Ayman Ae El-Mohandes

Recruitment and retention of low-income minority women in a behavioral intervention to reduce smoking, depression, and intimate partner violence during pregnancy

BackgroundResearchers have frequently encountered difficulties in the recruitment and retention of minorities resulting in their under-representation in clinical trials. This report describes the successful strategies of recruitment and retention of African Americans and Latinos in a randomized clinical trial to reduce smoking, depression and intimate partner violence during pregnancy. Socio-demographic characteristics and risk profiles of retained vs. non-retained women and lost to follow-up vs. dropped-out women are presented. In addition, subgroups of pregnant women who are less (more) likely to be retained are identified.MethodsPregnant African American women and Latinas who were Washington, DC residents, aged 18 years or more, and of 28 weeks gestational age or less were recruited at six prenatal care clinics. Potentially eligible women were screened for socio-demographic eligibility and the presence of the selected behavioral and psychological risks using an Audio Computer-Assisted Self-Interview. Eligible women who consented to participate completed a baseline telephone evaluation after which they were enrolled in the study and randomly assigned to either the intervention or the usual care group.ResultsOf the 1,398 eligible women, 1,191 (85%) agreed to participate in the study. Of the 1,191 women agreeing to participate, 1,070 completed the baseline evaluation and were enrolled in the study and randomized, for a recruitment rate of 90%. Of those enrolled, 1,044 were African American women. A total of 849 women completed the study, for a retention rate of 79%. Five percent dropped out and 12% were lost-to-follow up. Women retained in the study and those not retained were not statistically different with regard to socio-demographic characteristics and the targeted risks. Retention strategies included financial and other incentives, regular updates of contact information which was tracked and monitored by a computerized data management system available to all project staff, and attention to cultural competence with implementation of study procedures by appropriately selected, trained, and supervised staff. Single, less educated, alcohol and drug users, non-working, and non-WIC women represent minority women with expected low retention rates.ConclusionWe conclude that with targeted recruitment and retention strategies, minority women will participate at high rates in behavioral clinical trials. We also found that women who drop out are different from women who are lost to follow-up, and require different strategies to optimize their completion of the study.

Pregnancy Intentions and Happiness Among Pregnant Black Women at High Risk for Adverse Infant Health Outcomes

CONTEXT Unintended pregnancy is associated with risk behaviors and increased morbidity or mortality for mothers and infants, but a womans feelings about pregnancy may be more predictive of risk and health outcomes than her intentions. METHODS A sample of 1,044 black women who were at increased risk were enrolled at prenatal care clinics in the District of Columbia in 2001-2003. Bivariate and multivariate analyses assessed associations between pregnancy intentions or level of happiness about being pregnant and multiple psychosocial and behavioral risk factors, and identified correlates of happiness to be pregnant. RESULTS Pregnancy intentions and happiness were strongly associated, but happiness was the better predictor of risk. Unhappy women had higher odds than happy women of smoking, being depressed, experiencing intimate partner violence, drinking and using illicit drugs (odds ratios, 1.7-2.6). The odds of being happy were reduced among women who had other children or a child younger than two, who were single or did not have a current partner, who had had more than one sexual partner in the past year and who reported that the babys father did not want the pregnancy (0.3-0.6). In contrast, the odds of being happy were elevated among women who had better coping strategies (1.03), who had not used birth control at conception (1.6) and who had 1-2 household members, rather than five or more (2.1). CONCLUSIONS Additional psychosocial screening for happiness about being pregnant and for partner characteristics, particularly the fathers desire to have this child, may help improve prenatal care services and prevent adverse health outcomes.

