Arden Handler

Very Low Birthweight in African American Infants: The Role of Maternal Exposure to Interpersonal Racial Discrimination

OBJECTIVES We determined whether African American womens lifetime exposure to interpersonal racial discrimination is associated with pregnancy outcomes. METHODS We performed a case-control study among 104 African American women who delivered very low birthweight (<1500 g) preterm (<37 weeks) infants and 208 African American women who delivered non-low-birthweight (>2500 g) term infants in Chicago, Ill. RESULTS The unadjusted and adjusted odds ratio of very low birthweight infants for maternal lifetime exposure to interpersonal racism in 3 or more domains equaled 3.2 (95% confidence intervals=1.5, 6.6) and 2.6 (1.2, 5.3), respectively. This association tended to persist across maternal sociodemographic, biomedical, and behavioral characteristics. CONCLUSIONS The lifelong accumulated experiences of racial discrimination by African American women constitute an independent risk factor for preterm delivery.

A Conceptual Framework to Measure Performance of the Public Health System

OBJECTIVES This article describes a unifying conceptual framework for the public health system as a way to facilitate the measurement of public health system performance. METHODS A conceptual framework for the public health system was developed on the basis of the work of Donabedian and a conceptual model previously developed by Bernard Turnock and Arden Handler. RESULTS The conceptual framework consists of 5 components that can be considered in relationship to each other: macro context, mission, structural capacity, processes, and outcomes. Although the availability of measures for each of these components varies, the framework can be used to examine the performance of public health systems as well as that of agencies and programs. CONCLUSIONS A conceptual framework that explicates the relationships among the various components of the public health system is an essential step toward providing a science base for the study of public health system performance.

Urinary tract infection during pregnancy: its association with maternal morbidity and perinatal outcome.

OBJECTIVES. The effects of antepartum urinary tract infection on adverse maternal and perinatal outcomes were examined. Antepartum urinary tract infection has been previously implicated as a risk factor for numerous outcomes. METHODS. Crude and multivariable analyses were performed with a perinatal registry cohort of 25,746 mother/infant pairs. RESULTS. Elevated risks were observed for exposure to urinary tract infection and low birthweight, prematurity, preterm low birthweight, premature labor, hypertension/preeclampsia, maternal anemia, and amnionitis. Urinary tract infection was associated with perinatal death only among subjects 20 to 29 years of age. CONCLUSIONS. These findings underscore the importance of antepartum urine screening to identify patients at risk for adverse outcomes.

Core function-related local public health practice effectiveness.

This article assesses the extent to which the U.S. population in 1995 was being effectively served by public healths three core functions (assessment, policy development, and assurance). A random sample of local health departments (LHDs) stratified by population size and type of jurisdiction was asked to provide their opinion of, as well as indicate performance on 20 core function-related measures of local public health practice. The article concludes that, in 1995, the nation fell far short of its year 2000 national objective, which called for 90 percent of the population to be served by an LHD effectively carrying out public healths core functions. Considerable capacity building and performance improvement is needed within the public health system.

Local Health Department Effectiveness in Addressing the Core Functions of Public Health: Essential Ingredients

Objectives: Objective 8.14 of the U.S. Healthy People 2000 objectives calls for 90% of the population to be served by a local health department (LHD) which is effectively carrying out the core functions of public health (assessment, policy development, assurance). This study seeks to describe the structural and service characteristics of an effective LHD.Methods: Data from a 1993 national random sample survey of LHD practice were merged with data from the 1992–1993 National Association of County and City Health Officials (NACCHO) profile of local health agencies. Using a definition of effectiveness related to the core functions of public health, the correlates of effectiveness were examined for 264 health departments in the matched sample.Results: Effectiveness of local health agencies was not related to jurisdiction size or type. Inputs (structural factors) associated with effectiveness included having a full-time agency head, a larger budget derived from a greater number of funding sources, and a larger number of staff. With respect to outputs (services), effective health departments were also more likely to provide a greater number of services directly, particularly personal preventive and treatment services.Conclusions: Only a few inputs are correlated with core-function related effectiveness. However, a profile of an effective health department emerges. Effective LHDs appear more likely to have full-time leadership which is able to tap diverse funding sources to provide the mix and match of community and personal prevention and treatment services needed to address community needs and improve the publics health.

HEALTH CARE CHARACTERISTICS ASSOCIATED WITH WOMEN'S SATISFACTION WITH PRENATAL CARE

OBJECTIVES The objective of this study was to explore the relation between prenatal care characteristics and satisfaction among Medicaid recipients. METHODS African-American (n = 75) and Mexican-American (n = 26) nonadolescent primiparous pregnant women who had at least three prenatal care visits participated in a 25-minute telephone survey that asked them about satisfaction with prenatal care (art of care, technical quality, physical environment, access, availability and efficacy); prenatal care characteristics (practitioner attributes, service availability, and features of the delivery of care); and, personal characteristics (sociodemographics, health status and behaviors, and pregnancy-related variables). Univariate and multivariable analyses were conducted to explore the relations between personal characteristics and satisfaction and between care characteristics and satisfaction. RESULTS For the overall sample, the following prenatal care characteristics were associated with increased satisfaction: having procedures explained by the provider, short waiting times at the prenatal care site, the availability of ancillary services, and reporting that the prenatal care practitioner was male. When examining the data by ethnicity, whether the provider explained procedures was the most important determinant of satisfaction for both African-American and Mexican-American women. CONCLUSIONS Knowledge of the care characteristics that impact low-income pregnant womens satisfaction can be utilized to alter service delivery to increase use of prenatal care and ultimately to improve perinatal outcomes.

