A Human Microbiota-Associated Murine Model for Assessing the Impact of the Vaginal Microbiota on Pregnancy Outcomes.

Disease states are often linked to large scale changes in microbial community structure that obscure the contributions of individual microbes to disease. Establishing a mechanistic understanding of how microbial community structure contribute to certain diseases, however, remains elusive thereby limiting our ability to develop successful microbiome-based therapeutics. Human microbiota-associated (HMA) mice have emerged as a powerful approach for directly testing the influence of microbial communities on host health and disease, with the transfer of disease phenotypes from humans to germ-free recipient mice widely reported. We developed a HMA mouse model of the human vaginal microbiota to interrogate the effects of Bacterial Vaginosis (BV) on pregnancy outcomes. We collected vaginal swabs from 19 pregnant African American women with and without BV (diagnosed per Nugent score) to colonize female germ-free mice and measure its impact on birth outcomes. There was considerable variability in the microbes that colonized each mouse, with no association to the BV status of the microbiota donor. Although some of the women in the study had adverse birth outcomes, the vaginal microbiota was not predictive of adverse birth outcomes in mice. However, elevated levels of pro-inflammatory cytokines in the uterus of HMA mice were detected during pregnancy. Together, these data outline the potential uses and limitations of HMA mice to elucidate the influence of the vaginal microbiota on health and disease.

Extreme obesity and risk of stillbirth among black and white gravidas.

OBJECTIVE: To estimate the risk for stillbirth among three generally accepted obesity subtypes based on severity. METHODS: We used the Missouri maternally linked cohort data containing births from 1978 to 1997. Using prepregnancy weight and height, mothers were classified on the basis of calculated body mass index (BMI) above 30 into three subsets: class I (30-34.9), class II (35-39.9), and extreme obesity (greater than or equal to 40). Using normal-weight, white women (18.5-24.9) as a reference, we applied Cox proportional hazard regression models to estimate risks for stillbirth. RESULTS: The prevalence of obesity in pregnant women was 9.5% (12.8% among blacks and 8.9% among whites). Overall, obese mothers were about 40% more likely to experience stillbirth compared with nonobese gravidas (adjusted hazard ratio 1.4; 95% confidence interval [CI] 1.3-1.5). The risk for stillbirth increased in a dose-dependent fashion with increase in BMI: class I (adjusted hazard ratio 1.3; 95% CI 1.2-1.4); class II (adjusted hazard ratio 1.4; 95% CI 1.3-1.6) and extreme obesity (adjusted hazard ratio 1.9; 95% CI 1.6-2.1; P for trend <.01). Obese black mothers experienced more stillbirths than their white counterparts (adjusted hazard ratio 1.9; 95% CI 1.7-2.1 compared with adjusted hazard ratio 1.4; 95% CI 1.3-1.5). The black disadvantage in stillbirth widened with increase in BMI, with the greatest difference observed among extremely obese black mothers (adjusted hazard ratio 2.3; 95% CI 1.8-2.9). CONCLUSION: Obesity is a risk factor for stillbirth, particularly among extremely obese, black mothers. Strategies to reduce black-white disparities in birth outcomes should consider targeting obese, black women. LEVEL OF EVIDENCE: II.

mHealth to promote pregnancy and interconception health among African-American women at risk for adverse birth outcomes: a pilot study.

