Diane L. Rowley

The epidemiology of placenta previa in the United States, 1979 through 1987

OBJECTIVE Placenta previa can cause serious, occasionally fatal complications for fetuses and mothers; however, data on its national incidence and sociodemographic risk factors have not been available. STUDY DESIGN We analyzed data from the National Hospital Discharge Survey for the years 1979 through 1987 and from the Retrospective Maternal Mortality Study (1979 through 1986). RESULTS We found that placenta previa complicated 4.8 per 1000 deliveries annually and was fatal in 0.03% of cases. Incidence rates remained stable among white women but increased among black and other minority women (p < 0.1). In addition, the risk of placenta previa was higher for black and other minority women than for white women (rate ratio 1.3, 95% confidence interval 1.0 to 1.7), and it was higher for women > or = 35 years old than for women <20 years old (rate ratio 4.7, 95% confidence interval 3.3 to 7.0). Women with placenta previa were at an increased risk of abruptio placentae (rate ratio 13.8), cesarean delivery (rate ratio 3.9), fetal malpresentation (rate ratio 2.8), and postpartum hemorrhage (rate ratio 1.7). CONCLUSION Our findings support the need for improved prenatal and intrapartum care to reduce the serious complications and deaths associated with placenta previa.

Hospitalizations for severe complications of pregnancy, 1987–1992

Objective To compute ratios of severe pregnancy complications (the number of hospitalizations for pregnancy complications per 100 deliveries) and to examine factors associated with their prevalence. Methods Using population-based California hospital discharge data to estimate hospitalization ratios of pregnancy complications during 1987--1992, we defined cases by preselected pregnancy complication codes from the International Classification of Diseases, Ninth Revision, Clinical Modification, excluding induced abortions and delivery-associated complications. All hospital deliveries of liveborn or stillborn infants were included in our denominator. We examined ratios by age, race-ethnicity, payment source, total hospitalization charges, and length of hospital stay. Results There were 833,264 hospitalizations for pregnancy complications in California (25 complications per 100 deliveries), which included admissions for preterm labor (33%), genitourinary infection (16%), and pregnancy-induced hypertension (15%). Age-specific ratios were highest for women 14 years old and younger (38 per 100 deliveries) and lowest for women 25--29 years old (23 per 100 deliveries). Ratios of complications varied by race-ethnicity; black women had the highest (42 per 100 deliveries), and Asian-Pacific Islander women had the lowest (21 per 100 deliveries). Ratios were unaffected by payment source. In 1987, Medicaid charges were

Life course, social determinants, and health inequities: Toward a national plan for achieving health equity for African American infants - A concept paper

118 million for 33% of the number of total hospitalizations for complications. In 1992, such Medicaid hospitalizations accounted for

Contextualized Stress, Global Stress, and Depression in Well-Educated, Pregnant, African-American Women

356 million (49%) of the

Disparities in infant mortality and effective, equitable care: are infants suffering from benign neglect?

734 million in total charges and for 183,295 (45%) of the 409,000 total hospital days. Conclusion Our results showed disparities in ratios of severe complications of pregnancy by age and race-ethnicity as well as a shift of financial burden to Medicaid. These findings suggest that such complications may be reduced by identifying risk factors and targeting high-risk groups.

The Impact of Social Disadvantage on Preconception Health, Illness, and Well-Being: An Intersectional Analysis:

Despite the best efforts by the public health community, the existence of disparity in African American infant mortality appears to be insurmountable. Eliminating this disparity is the public health challenge of the next decade. The public health community has engaged in copious activity regarding the identification and analysis of the etiology of health disparities. The resulting literature is substantial, yet, despite well-meaning interventions that have had varying degrees of success, the problem is so daunting that there has been very little progress in developing a comprehensive national plan to eradicate health disparities, in general, and, African American infant-mortality disparities, in particular. The process of identifying the causal pathways and risks of adverse African American birth outcomes could potentially impact the elimination of other health disparities since infant outcomes are the foundation for adult health. Unfortunately, as a nation, we have never deliberately invested the time and resources into developing an evidence base specific to the achievement of health equity. This endeavor will require dedicated resources, creativity, and a breadth of vision to work within, and exceed, the limits of traditional epidemiological and social science theory and methods. The literature cites various causes of overall disparities, including adverse health behaviors like smoking or drug use, poor nutrition, inadequate health care, and stress, to name a few [1]. The World Health Organization (WHO) Commission on Social Determinants of Health considers the major contributors to health disparities to be the conditions in which people are born, grow, live, work, and age [2]. In the United States, ethnic minorities, particularly African Americans, are more likely to be in socially and economically vulnerable positions. A number of studies have demonstrated that even while controlling for SES, racial and ethnic disparities are still found in health outcomes [3]. For example, African American women in Illinois at the highest education level have higher, i.e., worse low-birthweight rates than women of any other ethnicity at lower strata. The process that determines social stratification leading to poorer health outcomes is rooted in history, and while it is not about ‘‘race’’ as a risk factor, scientific investigation has resulted in a corpus of knowledge that places racism, perceived acts of racism, poverty, socialenvironment degradation, and violence into the etiological pathway [4–10]. These manifestations of ‘‘social ecology’’ are the type that WHO describes as resulting in unfair and avoidable differences in health status [2]. Some think that because racism is a causal factor, any quest for solutions may be doomed to failure, because, as one funding institution’s peer reviewer stated, ‘‘It is not a good investment of [our] dollars to study racism [as a cause of health disparities], because even if we fund something, there is nothing we can do about it’’ [11]. However, pre-term birth (PTB) and low birth weight (LBW) are the causes of firstyear mortality for African American infants. Therefore, understanding and eliminating the factors that cause high rates of PTB and LBW should remain at the forefront. V. K. Hogan (&) ! D. Rowley ! T. Bennett Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 425 Rosenau Hall, 421 Pittsboro Street, 135 Dauer Drive, Campus Box 7445, Chapel Hill, NC 27599, USA e-mail: vhogan@email.unc.edu