The relationship between exposure during pregnancy to cigarette smoking and cocaine use and placenta previa

OBJECTIVE This study examined the relationship between two maternal exposures, cigarette smoking and cocaine use, and placenta previa. STUDY DESIGN A hospital-based case-control study was conducted. Three hundred four cases of placenta previa were compared with 2732 controls with respect to demographic characteristics, substance use, and perinatal characteristics. Logistic regression was used to examine the individual effects of cigarette smoking and cocaine use on placenta previa, independent of other known risk factors. RESULTS A dose-response relationship between smoking cigarettes and placenta previa was observed independent of other known risk factors (ptrend < 0.01). Pregnant women who smoked > or = 20 cigarettes per day were over two times more likely to experience a placenta previa relative to nonsmokers (odds ratio 2.3, 95% confidence interval 1.5 to 3.5). Pregnant women who used cocaine were 1.4 times (95% confidence interval 0.8 to 2.4) as likely to experience a placenta previa as nonusers. CONCLUSIONS The previously observed association between smoking and placenta previa is supported by the dose-response relationship observed in this study. The potential association of cocaine with placenta previa needs more exploration.

The relationship of smoking and ectopic pregnancy.

A case-control study, using data abstracted between 1983 and 1987 from a large perinatal registry, was conducted to explore the relationship between smoking and ectopic pregnancy. Women with ectopic pregnancy (n = 634) seen at University of Illinois Perinatal Network Hospitals were compared to women who were delivered of a single live-born infant (n = 4287). Adjusted for age and race, women who reported smoking during pregnancy had a greater than twofold risk of ectopic pregnancy (Odds Ratio = 2.5, 95% confidence interval = 1.9, 3.2) compared to women who never smoked. The estimated relative risk rose from 1.4 (95% CI = 0.8, 2.5) for a woman smoking fewer than 10 cigarettes a day to 5.0 (95% CI = 2.9, 8.7) at one and a half or more packs of cigarettes per day (p-value for trend less than 0.001). Although further basic and epidemiologic research is necessary, the observed dose-response relation strengthens the argument that smoking may be a causal factor in the development of ectopic pregnancy.

A review of prenatal home-visiting effectiveness for improving birth outcomes.

OBJECTIVE To determine the effectiveness of prenatal home visiting for improving prenatal care utilization and preventing preterm birth and low birth weight. DATA SOURCES Medline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Social Work Abstract databases were searched for articles that examined prenatal home-visiting and prenatal care utilization or neonatal outcomes, with additional ascendancy and descendancy searches. Listservs were also used to identify unpublished evaluations. STUDY SELECTION Quantitative studies meeting the following criteria were included in the analyses: published between 1985 and 2009, published in English, reported providing prenatal home visiting, and reported on prenatal care utilization or a neonatal outcome. DATA EXTRACTION Study characteristics and findings related to prenatal care utilization, gestational age, and birth weight were abstracted independently by at least two authors. Study quality was assessed across five domains. DATA SYNTHESIS The search yielded 28 studies comparing outcomes for women who did and did not receive prenatal home visiting, with 14 (59%) using an RCT design. Five (17%) studies reporting on prenatal care utilization found a statistically significant improvement in use of prenatal care for women with home visiting. Of 24 studies reporting an effect on birth outcomes, five (21%) found a significant positive effect on gestational age, and seven of 17 (41%) found a significant positive effect on birth weight. CONCLUSIONS More evidence suggests that prenatal home visiting may improve the use of prenatal care, whereas less evidence exists that it improves neonatal birth weight or gestational age. These findings have implications for implementing Title II of the Affordable Care Act.

Prenatal care initiation among very low-income women in the aftermath of welfare reform: does pre-pregnancy Medicaid coverage make a difference?

Objectives: To examine pre-pregnancy Medicaid coverage and initiation of prenatal care among women likely eligible for Medicaid coverage regardless of pregnancy. Methods: The Pregnancy Risk Assessment Monitoring System (PRAMS) was used to identify very low-income women with Medicaid payment for delivery. We then compared prenatal care initiation among women with (Non-GAP) and without (Medicaid GAP) pre-pregnancy Medicaid coverage. Results: Rates of first trimester prenatal care were 47.3% for women in the Medicaid GAP, 70.0% for women who were not. The adjusted odds ratio for being in the Medicaid GAP and delayed prenatal care was 2.7 (95% CI 1.2, 6.2), although this varied by race/ethnicity and education. The relationship was strongest among White and Hispanic women with less than a high school education: OR=13.8, (95% CI 3.0, 62.7) and OR=19.0 (95% CI 2.4, 149.2), respectively. Conclusions: Pre-pregnancy Medicaid coverage appears to be associated with early initiation of prenatal care. Almost a decade after welfare reform, it is essential to preserve the Medicaid expansions for pregnant women, foster Medicaid family planning waivers, and promote access to primary care and early prenatal care, particularly for very low-income women.