Environmental Tobacco Smoke Avoidance Among Pregnant African-American Nonsmokers

BACKGROUND Environmental tobacco smoke (ETS) exposure during pregnancy contributes to adverse infant health outcomes. Limited previous research has focused on identifying correlates of ETS avoidance. This study sought to identify proximal and more distal correlates of ETS avoidance early in pregnancy among African-American women. METHODS From a sample of low-income, black women (n=1044) recruited in six urban, prenatal care clinics (July 2001-October 2003), cotinine-confirmed nonsmokers with partners, household/family members, or friends who smoked (n=450) were identified and divided into two groups: any past-7-day ETS exposure and cotinine-confirmed ETS avoidance. Bivariate and multivariate logistic regression analyses identified factors associated with ETS avoidance. Data were initially analyzed in 2004. Final models were reviewed and revised in 2007 and 2008. RESULTS Twenty-seven percent of pregnant nonsmokers were confirmed as ETS avoiders. In multivariate logistic regression analysis, the odds of ETS avoidance were increased among women who reported household smoking bans (OR=2.96; 95% CI=1.83, 4.77; p<0.0001), that the father wanted the baby (OR=2.70; CI=1.26, 5.76; p=0.01), and that no/few family members/friends smoked (OR=3.15; 95% CI=1.58, 6.29; p<0.001). The odds were decreased among women who had a current partner (OR=0.42; 95% CI=0.23, 0.76; p<0.01), reported any intimate partner violence during pregnancy (OR=0.43; 95% CI=0.19, 0.95; p<0.05), and reported little social support to prevent ETS exposure (OR=0.50; 95% CI=0.30, 0.85; p=0.01). Parity, emotional coping strategies, substance use during pregnancy, partner/household member smoking status, and self-confidence in avoiding ETS were significant in bivariate, but not multivariate analyses. CONCLUSIONS Social contextual factors were the strongest determinants of ETS avoidance during pregnancy. Results highlight the importance of prenatal screening to identify pregnant nonsmokers at risk, encouraging household smoking bans, gaining support from significant others, and fully understanding the interpersonal context of a womans pregnancy before providing behavioral counseling and advice to prevent ETS exposure.

Does Elevated Peak Bilirubin Protect from Retinopathy of Prematurity in Very Low Birthweight Infants

OBJECTIVE: Bilirubin is a potent in vitro antioxidant. Despite repeated study, its in vivo significance has yet to be defined. Bilirubin is universally elevated in very low birthweight (VLBW) infants. Retinopathy of prematurity (ROP) is a disease thought to be associated with exposure to oxygen free radicals in VLBW infants. The objective of this study was to determine whether there was an association between peak bilirubin levels and ROP.METHODS: The risk for ROP, stages III and IV was measured as a function of increasing peak bilirubin levels in VLBW infants admitted to the neonatal ICU. A similar analysis was performed on a subgroup of VLBW infants with prolonged (≥28 days) oxygen requirement. The relation between peak bilirubin level and the duration of oxygen requirement was tested by logistic regression analysis. All analyses were conducted after controlling for birthweight and presence of intraventricular hemorrhage (IVH).RESULTS: There was an increased risk for ROP, stages III and IV (OR 1.187; 95% CI 1.013 to 1.390; p=0.034) with elevated peak serum bilirubin levels in the entire population. Duration of oxygen requirement was not related to peak bilirubin (p>0.1). In the subgroup of infants with prolonged oxygen requirement (≥28 days), there was no association between peak serum bilirubin levels and ROP III and IV (p>0.1); however, there was an association with further increased duration of oxygen requirement (p=0.034).CONCLUSION: Elevated peak bilirubin does not protect from and may be a risk for ROP in VLBW infants.

Prediction of Birth Weight By Cotinine Levels During Pregnancy in a Population of Black Smokers

OBJECTIVE: The goal was to investigate the association between maternal salivary cotinine levels (SCLs) and pregnancy outcomes among black smokers. METHODS: In a randomized, controlled trial conducted in 2001–2004 in Washington, DC, 714 women (126 active smokers [18%]) were tested for SCLs at the time of recruitment and later in pregnancy. Sociodemographic health risks and pregnancy outcomes were recorded. RESULTS: Birth weights were significantly lower for infants born to mothers with baseline SCLs of ≥20 ng/mL in comparison with <20 ng/mL (P = .024), ≥50 ng/mL in comparison with <50 ng/mL (P = .002), and ≥100 ng/mL in comparison with <100 ng/mL (P = .002), in bivariate analyses. In linear regression analyses adjusting for sociodemographic and medical factors, SCLs of ≥20 ng/mL were associated with a reduction in birth weight of 88 g when SCLs were measured at baseline (P = .042) and 205 g when SCLs were measured immediately before delivery (P < .001). Corresponding results were 129 g (P = .006) and 202 g (P < .001) for ≥50 ng/mL and 139 g (P = .007) and 205 g (P < .001) for ≥100 ng/mL. Gestational age was not affected significantly at any SCL, regardless of when SCLs were measured. CONCLUSIONS: Elevated SCLs early in pregnancy or before delivery were associated with reductions in birth weight. At any cutoff level, birth weight reduction was more significant for the same SCL measured in late pregnancy. Maintaining lower levels of smoking for women who are unable to quit may be beneficial.

