Investigating the Decline of Fetal and Infant Mortality Rates in Alaska During 2010 and 2011.

INTRODUCTION: The U.S. infant mortality rate has been steadily declining since 2007. Although the downward trend has been notable in Alaska since 2006 when the rate was 6.9 infant deaths per 1000 live births, a dramatic drop in infant mortality occurred in 2010 and 2011 when the infant mortality rate fell to 3.8 infant deaths per 1000 live births during both years. The purpose of this study was to investigate the sudden decrease in fetal and infant mortality rates (FIMR) using the perinatal periods of risk (PPOR) method, an approach that has not been used previously in Alaska. METHODS: The study was conducted for 251 fetal and infant deaths in 2004-2006, 265 deaths in 2007-2009, and 129 deaths in 2010-2011. Data were stratified by Alaska Native (AN) and White maternal race and urban/rural residence. RESULTS: Among both urban and rural White women, the rate ratios (RR) for FIMRs between the earlier and later time periods were not significantly different. The postneonatal mortality rate (PNMR) among AN infants living in rural areas decreased significantly (RR 0.40; 95 % confidence interval 0.21-0.76) between 2007-2009 and 2010-2011. An unexplained increase in sudden unexplained infant death was noted in 2009, followed by a precipitous decrease in 2010-2011. No other unusual distribution of the cause specific mortality rates was observed. DISCUSSION: The decrease in the Alaska Native FIMR might have been due to focused efforts for preventing postneonatal sleep associated deaths. Education for prevention of sleep related deaths, particularly in rural communities, is necessary to maintain Alaska's low PNMR.

Prenatal smoking prevalence ascertained from two population-based data sources: birth certificates and PRAMS questionnaires, 2004.

OBJECTIVES: This study provided a population-based estimate of the prevalence of smoking during pregnancy by combining information from two data sources: birth certificates (BCs) and a self-administered questionnaire. METHODS: We analyzed data from 39,345 women who delivered live births in one of 24 states and responded to a questionnaire from the Pregnancy Risk Assessment Monitoring System (PRAMS), an ongoing, state- and population-based surveillance system. We compared prevalence of smoking during pregnancy based on the BC, the PRAMS questionnaire, and the two data sources combined. Data were weighted to represent all women delivering live births in each of the 24 states during 2004. RESULTS: The combined estimate indicated that 15.1% of women reported smoking during pregnancy, whereas the BCs alone reported 10.4% and the PRAMS questionnaires alone reported 13.4%. CONCLUSIONS: Based on the combined BC and PRAMS questionnaire data, the number of infants exposed to tobacco in-utero may be 31% higher than is currently reported on the BCs. Combining the data from the two different sources led to higher ascertainment of prenatal smoking.

Exercise and pregnancy outcome among urban, low-income, black women.

Few studies have focused on the association between maternal exercise and outcomes of pregnancy among low-income, Black women. The analysis reported here examines the associations between exercise before and during pregnancy and pregnancy outcomes of preterm birth and low birth weight among a sample of urban, low-income, Black women. Women (N=922) were enrolled in this prospective cohort study during their first prenatal visit at five hospital-based prenatal clinics located in Baltimore City, Maryland, from 1993 to 1995. A questionnaire was used to ask women about their participation in strenuous and non-strenuous exercise before and during pregnancy. Nearly two thirds of the women reported participating in exercise during pregnancy; most women participated in non-strenuous exercise (56%). The risks of both low birth weight (12.2%) and preterm birth (13.7%) were not significantly different whether women reported exercising or not, either before or during pregnancy. For women who were considered high risk because of chronic diseases or previous poor pregnancy outcome, stratified analysis indicated no significant difference in preterm birth or low birth weight between those who exercised and those who did not. Our analysis failed to identify any association between exercise and pregnancy outcomes among low-income, urban, Black women.

Discharge timing, outpatient follow-up, and home care of late-preterm and early-term infants.

