Indu B. Ahluwalia

Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System.

Objective. We examined breastfeeding behaviors, periods of vulnerability for breastfeeding cessation, reasons for breastfeeding cessation, and the association between predelivery intentions and breastfeeding behaviors. Study Design. Using 2 years (2000 and 2001) of data from the Pregnancy Risk Assessment and Monitoring System we assessed the percentage of women who began breastfeeding, continued for <1 week, continued for 1 to 4 weeks, and continued for >4 weeks and their reasons for not initiating or stopping. Predelivery breastfeeding intentions of women and their relationship with subsequent breastfeeding behaviors were examined also. Results. We found that 32% of women did not initiate breastfeeding, 4% started but stopped within the first week, 13% stopped within the first month, and 51% continued for >4 weeks. Younger women and those with limited socioeconomic resources were more likely to stop breastfeeding within the first month. Reasons for cessation included sore nipples, inadequate milk supply, infant having difficulties, and the perception that the infant was not satiated. Women who intended to breastfeed, thought they might breastfeed, or had ambivalent feelings about breastfeeding were more likely to initiate breastfeeding and to continue through the vulnerable periods of early infancy than were those who did not plan to breastfeed. Conclusions. Our findings indicate a need to provide extensive breastfeeding support after delivery, particularly to women who may experience difficulties in breastfeeding.

Risk factors for kala-azar in Bangladesh

Since 1990, South Asia has experienced a resurgence of kala-azar (visceral leishmaniasis). To determine risk factors for kala-azar, we performed cross-sectional surveys over a 3-year period in a Bangladeshi community. By history, active case detection, and serologic screening, 155 of 2,356 residents had kala-azar with onset from 2000 to 2003. Risk was highest for persons 3–45 years of age, and no significant difference by sex was seen. In age-adjusted multivariable models, 3 factors were identified: proximity to a previous kala-azar patient (odds ratio [OR] 25.4, 95% confidence interval [CI] 15–44 within household; OR 3.2 95% CI 1.7–6.1 within 50 m), bed net use in summer (OR 0.7, 95% CI 0.53–0.93), and cattle per 1,000 m2 (OR 0.8, 95% CI 0.70–0.94]). No difference was seen by income, education, or occupation; land ownership or other assets; housing materials and condition; or keeping goats or chickens inside bedrooms. Our data confirm strong clustering and suggest that insecticide-treated nets could be effective in preventing kala-azar.

Correlates of postpartum smoking relapse. Results from the Pregnancy Risk Assessment Monitoring System (PRAMS).

BACKGROUND Using population-based data from the Pregnancy Risk Assessment Monitoring System (PRAMS), this study examines the prevalence and intensity of smoking before, during, and after pregnancy, and identifies correlates of postpartum smoking relapse. METHODS Women who delivered live births in 1996 responded to a mailed questionnaire approximately 2 to 6 months after delivery (N =17,378). Data from 10 states participating in PRAMS were included in the study, and the overall participation rate was 75%. Analyses were adjusted for survey design and sampling strategy. Logistic regression analysis identified independent correlates of smoking relapse. RESULTS Overall, 25.6% of women reported cigarette smoking before pregnancy. Among women who smoked before pregnancy, 44.5% quit during pregnancy. Among women who quit during pregnancy, half relapsed by the time of the survey. Independent correlates associated with increased risk of postpartum relapse included African American race/ethnicity, multiparity, high maternal weight gain, late or no prenatal care, and stressful life events. CONCLUSIONS Correlates of postpartum smoking relapse identified by this study may contribute to the development of effective and targeted interventions to maintain long-term smoking cessation.

Social Support and Coping Behaviors of Low-Income Families Experiencing Food Insufficiency in North Carolina

The Food Research and Action Center estimates that approximately 12% of all families with children younger than 12 years old experience food insufficiency in the United States. The authors conducted 16 focus groups with 141 participants, who were either at risk or experienced food insufficiency, to learn about coping strategies. Individual and network-level coping mechanisms were used to manage insufficient food supply. Social networks included family, friends, and neighbors. The assistance provided included food aid, information, and emotional support. Not all networks were relied on or accessed by everyone. Most participants reported that they relied on family members first, followed by friends, and then neighbors. Parents found reliance on anyone as stressful and often threatening. In conclusion, as the social welfare system becomes constrained, more and more households may experience food insufficiency. Responsive policies are therefore needed to assist low-income families.

Influenza Vaccination Coverage Among Pregnant Women--United States, 2014-15 Influenza Season.

Pregnant women and their infants are at increased risk for severe influenza-associated illness (1), and since 2004, the Advisory Committee on Immunization Practices (ACIP) has recommended influenza vaccination for all women who are or might be pregnant during the influenza season, regardless of the trimester of the pregnancy (2). To assess influenza vaccination coverage among pregnant women during the 2016-17 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 7, 2017. Among 1,893 survey respondents pregnant at any time during October 2016-January 2017, 53.6% reported having received influenza vaccination before (16.2%) or during (37.4%) pregnancy, similar to coverage during the preceding four influenza seasons. Also similar to the preceding influenza season, 67.3% of women reported receiving a provider offer for influenza vaccination, 11.9% reported receiving a recommendation but no offer, and 20.7% reported receiving no recommendation; among these women, reported influenza vaccination coverage was 70.5%, 43.7%, and 14.8%, respectively. Among women who received a provider offer for vaccination, vaccination coverage differed by race/ethnicity, education, insurance type, and other sociodemographic factors. Use of evidence-based practices such as provider reminders and standing orders could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.