Barriers to women's participation in inter-conceptional care: a cross-sectional analysis

PURPOSE Well-educated, pregnant, African-American women are disproportionately at risk for adverse birth outcomes and depression linked to stress has been established as a significant contributor to poor birth outcomes. Since racial and gendered stress have been identified as threats to birth outcomes, a cross-sectional study was conducted that utilized the Jackson, Hogue, Phillips Contextualized Stress Measure (JHP), a measurement of racial and gendered stress, and the Perceived Stress Scale (PSS), an assessment of global stress, to detect their associations and predictions for depression as measured by the Beck Depression Inventory II (BDI-II). METHOD We recruited 101 pregnant, well-educated, African-American women from ob-gyn offices who were administered the JHP, the PSS, and the BDI-II. Correlational, chi-square, and stepwise regression analyses were conducted with the measures and the demographic variables of relationship status, the presence of other children, and annual household income. FINDINGS The results revealed significant linear and covariate associations for the JHP, PSS, and BDI-II. Correspondingly, chi-square analysis found significant associations for the JHP and the BDI-II and the presence of other children, relationship status, and annual household income. Results from the regression models found that the contextualized and global stress measures were both predictive of depression. Demographic characteristics did not predict depression. CONCLUSION The results argue for prenatal depression and stress screening. Furthermore, the link between contextualized stress and depression alerts health care providers and local communities to be responsive to the particular stressors that pose risks for pregnant African-American women and their babies.

The Enigma of Spontaneous Preterm Birth

Quality care for infant mortality disparity elimination requires services that improve health status at both the individual and the population level. We examine disparity reduction due to effective care and ask the following question: Has clinical care ameliorated factors that make some populations more likely to have higher rates of infant mortality compared with other populations? Disparities in postneonatal mortality due to birth defects have emerged for non-Hispanic black and Hispanic infants. Surfactant and antenatal steroid therapy have been accompanied by growing disparities in respiratory distress syndrome mortality for black infants. Progesterone therapy has not reduced early preterm birth, the major contributor to mortality disparities among non-Hispanic black and Puerto Rican infants. The Back to Sleep campaign has minimally reduced SIDS disparities among American Indian/Alaska Native infants, but it has not reduced disparities among non-Hispanic black infants. In general, clinical care is not equitable and contributes to increasing disparities.

Current Approaches to Reducing Premature Births and Implications for Disparity Elimination

Purpose. To understand how social and structural contexts shape individual risk, vulnerability, and interconception health-related behaviors of African-American women. Approach or Design. A longitudinal ethnographic study was conducted. Setting. The study was conducted in Philadelphia, Pennsylvania. Participants. The sample included 19 African-American women who were participants in the intervention group of a randomized clinical trial of interconceptional care. Method. Data were collected through interaction with participants over a period of 6 to 12 months. Participant observation, structured and unstructured interviews, and Photovoice were used to obtain data; grounded theory was used for analysis. The analysis was guided by intersectional theory. Results. Social disadvantage influenced health and health care–seeking behaviors of African-American women, and the disadvantage centered on the experience of racism. The authors identify seven experiences grounded in the interactions among the forces of racism, class, gender, and history that may influence womens participation in and the effectiveness of preconception and interconception health care. Conclusion. African-American womens health and wellness behaviors are influenced by an experience of racism structurally embedded and made more virulent by its intersection with class, gender, and history. These intersecting forces create what may be a unique exposure that contributes significantly to the proximal determinants of health inequities for African-American women. Health promotion approaches that focus on the individual as the locus of intervention must concomitantly unravel and address the intertwining structural forces that shape individual circumstance in order to improve womens interconceptional health and to reduce disparities.

Low maternal adherence to a Mediterranean diet is associated with increase in methylation at the MEG3-IG differentially methylated region in female infants

BackgroundWe describe participation rates in a special interconceptional care program that addressed all commonly known barriers to care, and identify predictors of the observed levels of participation in this preventive care service.MethodsA secondary analysis of data from women in the intervention arm of an interconceptional care clinical trial in Philadelphia (n = 442). Gelberg-Andersen Behavioral Model for Vulnerable Populations to Health Services (herein called Andersen model) was used as a theoretical base. We used a multinomial logit model to analyze the factors influencing womens level of participation in this enhanced interconceptional care program.ResultsAlthough common barriers were addressed, there was variable participation in the interconceptional interventions. The Andersen model did not explain the variation in interconceptional care participation (Wald ch sq = 49, p = 0.45). Enabling factors (p = 0.058), older maternal age (p = 0.03) and smoking (p = < 0.0001) were independently associated with participation.ConclusionsActively removing common barriers to care does not guarantee the long-term and consistent participation of vulnerable women in preventive care. There are unknown factors beyond known barriers that affect participation in interconceptional care. New paradigms are needed to identify the additional factors that serve as barriers to participation in preventive care for vulnerable women.