 2008.

Adherence to antiretrovirals among US women during and after pregnancy.

BACKGROUND: Antiretrovirals (ARVs) are recommended for maternal health and to reduce HIV-1 mother-to-child transmission, but suboptimal adherence can counteract its benefits. OBJECTIVES: To describe antepartum and postpartum adherence to ARV regimens and factors associated with adherence. METHODS: We assessed adherence rates among subjects enrolled in Pediatric AIDS Clinical Trials Group Protocol 1,025 from August 2002 to July 2005 on tablet formulations with at least one self-report adherence assessment. Perfectly adherent subjects reported no missed doses 4 days before their study visit. Generalized estimating equations were used to compare antepartum with postpartum adherence rates and to identify factors associated with perfect adherence. RESULTS: Of 519 eligible subjects, 334/445 (75%) reported perfect adherence during pregnancy. This rate significantly decreased 6, 24, and 48 weeks postpartum [185/284 (65%), 76/118 (64%), and 42/64 (66%), respectively (P < 0.01)]. Pregnant subjects with perfect adherence had lower viral loads. The odds of perfect adherence were significantly higher for women who initiated ARVs during pregnancy (P < 0.01), did not have AIDS (P = 0.02), never missed prenatal vitamins (P < 0.01), never used marijuana (P = 0.05), or felt happy all or most of the time (P < 0.01). CONCLUSIONS: Perfect adherence to ARVs was better antepartum, but overall rates were low. Interventions to improve adherence during pregnancy are needed.

HIV-infected mothers' perceptions of uncertainty, stress, depression and social support during HIV viral testing of their infants.

To explore relationships between mothers' uncertainty about infant HIV serostatus with stress, distress, depressive symptoms, and social support during infant HIV testing. This prospective longitudinal study of 20 HIV-infected mothers involved a prenatal visit and five postpartum visits clustered around infant HIV viral testing. Maternal uncertainty about infant HIV serostatus significantly decreased over time (p < 0.001). Before testing, uncertainty was inversely related to social support (r = -0.67), and positively related to perceived stress (r = 0.54), interpersonal social conflict (r = 0.57), symptom distress (r = 0.62), and depressive symptoms (r = 0.50); these relationships persisted throughout the infant testing period. Mothers with depressive symptoms during pregnancy demonstrated significantly more uncertainty within a few weeks after birth than mothers without depressive symptoms (p < 0.05). Several weeks after learning their infants were HIV negative, mothers' uncertainty was only associated with social conflict (r = 0.49). Maternal uncertainty about infant HIV status declined significantly over time. There were no changes in perceptions of stress, distress or social support. Mothers with depressive symptoms experienced greater uncertainty about infants' HIV status. Strategies to enhance support and treat depressive symptoms may reduce the uncertainty, stress, and distress HIV-infected mothers experience during viral testing of their infants.

HIV-infected mothers' foci of concern during the viral testing of their infants.

The objective of this study was to explore HIV-infected mothers' most worrisome concerns during their infants' HIV viral testing. A total of 20 HIV-infected women consented to one antepartum and five postpartum study visits clustered around infant HIV viral testing time points. Content analysis was used to categorize maternal responses about their concerns. The majority (80%) of mothers identified infant health as the most worrisome concern during the prenatal and early postpartum periods. This concern declined after the second infant viral test result but rebounded before obtaining the final viral test. Once the final viral test result was known, the majority (60%) of mothers identified psychosocial issues as most worrisome. Maternal health did not surpass infant health or psychosocial issues as a primary concern. The primary concern of the HIV-infected mothers in this study was infant health during the infant viral testing period. Maternal health issues remained secondary to infant health and psychosocial issues as major concerns several months after infant viral testing was completed.

Allostasis: a theoretical framework for understanding and evaluating perinatal health outcomes.

OBJECTIVE: To explore the theory of allostasis within the context of childbearing women's perceptions or experiences of stress and perinatal health outcomes. DATA SOURCES: Articles published in refereed journals and selected chapters from published books that addressed physiological and psychological effects of perceived or actual stress experiences, or both, including the theory of allostasis, on health outcomes. STUDY SELECTION: Qualitative, quantitative, and review articles that focused on psychoneurohormonal responses to physical and psychological stress in pregnant and nonpregnant human cohorts and the theory of allostasis. DATA EXTRACTION AND SYNTHESIS: The impact of abnormal allostatic states in childbearing women in response to physiological and psychological perceptions or experiences of stress, or both was analyzed. There is a growing body of epidemiologic evidence to support the relationship between maternal stress and adverse pregnancy outcomes. CONCLUSIONS: The theory of allostasis provides a framework for understanding and evaluating the complex elements of stress, coping, and adaptation during childbearing on perinatal health outcomes and has the potential to provide new insight into previously unexplained adverse perinatal events.

Big dreams, little sleep: dreams during pregnancy after prior pregnancy loss.

Sleep patterns and dream content may be affected by stressful life events such as pregnancy loss. Women who are pregnant subsequent to a prior pregnancy loss tend to have anxious and emotionally charged experiences during their pregnancies. Dreams can affect pregnancy outcomes, specifically premature birth. This qualitative study is the first investigation to explore sleep disturbances caused by dreams as experienced by a diverse group of women pregnant subsequent to a pregnancy loss. Our analysis resulted in the identification of 4 categories of dreams. We offer clinical assessment and intervention strategies to support these women prenatally and present suggestions for research to facilitate our understanding of their experiences.