BACKGROUND: The use of mobile phone applications (mHealth) to provide health education and behavioral prompts is 1 of the 12 common mHealth functions identified by the World Health Organization as innovations to strengthen health systems. Among low-income pregnant and parenting women, health education is widely recognized as a way to improve maternal and infant health outcomes, but the efficacy of written health education materials to change knowledge and behavior for this population is questionable. mHealth prompts, in contrast, is a promising alternative. METHODS: A team of researchers in medicine/epidemiology, anthropology/midwifery, computer science/sensors, and community-based case management created and pilot tested a mHealth application (mHealth app) for African-American women at high risk for adverse birth outcomes. We tested the acceptability and feasibility of the interactive application among women during the reproductive stages of early and late pregnancy, postpartum, and interconception. RESULTS: Interview data from 14 women in the various reproductive stages revealed that most women found the mHealth messages helpful. Also, 62 Ob-Gyn physicians and nurses and 19 Family Medicine residents provided feedback. Women's responses to specific messages trended down over time. Women in the postpartum phase had the highest response rate to particular text messages, followed by those in the pregnancy phase. Responses dropped off dramatically during the interconception period. About 21% of women lost their phones. Unexpected findings were that all participants already had smartphones, women wanted messages about depression, and clinicians wanted the app to link to case management for individualized medical care. CONCLUSIONS: Logistical challenges to app management were limitations but are useful for consideration before scale-up. This study corroborates findings in the health literacy literature that women most at risk for adverse birth outcomes need additional face-to-face support with mHealth applications.

Perinatal origins of first-grade academic failure: role of prematurity and maternal factors.

OBJECTIVE: We examined the relationships among gestational age at birth, maternal characteristics, and standardized test performance in Georgia first-grade students. METHODS: Live births to Georgia-resident mothers aged 11 to 53 years from 1998 through 2003 were deterministically linked with standardized test results for first-grade attendees of Georgia public schools from 2005 through 2009. Logistic models were used to estimate the odds of failure of the 3 components of the first-grade Criterion-Referenced Competency Test (CRCT). RESULTS: The strongest risk factor for failure of each of the 3 components of the first-grade CRCT was level of maternal education. Child race/ethnicity and maternal age at birth were also associated with first-grade CRCT failure irrespective of the severity of preterm birth, but these factors were more important among children born moderately preterm than for those born on the margins of the prematurity distribution. Adjusting for maternal and child characteristics, there was an increased odds of failure of each component of the CRCT for children born late preterm versus term, including for math (adjusted odds ratio [aOR]: 1.17, 95% confidence interval [CI]: 1.13-1.22), reading (aOR: 1.13, 95% CI: 1.08-1.18), and English/language arts, for which there was an important interaction with being born small for gestational age (aOR: 1.17, 95% CI: 1.07-1.29). CONCLUSIONS: Preterm birth and low maternal education increase children's risk of failure of first-grade standardized tests. Promoting women's academic achievement and reduce rates of preterm birth may be important to achieving gains in elementary school performance.

Integrating reproductive planning with primary health care: an exploration among low-income, minority women and men.

INTRODUCTION: Despite recommendations to integrate reproductive and preconception health care services with primary health care, integration of such services is uncommon. The purpose of this study was to explore the acceptability and utility of integrating an assessment of reproductive plans into primary care encounters. METHODOLOGY: Using a purposive sampling strategy, we purposively selected 144 African-American and Hispanic females and males from publicly-funded clinics. We assessed their desire for a child and contraceptive practices via a reproductive plans questionnaire. Patients' written responses were attached to the medical record for provider use. After the encounter, we administered semi-structured interviews to elicit patients' opinions about the questionnaire. We audio-recorded and transcribed verbatim responses and qualitatively analyzed them by content analysis. RESULTS: Overall, 58/72 (81%) of females and 30/72 (42%) of males reported the reproductive plans assessment was important to their encounter, with variation in the reason according to reported desire for a child. According to reported contraceptive practices, >45% who reported never wanting a child or not wanting a child for at least one year were 'at-risk for unintended pregnancy.' A substantial proportion of patients reported uncertainty about desiring a child, and a minority of these reported consistent contraception use. DISCUSSION: Questions to assess patients' reproductive plans were viewed as important by the majority of female and a substantial proportion of male primary care patients, and a substantial proportion were at-risk for unintended pregnancy. Primary care practices should consider implementing a reproductive plans assessment to facilitate linkage of patients to appropriate family planning, preconception, and sexually-transmitted infection services.

Interpregnancy primary care and social support for African-American women at risk for recurrent very-low-birthweight delivery: a pilot evaluation.