OBJECTIVE: To compare the timing of hospital discharge, time to outpatient follow-up, and home care practices (breastfeeding initiation and continuation, tobacco smoke exposure, supine sleep position) for late-preterm (LPT; 34 0/7-36 6/7 weeks) and early-term (ET; 37 0/7-38/6/7 weeks) infants with term infants. METHODS: We analyzed 2000-2008 data from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System. χ(2) Analyses were used to measure differences in maternal and infant characteristics, hospital discharge, outpatient care, and home care among LPT, ET, and term infants. We calculated adjusted risk ratios for the risk of adverse care outcomes among LPT and ET infants compared with term infants. RESULTS: In the adjusted analysis, LPT infants were less likely to be discharged early compared with term infants, whereas there was no difference for ET infants (risk ratio [RR; 95% confidence interval (CI)]: 0.65 [0.54-0.79]; 0.95 [0.88-1.02]). [corrected]. LPT and ET infants were more likely to have timely outpatient follow-up (1.07 [1.06-1.08]; 1.02 [1.02-1.03]), more likely to experience maternal tobacco smoke exposure (1.09 [1.05-1.14]; 1.08 [1.06-1.11]), less likely to be initially breastfed (0.95 [0.94-0.97]; 0.98 [0.97-0.98]), less likely to be breastfed for ≥10 weeks (0.88 [0.86-0.90]; 0.94 [0.93-0.96]), and less likely to be placed in a supine sleep position (0.95 [0.93-0.97]; 0.97 [0.96-0.98]). CONCLUSIONS: Given that LPT and ET infants bear an increased risk of morbidity and mortality, greater efforts are needed to ensure safe and healthy posthospitalization and home care practices for these vulnerable infants.

Postpartum depressive symptoms and smoking relapse.

BACKGROUND: Smokers with depressive symptoms are more likely to relapse after attempting to quit than those without depressive symptoms. Little is known about the relationship between depressive symptoms and relapse during the postpartum period; thus the aim of the present study is to assess the relationship between postpartum smoking relapse and depressive symptoms. METHODS: Analysis of 2004 Pregnancy Risk Assessment Monitoring System (PRAMS) data from women in 16 states who reported smoking 3 months before pregnancy and reported abstinence from smoking during the last 3 months of pregnancy (n=2566). For women experiencing postpartum depressive symptoms, chi-square tests were computed for homogeneity of distribution between two groups (sustained abstinence versus relapsed) and an OR for relapsing during the postpartum period. Potential confounders, including demographic characteristics, intensity of smoking before pregnancy, and time since delivery, were computed. RESULTS: Compared to women who did not experience postpartum depressive symptoms, women who did were 1.86 (95% CI=1.31, 2.65) times as likely to relapse during the postpartum period. After adjusting for demographic characteristics, intensity of smoking, and time since delivery, the association decreased slightly (adjusted OR=1.77, 95% CI=1.21, 2.59). CONCLUSIONS: Women who quit smoking during pregnancy may be more likely to relapse if they experience depressive symptoms. Further research is needed into the screening and treatment of postpartum depressive symptoms as a possible method for preventing postpartum smoking relapse.

Comparison of manual and electric breast pumps among WIC women returning to work or school in Hawaii.

INTRODUCTION: The Women, Infants, and Children (WIC) branch of the Hawaii Department of Health encourages and assists mothers in breastfeeding. A study was done to determine whether an electric breast pump (vs. a manual pump) would increase breastfeeding duration in those returning to work or school full-time. MATERIALS AND METHODS: During 2002-2003, a randomized trial was conducted among 280 women, with the duration of breastfeeding analyzed in 229 of these women. Descriptive analyses and a multivariate logistic regression analysis assessed factors associated with breastfeeding at 6 months. Unadjusted and adjusted survival analyses were performed to estimate the duration of breastfeeding. RESULTS: In all, 76.8% of women using the manual breast pump and 72.3% of those using the electric breast pump breastfed for at least 6 months. This difference did not reach statistical significance. In the survival analysis adjusted for pump assignment, maternal age, race/ethnicity, marital status, and parity, women with at least some college education breastfed for a 38% shorter time than women with a high school or lower education. CONCLUSIONS: Our findings suggest that the manual breast pump may work as well as the electric breast pump when breastfeeding is encouraged and supported among women returning to work or school full-time. Particular attention should be given to examining reasons why women with greater education breastfed for a shorter duration. Further research is needed to validate these results to better inform breastfeeding women returning to work or school.

Factors associated with ease of using community-based systems of care for CSHCN in Hawai'i.