PREVALENCE AND CORRELATES OF UNDIAGNOSED DEPRESSION AMONG U.S. ADULTS WITH DIABETES: THE BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM, 2006

AIMS Many people with depression may be undiagnosed and thus untreated. We sought to assess the prevalence and correlates of undiagnosed depression among adults with diabetes. METHODS Data of U.S. adults from the Behavioral Risk Factor Surveillance System in 2006 were analyzed. Cox proportional hazard regression analysis was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) of correlates for undiagnosed depression. RESULTS The unadjusted and age-adjusted prevalences of undiagnosed depression were 8.7% and 9.2%. About 45% of diabetes patients with depression were undiagnosed. After adjustments for all correlates, female gender (PR, 1.4; 95% CI: 1.1-1.8), poor or fair health (PR, 2.8; 95% CI: 2.1-3.6), lack of social and emotional support (PR, 2.5; 95% CI: 1.8-3.3), life dissatisfaction (PR, 3.5; 95% CI: 2.2-5.5), use of special equipment (PR, 1.4; 95% CI: 1.1-1.8), no leisure-time physical activity (PR, 1.5; 95% CI: 1.2-1.9), and comorbid cardiovascular disease (PR, 1.5; 95% CI: 1.2-1.9) were associated with undiagnosed depression. CONCLUSIONS Undiagnosed depression among people with diabetes was common. Because depression is associated with increased risk of diabetes-related complications, early detection of depression is needed in clinical settings.

Correlates of Seasonal Influenza Vaccine Coverage Among Pregnant Women in Georgia and Rhode Island

OBJECTIVE: To identify facilitators of and barriers to pregnant women being vaccinated against seasonal influenza by identifying factors associated with influenza vaccination during pregnancy among women who had recently given birth to a live infant. METHODS: We analyzed pooled data from Georgia (n=2,692) and Rhode Island (n=2,732) participants in the 2006 and 2007 surveys of the Pregnancy Risk Assessment and Monitoring System, which conducts cross-sectional surveys of women with live births. SUDAAN software was used for analysis to account for complex survey design. We estimated rates of seasonal influenza vaccination among pregnant women in Georgia and Rhode Island and identified factors associated with being vaccinated. RESULTS: The prevalence of immunization for seasonal influenza in 2006 and 2007 combined was 18.4% (95% confidence interval [CI]: 15.9–21.1) in Georgia and 31.9% (95% CI 29.8–34.0) in Rhode Island. Multivariable analyses showed that in Georgia, multiparous women were significantly less likely to have been vaccinated than primiparous women (adjusted odds ratio [OR] 0.60; 95% CI 0.40–0.89). In Georgia, among those not vaccinated, 43% indicated that their health care providers did not mention anything about the seasonal influenza vaccination. In Rhode Island, women whose health care provider encouraged them to be vaccinated (adjusted OR 56.62; 95% CI 37.43–85.63) and those who did not smoke cigarettes (adjusted OR 1.92; 95% CI 1.25–2.94) were significantly more likely to be vaccinated. CONCLUSION: Our findings indicate a need for strategies to promote seasonal influenza vaccine use among pregnant women. Health care providers can play a significant role in increasing influenza vaccination coverage rates among pregnant women by advising women to be vaccinated and by addressing their concerns about vaccine safety. LEVEL OF EVIDENCE: III

Multiple lifestyle and psychosocial risks and delivery of small for gestational age infants

Objective To examine the occurrence of multiple risk behaviors during pregnancy among women who delivered a live birth and to examine the risk of delivering small for gestational age (SGA) infants for women with multiple risks. Methods We used data from the Pregnancy Risk Assessment Monitoring System to conduct the research. Pregnancy Risk Assessment System is a population-based, mixed-mode surveillance system that collects information on maternal behaviors and experiences. We used data for 1997 from 13 (n = 19,331) states that had response rates of over 70%. We considered ten self-reported individual risk behaviors or exposures (eg, smoking, unintended pregnancy) and several demographic variables. The main outcome was SGA. Results Pregnant women engage in or are exposed to multiple risks and often these risks are inter-related. The occurrence of multiple risks appears to be associated with an increased likelihood of delivering an SGA infant. Compared with women with no reported risks or exposures, the adjusted odds ratios for delivering an SGA infant were as follows: 1.29 (95% confidence interval [CI] 0.69, 2.43) for one, 1.86 (95% CI 1.00, 3.44) for two, 1.67 (95% CI 0.90, 3.10) for three, 2.06 (95% CI 1.10, 3.89) for four, 3.53 (95% CI 1.71, 7.30) for five, and 3.82 (95% CI 1.97, 7.41) for six or more risks or exposures. Conclusion A large proportion of pregnant women engage in or are exposed to multiple risks. Women with a larger number of risks are at greater risk for delivering an SGA infant than women with fewer or no risks.

The economic impact of visceral leishmaniasis on households in Bangladesh.

Objectives  To explore current patterns of diagnosis and treatment, quantify household economic impact and identify household strategies to cover the costs of visceral leishmaniasis (VL) care in rural Bangladesh.

Transportation for Maternal Emergencies in Tanzania: Empowering Communities Through Participatory Problem Solving

Inadequate health care and long delays in obtaining care during obstetric emergencies are major contributors to high maternal death rates in Tanzania. Formative research conducted in the Mwanza region identified several transportation-related reasons for delays in receiving assistance. In 1996, the Cooperative for Assistance and Relief Everywhere (CARE) and the Centers for Disease Control and Prevention (CDC) began an effort to build community capacity for problem-solving through participatory development of community-based plans for emergency transportation in 50 villages. An April 2001 assessment showed that 19 villages had begun collecting funds for transportation systems; of 13 villages with systems available, 10 had used the system within the last 3 months. Increased support for village health workers and greater participation of women in decision making were also observed.