Membrane Antigen and Ligand Receptor Expression on Neonatal Monocytes

The monocyte/macrophage cell lineage is an essential component of host defense. Functional deficiencies have been described in neonatal monocytes, but knowledge of membrane antigen and receptor ligand expression in neonatal monocytes is incomplete. In this study, antigen and receptor ligand expression of cord blood monocytes (CBM) was examined and compared to adult peripheral blood monocytes (PBM). Leu-M3 and Leu-M5 antigens were shown to be present on all CBM. Using dual fluorescence microfluorometry, the percentage and intensity of expression of HLA-DR, CD4 antigens, Fc gamma and IL-2 receptors (IL-2R) on Leu-M3+ and Leu-M5+ CBM were compared to PBM. A lower percentage of expression of HLA-DR+ (87 +/- 3% vs. 95 +/- 1%, p = 0.02) and FC gamma RII+ (96 +/- 1% vs. 99 +/- 0.2%, p = 0.04) was noted on CBM. CD4, FC gamma RI, and FC gamma RIII expression on CBM were comparable to PBM. LPS stimulation of CBM induced IL-2R expression and enhanced HLA-DR antigen expression as seen previously on PBM. These findings indicate that CBM are phenotypically comparable to adult PBM with deficiencies localized only to a few specific areas.

Illicit Drug Use is Associated with a Significant Increase in Neonatal and Perinatal Mortality 1371

Illicit Drug Use is Associated with a Significant Increase in Neonatal and Perinatal Mortality 1371

Poor Prenatal Care or Illicit Drug Use: Which of the Two is a Stronger Risk Association for Prematurity and Low Birth Weight |[dagger]| 1245

7,552 DC mothers were screened in the post partum period, and correlations were made between the adequacy of prenatal care (PNC) they received, their use of illicit drugs in pregnancy, and the incidence of low birth weight (LBW) and prematurity. 29% of the mothers had received no/poor prenatal care (< 5 visits or care initiated after 24 weeks gestation), and 12% of the mothers were identified with illicit drug use (IDU) in pregnancy by history and/or urine testing. The incidence of prematurity and LBW in mothers with IDU versus no IDU was 33% versus 12.5%, and 36% versus 11% respectively. The incidence of prematurity and LBW in mothers with poor PNC versus good PNC was 25.4% versus 10%, and 25% versus 9%. The adjusted risk fractions (ARF) for prematurity and LBW were calculated, comparing the risk associated with IDU when controlling for poor PNC, to the risk associated with poor PNC when controlling for IDU(see table). These results indicate that poor PNC is a more serious risk factor with respect to prematurity and low birth weight than illicit drug use in pregnancy. However, inadequate prenatal care might be a proxy of other events that occur in the womens lives. Combining inadequate PNC with IDUduring pregnancy puts DC women at even higher risk for poor pregnancy outcomes.

Poor Prenatal Care Utilization in a Population of DC Residents Correlates with Their Health Beliefs † 1244

261 DC residents were identified in their post partum period as having used prenatal care poorly during pregnancy (defined as < 5 visits and/or care initiated after 24 weeks gestation). Of the mothers who received prenatal care, 31% received care with a private physician, 37% in a hospital based clinic, 20% in a public clinic, and 2% listed the ER as where they received care; 11% had received no prenatal care. When interviewed, 93% agreed that prenatal care was important, yet 56% had not initiated care until the third trimester, and 76% until the second trimester of pregnancy. Mean number of prenatal care visits was 3.7 ± 2.7, and time of initiating prenatal care was 26 ± 7 weeks gestation. The top four reasons listed for non-adherence to prenatal care schedule were lack of funds (19%), transportation difficulties (12%), the baby being in good health (7%), and lack of child care (7%). When the Health Beliefs Questionnaire was administered to these mothers, although their perception of severity of illness was relatively higher (79/96), their perception of susceptibility to illness (28/46), and efficacy of medical care (27/48) were relatively low. These findings suggest that although mothers with poor prenatal care express practical difficulties as barriers to seeking care, underlying beliefs about susceptibility to illness and the efficacy of medical care also impact on their behaviors.