OBJECTIVES: To study factors contributing to difficulty using community-based services by families of children with special health care needs (CSHCN) in Hawai'i. METHODS: Data source was the 2001 National Survey of Children With Special Health Care Needs. The study population included the 449 respondents who were surveyed after additional items were added to the original questionnaire. Outcome of interest was "% of CSHCN whose families report community-based service systems are organized so they can use them easily." Explanatory variables included child health conditions (functional limitation, degree of severity, types of service needs), child and family characteristics (child age, maternal education, poverty level), and health services characteristics (partnership of family in decision making, family-centered coordinated care, adequate health insurance). RESULTS: Children with special health care needs comprised 11.0% of < 18 years old children. Overall, 69% of respondents reported that community-based services could be used easily. Logistic regression analysis showed that the odds of reporting difficulties in using community-based services were almost 5 times higher for families who did not partner in decision making, 2.9 times higher for families who did not receive family-centered coordinated care, and 2.7 times higher for families who did not have adequate health insurance compared with families who were satisfied with the care received. Need for services contributed independently to reporting difficulties in community-based service use. Contrary to the hypothesized associations, severe health conditions or limited functionality did not contribute significantly to reporting difficulties in service use. CONCLUSIONS: Families who reported difficulties in using community-based services were those who have children who need extensive and varied services. Lack of involvement in decision making, lack of coordinated care in a medical home, and insufficient health insurance were the main obstacles to their ability to use community-based services easily.

Epidemiology of early hearing loss detection in Hawaii.

OBJECTIVE: Universal Newborn Hearing Screening began in 2 Honolulu hospitals in 1992, and by 1999, all 14 civilian birthing facilities in Hawaii were providing screening. Examination of 1998 Hawaii data indicated that approximately 13% of infants who did not pass initial hearing screening in the hospital did not return for the indicated follow-up. The purpose of this study was to determine the epidemiologic profile of infants who were born in 1999 and did not return for follow-up. METHODS: A population-based, cohort study of the hearing screening completion rates among the 13 civilian birthing facilities in Hawaii that provided data to the Department of Health was conducted. Analysis included a bivariate analysis of the demographic characteristics of infants who completed the screening/follow-up process compared with those who did not and logistic regression modeling to ascertain the demographic profile of infants at high risk for being lost to follow-up. RESULTS: Of 12 456 infants, hearing screening data could be linked to the birth certificate file, and a final disposition regarding completion of the screening/follow-up process was determined for 10 328 (83%). Less than 2% (n = 176) of the linked infants failed to complete the screening/follow-up procedures. Low birth weight and white infants and infants born to women who had not completed high school were approximately twice as likely not to complete the screening as were their normal birth weight or nonwhite counterparts. CONCLUSIONS: Failure to complete the hearing screening follow-up may be related to cultural differences that have been previously reported in other maternal and child health studies of the diverse populations in Hawaii. The results of this study will allow the Hawaii Newborn Hearing Screening Program to target its efforts and limited resources toward infants who are at higher risk of not completing the screening and who may need special attention to encourage their mothers to complete the screening process, and to move quickly with rescreening infants whose initial tests are positive so that infants are not lost to follow-up.

Perinatal substance use among high risk women in Hawaii: patterns and impact on pregnancy outcomes.

PURPOSE: This study examines the relationship between perinatal substance use and adverse pregnancy outcomes among a select group of high risk women residing in the state of Hawaii. METHODS: Participants were the 2,750 women who had live births during 1994 and 1995 and were enrolled in Hawaii's Perinatal Support Services (PSS) program. Demographic and behavioral risk factors associated with selection for participation in the PSS program were examined along with patterns of substance use and adverse perinatal outcomes. PRINCIPAL FINDINGS: After adjustment for demographic factors, Hawaiian/part Hawaiian women compared to non-Hawaiian women were 1.5 times as likely to drink alcohol (p<0.01) and 1.8 times as likely to smoke (p<0.001). Among these women, the relative risk (RR) for preterm delivery was significantly higher for those who used alcohol (RR=1.7, p=0.027), tobacco (RR=1.6, p=0.027), or illicit drugs (RR=1.8, 0.029). Among the same women, the relative risk for low birth weight was significantly higher for those who smoked (RR=1.6, p=0.010) or used illicit drugs (RR=1.7, p=0.046). CONCLUSION: Hawaiian/part Hawaiian PSS women had a higher prevalence of substance use than non-Hawaiian PSS women, even after adjusting for age, education, and marital status. RELEVANCE TO ASIAN AMERICAN AND PACIFIC ISLANDER POPULATIONS: Special attention must be paid to the reasons why Hawaiian/part Hawaiian pregnant women use tobacco and alcohol at higher rates than women of other ethnic groups enrolled in Hawaii's PSS Program. Furthermore, services to assist pregnant women refraining from using illicit drugs should be supported.

