Cheryl L. Robbins

Depression and Treatment Among U.S. Pregnant and Nonpregnant Women of Reproductive Age, 2005–2009

BACKGROUND Depression is often undiagnosed and untreated. It is not clear if differences exist in the diagnosis and treatment of depression among pregnant and nonpregnant women. We sought to estimate the prevalence of undiagnosed depression, treatment by modality, and treatment barriers by pregnancy status among U.S. reproductive-aged women. METHODS We identified 375 pregnant and 8,657 nonpregnant women 18-44 years of age who met criteria for past-year major depressive episode (MDE) from 2005-2009 nationally representative data. Chi-square statistics and adjusted prevalence ratios (aPR) were calculated. RESULTS MDE in pregnant women (65.9%) went undiagnosed more often than in nonpregnant women (58.6%) (aPR 1.1, 95% confidence interval [CI] 1.0-1.3). Half of depressed pregnant (49.6%) and nonpregnant (53.7%) women received treatment (aPR 1.0, 95% CI 0.90-1.1), with prescription medication the most common form for both pregnant (39.6%) and nonpregnant (47.4%) women. Treatment barriers did not differ by pregnancy status and were cost (54.8%), opposition to treatment (41.7%), and stigma (26.3%). CONCLUSIONS Pregnant women with MDE were no more likely than nonpregnant women to be diagnosed with or treated for their depression.

HIV seroprevalence among orphaned and homeless youth: no place like home.

Objectives:We evaluated the combined influences of orphaned status and homelessness on HIV seroprevalence and risk among street-involved Ukrainian youth in 2008. Design:Systematic, multicity, community-based, cross-sectional assessment. Methods:Time-location sampling was used to identify eligible youth aged 15–24 after city-wide mapping of 91 sites where street-involved youth gathered in Odessa, Kiev, and Donetsk. Universal sampling identified 961 youth in 74 randomly selected sites; 97% consented. Youth reporting one or both parents dead were classified as orphaned; those without a stable residence or sleeping outside their residence at least two nights per week were classified as homeless. Trained staff provided HIV counseling and rapid testing via mobile vans. Adjusted odds ratios (AORs) were calculated using logistic regression, accounting for intracluster homogeneity. Results:We found 32% (300 of 929) were both orphaned and homeless; 48% either (but not both) homeless [37% (343 of 929)] or orphaned [11% (104 of 929)]; and [20% (182 of 929)] neither orphaned nor homeless. HIV seroprevalences were 7% for neither orphaned/homeless; 16 and 17%, respectively, for either orphaned/homeless; 28% for both orphaned/homeless (P for trend <0.0001). AORs for HIV infection were 1 for neither; 2.3 and 2.4 for either homeless [95% confidence interval (CI) 1.7–2.9] or orphaned (CI 1.8–3.3); 3.3 for both orphaned/homeless (CI 2.3–4.4). Ever-use of injection drugs increased from 15 to 32 to 48% for those who neither, either, or both orphaned and homeless, respectively (P for trend <0.0001). Conclusions:One of four youths who were both homeless and orphaned was HIV-infected; these youths were significantly more likely to be HIV infected and to report injection drug use than those with adequate housing and living parents.

Outbreak of Pneumonia Associated with Emergent Human Adenovirus Serotype 14—Southeast Alaska, 2008

BACKGROUND In September 2008, an outbreak of pneumonia associated with an emerging human adenovirus (human adenovirus serotype 14 [HAdV-14]) occurred on a rural Southeast Alaska island. Nine patients required hospitalization, and 1 patient died. METHODS To investigate the outbreak, pneumonia case patients were matched to control participants on the basis of age, sex, and community of residence. Participants in the investigation and their household contacts were interviewed, and serum samples and respiratory tract specimens were collected. Risk factors were evaluated by means of conditional logistic regression. RESULTS Among 32 pneumonia case patients, 21 (65%) had confirmed or probable HAdV-14 infection. None of 32 matched control participants had evidence of HAdV-14 infection (P<.001 for the difference). Factors independently associated with pneumonia included contact with a known HAdV-14-infected case patient (odds ratio [OR], 18.3 [95% confidence interval {CI}, >or=2.0]), current smoking (OR, 6.7 [95% CI, >or=0.9]), and having neither traveled off the island nor attended a large public gathering (OR, 14.7 [95% CI, >or=2.0]). Fourteen (67%) of 21 HAdV-14-positive case patients belonged to a single network of people who socialized and often smoked together and infrequently traveled off the island. HAdV-14 infection occurred in 43% of case-patient household contacts, compared with 5% of control-participant household contacts (P = .005). CONCLUSIONS During a community outbreak in Alaska, HAdV-14 appeared to have spread mostly among close contacts and not widely in the community. Demographic characteristics and illness patterns among the case patients were similar to those observed in other recent outbreaks of HAdV-14 infection in the United States.