OBJECTIVES: Very-low-birthweight (VLBW) delivery accounts for the majority of neonatal mortality and the black-white disparity in infant mortality. The risk of recurrent VLBW is highest for African-Americans of lower socioeconomic status. This study explores whether the provision of primary health care and social support following a VLBW delivery improves subsequent child spacing and pregnancy outcomes for low-income, African-American women. METHODS: This pilot study of mixed prospective-retrospective cohort design enrolled African-American women who qualified for indigent care and delivered a VLBW infant at a public hospital in Atlanta from November 2003 through March 2004 into the intervention cohort (n (1) = 29). The intervention consisted of coordinated primary health care and social support for 24 months following the VLBW delivery. A retrospective cohort was assembled from consecutive women meeting the same eligibility criteria who delivered a VLBW infant during July 2001 through June 2002 (n (2) = 58). The number of pregnancies conceived within 18 months of the index VLBW delivery and the number of adverse pregnancy outcomes for each cohort was compared with Poisson regression. RESULTS: Women in the control cohort had, on average, 2.6 (95% CI: 1.1-5.8) times as many pregnancies within 18 months of the index VLBW delivery and 3.5 (95% CI: 1.0-11.7) times as many adverse pregnancy outcomes as women in the intervention cohort. CONCLUSIONS: This small, pilot study suggests that primary health care and social support for low-income, African-American women following a VLBW delivery may enhance achievement of a subsequent 18-month interpregnancy interval and reduce adverse pregnancy outcomes.

Medical outreach following a remote disaster: lessons learned from Hurricane Katrina.

In the aftermath of Hurricane Katrina, many individuals were evacuated to the Atlanta area (1,306 medical evacuees, over 100,000 self-evacuees), placing considerable strain on an already overburdened healthcare system. With the aim of improving future disaster responsiveness, we designed this in-depth case study to identify systemic vulnerabilities and gaps in community responsiveness to an influx of evacuees from a remote disaster. Qualitative methods were used to interview key informants both individually and in focus groups. Coding and content analysis of transcribed interview data were used to identify shared observations and common themes. Twenty-three individuals in leadership roles at the Woodruff Health Sciences Center of Emory University or the Grady Health System completed individual interviews; an additional 24 healthcare providers participated in focus groups. A strategy-based data-coding scheme for interview data was used to identify key foci, including services that met needs of evacuees, unmet needs, service provision that was successful/unsuccessful, underlying reasons for success or failure, and future needs for disaster planning and responsiveness. Analysis of interview data revealed important accomplishments and deficits in the medical community's response in specific domains of community disaster planning and evaluation. For each key component of community disaster planning and evaluation, there are considerations at the institutional, regional, state, and federal levels. In the current study, these considerations were identified as instrumental in effectively meeting the healthcare needs of the evacuated population.

Promising practices in preconception care for women at risk for poor health and pregnancy outcomes.

OBJECTIVES: Two programs targeting urban African-American women are presented as promising models for preconception care, which includes interconception care. METHODS: The Grady Memorial Hospital Interpregnancy Care (IPC) Program in Atlanta, Georgia, and the Magnolia Project in Jacksonville, Florida, are described. The IPC program aims to investigate whether IPC can improve the health status, pregnancy planning and child spacing of women at risk of recurrent very low birthweight (VLBW). The Magnolia Project aims to reduce key risks in women of childbearing age, such as lack of family planning and repeat sexually transmitted diseases (STDs), through its case management activities. RESULTS: Seven out of 21 women in the IPC were identified as having a previously unrecognized or poorly managed chronic disease. 21/21 women developed a reproductive plan for themselves, and none of the 21 women became pregnant within nine months following the birth of their VLBW baby. The Magnolia Project had a success rate of greater than 70% in resolving the key risks (lack of family planning, repeat STDs) among case management participants. The black to white infant mortality (IM) ratio was better for the babies born to women managed in the Magnolia Project compared to the same ration for the United States. CONCLUSIONS: Preconception care targeted to African-American women at risk for poor birth outcomes appears to be effective when specific risk factors are identified and interventions are appropriate. Outreach to women at risk and case management can be effective in optimizing the woman's health and subsequent reproductive health outcomes.