Surveillance for disparities in maternal health-related behaviors--selected states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2001.

PROBLEM/CONDITION: Disparities in maternal and infant health have been observed among members of different racial and ethnic populations and persons of differing socioeconomic status. For the Healthy People 2010 objectives for maternal and child health to be achieved (US Department of Health and Human Services. Healthy People 2010. 2nd ed. With understanding and improving health and objectives for improving health [2 vols.]. Washington DC: US Department of Health and Human Services, 2000), the nature and extent of disparities in maternal behaviors that affect maternal or infant health should be understood. Identifying these disparities can assist public health authorities in developing policies and programs targeting persons at greatest risk for adverse health outcomes. REPORTING PERIOD COVERED: 2000-2001. DESCRIPTION OF THE SYSTEM: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver live-born infants. PRAMS employs a mixed mode data-collection methodology; up to three self-administered surveys are mailed to a sample of mothers, and nonresponders are followed up with telephone interviews. Self-reported survey data are linked to selected birth certificate data and weighted for sample design, nonresponse, and noncoverage to create annual PRAMS analysis data sets that can be used to produce statewide estimates of different perinatal health behaviors and experiences among women delivering live infants in 31 states and New York City. This report summarizes data for 2000-2001 from eight states (Alabama, Colorado, Florida, Hawaii, Illinois, Maine, Nebraska, and North Carolina) on four behaviors (smoking during pregnancy, alcohol use during pregnancy, breastfeeding initiation, and use of the infant back sleep position) for which substantial health disparities have been identified previously. RESULTS: Although the prevalence of each behavior varied by state, consistent patterns were observed among the eight states by age, race, ethnicity, education, and income level. Overall, the prevalence of smoking during pregnancy ranged from 9.0% to 17.4%. Younger (aged <25 years) women, white women, American Indian women, non-Hispanic women (except in Hawaii), women with a high school education or less, and women with low incomes consistently reported the highest rates of smoking. Overall, the prevalence of alcohol use during pregnancy ranged from 3.4% to 9.9%. In seven states, women aged >35 years, non-Hispanic women, women with more than a high school education, and women with higher incomes reported the highest prevalence of alcohol use during pregnancy. Overall, the prevalence of breastfeeding initiation ranged from 54.8% to 89.6%. Younger women, black women, women with a high school education or less, and women with low incomes reported the lowest rates of breastfeeding initiation. The size of the black-white disparity in breastfeeding varied among states. Overall, use of the back sleep position for infants ranged from 49.7% to 74.8%. Use of the back sleep position was lowest among younger women, black women, women with lower levels of education, and women with low incomes. Ethnic differences in sleep position varied substantially by state. INTERPRETATION: PRAMS data can be used to identify racial, ethnic, and socioeconomic disparities in critical maternal health-related behaviors. Although similar general patterns by age, education, and income were observed in at least seven states, certain racial and ethnic disparities varied by state. Prevalence of the four behaviors among each population often varied by state, indicating the potential impact of state-specific policies and programs. PUBLIC HEALTH ACTION: States can use PRAMS data to identify populations at greatest risk for maternal behaviors that have negative consequences for maternal and infant health and to develop policies and plan programs that target populations at high risk.sk. Although prevalence data cannot be used to identify causes or interventions to improve health outcomes, they do indicate the magnitude of disparities and identify populations that should be targeted for intervention. This report indicates a need for wider targeting than is often done. The results from this report can aid state and national agencies in creating more effective public health policies and programs. The data described in this report should serve as a baseline that states can use to measure the impact of policies and programs on eliminating these health disparities.