Contraceptive counseling and postpartum contraceptive use

OBJECTIVE The objective of the study was to examine the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use. STUDY DESIGN The Pregnancy Risk Assessment Monitoring System 2004-2008 data were analyzed from Missouri, New York state, and New York City (n = 9536). We used multivariable logistic regression to assess the associations between prenatal and postpartum contraceptive counseling and postpartum contraceptive use, defined as any method and more effective methods (sterilization, intrauterine device, or hormonal methods). RESULTS The majority of women received prenatal (78%) and postpartum (86%) contraceptive counseling; 72% received both. Compared with those who received no counseling, those counseled during 1 time period (adjusted odds ratio [AOR], 2.10; 95% confidence interval [CI], 1.65-2.67) and both time periods (AOR, 2.33; 95% CI, 1.87-2.89) had significantly increased odds of postpartum use of a more effective contraceptive method (32% vs 49% and 56%, respectively; P for trend < .0001). Results for counseling during both time periods differed by type of health insurance before pregnancy, with greater odds of postpartum use of a more effective method observed for women with no insurance (AOR, 3.51; 95% CI, 2.18-5.66) and Medicaid insurance (AOR, 3.74; 95% CI, 1.98-7.06) than for those with private insurance (AOR, 1.87; 95% CI, 1.44-2.43) before pregnancy. Findings were similar for postpartum use of any contraceptive method, except that no differences by insurance status were detected. CONCLUSION The prevalence of postpartum contraceptive use, including the use of more effective methods, was highest when contraceptive counseling was provided during both prenatal and postpartum time periods. Women with Medicaid or no health insurance before pregnancy benefited the most.

Multicity HIV seroprevalence in street youth, Ukraine.

We conducted the first systematic, community-based, multicity assessment outside the USA of HIV seroprevalence, risk factors and linkage into clinical services among 929 street youth. After city-wide mapping, we used time-location sampling and randomly selected 74 venues in Odesa, Kyiv and Donetsk, Ukraine. Rapid HIV testing with post-test counselling was offered to all eligible youths aged 15–24 years. Overall, 18.4% (95% confidence interval 16.2–20.2) were HIV positive and 85% had previously unknown status. Rates were identical by sex. Subgroups with highest rates included orphans (26%), youths with histories of exchanging sex (35%), sexually transmitted infections (STIs) (37%), injection drug use (IDU) (42%) and needle sharing (49%). Independent predictors, similar across age groups and city, included being orphaned, time on the street, history of anal sex, STIs, exchanging sex, any drug use, IDU and needle sharing. Two-thirds (68%) of HIV-positive youths were linked to services. This high-risk population has many immediate needs.

Use of contraception among US women with frequent mental distress.

BACKGROUND This study examines whether a womans mental health is associated with use of contraception. STUDY DESIGN We used national data from 2004 and 2006 to calculate the prevalence of contraceptive use among women with frequent mental distress. We examined associations among mental distress and permanent contraception and any highly or moderately effective, reversible contraceptive method. RESULTS Women with (86%) and without (87%) frequent mental distress reported using contraception, but contraceptive type varied by mental distress and income. Among women who use contraception, those with frequent mental distress had 1.4 times higher odds (95% CI: 1.2-1.6) of using permanent contraception. Among lower income women who use reversible contraception, those with frequent mental distress had lower odds of using highly [adjusted odds ratio (aOR)=0.5, 95% CI: 0.4-0.8] and moderately (aOR=0.6, 95% CI: 0.4-0.9) effective methods than less effective methods. CONCLUSION Contraceptive providers should consider mental health when providing counseling about contraception.

Trends in gestational weight gain: the Pregnancy Risk Assessment Monitoring System, 2000–2009

OBJECTIVE Achieving adequate gestational weight gain (GWG) is important for optimal health of the infant and mother. We estimate current population-based trends of GWG. STUDY DESIGN We analyzed data from the Pregnancy Risk Assessment Monitoring System for 124,348 women who delivered live infants in 14 states during 2000 through 2009. We examined prevalence and trends in GWG in pounds as a continuous variable, and within 1990 Institute of Medicine (IOM) recommendations (yes/no) as a dichotomous variable. We examined adjusted trends in mean GWG using multivariable linear regression and GWG within recommendations using multivariable multinomial logistic regression. RESULTS During 2000 through 2009, 35.8% of women gained within IOM GWG recommendations, 44.4% gained above, and 19.8% gained below. From 2000 through 2009, there was a biennial 1.0 percentage point decrease in women gaining within IOM GWG recommendations (P trend < .01) and a biennial 0.8 percentage point increase in women gaining above IOM recommendations (P trend < .01). The percentage of women gaining weight below IOM recommendations remained relatively constant from 2000 through 2009 (P trend = .14). The adjusted odds of gaining within IOM recommendations were lower in 2006 through 2007 (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) and 2008 through 2009 (adjusted odds ratio, 0.90; 95% confidence interval, 0.85-0.96) relative to 2000 through 2001. CONCLUSION Overall, from 2000 through 2009 the percentage of women gaining within IOM recommendations slightly decreased while mean GWG slightly increased. Efforts are needed to develop and implement strategies to ensure that women achieve GWG within recommendations.

Strategies Associated with Higher Postpartum Glucose Tolerance Screening Rates for Gestational Diabetes Mellitus Patients

BACKGROUND Most women with histories of gestational diabetes mellitus do not receive a postpartum screening test for type 2 diabetes, even though they are at increased risk. The objective of this study was to identify factors associated with high rates of postpartum glucose screening. METHODS This cross-sectional analysis assessed characteristics associated with postpartum diabetes screening for patients with gestational diabetes mellitus (GDM)-affected pregnancies self-reported by randomly sampled licensed obstetricians/gynecologists (OBs/GYNs) in Ohio in 2010. RESULTS Responses were received from 306 OBs/GYNs (56.5% response rate), among whom 69.9% reported frequently (always/most of the time) screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Compared to infrequent screeners, OBs/GYNs who frequently screen for postpartum glucose tolerance were statistically (p<0.05) more likely to have a clinical protocol addressing postpartum testing (67.2% vs. 26.7%), an electronic reminder system for providers (10.8% vs. 2.2%) and provide reminders to patients (16.4% vs. 4.4%). Frequent screeners were more likely to use recommended fasting blood glucose or 2-hour oral glucose tolerance test (61.8% vs. 34.6%, p<0.001) than infrequent screeners. CONCLUSIONS Strategies associated with higher postpartum glucose screening for GDM patients included clinical protocols for postpartum testing, electronic medical records to alert providers of the need for testing, and reminders to patients.

Gestational Diabetes Mellitus and Postpartum Care Practices of Nurse-Midwives

INTRODUCTION Postpartum screening for glucose intolerance among women with recent histories of gestational diabetes mellitus (GDM) is important for identifying women with continued glucose intolerance after birth, yet screening rates are suboptimal. In a thorough review of the literature, we found no studies of screening practices among certified nurse-midwives (CNMs). The objectives of our study were to estimate the prevalence of postpartum screening for abnormal glucose tolerance and related care by CNMs for women with recent histories of GDM and to identify strategies for improvement. METHODS From October through December 2010, the Ohio Department of Health sent a survey by mail and Internet to all licensed CNMs practicing in Ohio. We calculated prevalence estimates for knowledge, attitudes, clinical practices, and behaviors related to postpartum diabetes screening. Chi-square statistics were used to assess differences in self-reported clinical behaviors by frequency of postpartum screening. RESULTS Of the 146 CNMs who provided postpartum care and responded to the survey (62.2% response rate), 50.4% reported screening women with GDM-affected pregnancies for abnormal glucose tolerance at the postpartum visit. Of CNMs who screened postpartum, only 48.4% used fasting blood sugar or the 2-hour oral glucose tolerance test. Although 86.2% of all responding CNMs reported that they inform women with recent histories of GDM of their increased risk for type 2 diabetes mellitus, only 63.1% counseled these women to exercise regularly and 23.3% reported referring overweight/obese women to a diet support group or other nutrition counseling. CNMs reported that identification of community resources for lifestyle interventions and additional training in postpartum screening guidelines may help to improve postpartum care. DISCUSSION CNMs in Ohio reported suboptimal levels of postpartum diabetes testing and use of a recommended postpartum test. Providing CNMs with additional training and identifying community resources to support needed lifestyle behavior change may improve care for women with recent GDM-affected pregnancies.

Gestational hypertension: a neglected cardiovascular disease risk marker

OBJECTIVE The purpose of this study is to examine hypertension and cholesterol screening, knowledge of heart attack symptoms, and cardiovascular disease (CVD) risk factors among women with a history of gestational hypertension. STUDY DESIGN We used weighted 2008 National Health Interview Survey data to examine health indicators and modifiable CVD risk factors and to estimate prevalence and adjusted odds ratios for recommended CVD screening and knowledge of heart attack symptoms by hypertension history among 11,970 adult women. RESULTS Among women with gestational hypertension only (n = 301), 93% received the recommended screening for hypertension; 75% received screening for dyslipidemia, and 40% correctly identified 5 of 5 heart attack symptoms. The odds of CVD screenings and knowledge did not differ between women with a history of gestational hypertension and those with no hypertension. However, women with gestational hypertension had higher rates of obesity (43%), CVD (18%), and diabetes mellitus (13%), compared with women without a history of hypertension (21%, 8%, and 3%, respectively). CONCLUSION A history of gestational hypertension is a neglected CVD risk marker.