Margaret C. Heagarty

Factors associated with smoking in low-income pregnant women: relationship to birth weight, stressful life events, social support, health behaviors and mental distress

Since low-income women are at increased risk of having low birth weight infants, factors associated with birth weight among such groups have special relevance. Cigarette-smoking has emerged as an important predictor of low birth weight due to intrauterine growth retardation and pre-term delivery. After confirming the relation of smoking with birth weight, we examined the association of smoking with sociodemographic factors, attitudes towards pregnancy, health behaviors, stressful life events, social support, and symptoms of mental distress in a cohort of 458 Central Harlem women. We found that social support, stress and mental health were associated with smoking behavior but not directly with birth weight. These findings suggest that programs designed to modify health behaviors such as smoking during pregnancy must also take into account such characteristics of the women and their environments which may make behavioral change difficult. Moreover, programs aimed at fostering better health behaviors to improve pregnancy outcome may have to extend beyond the current pregnancy, as indicated by an association between prior adverse pregnancy outcome and smoking in the current pregnancy.

Physical and psychological development ofchildren with early failure to thrive

The medical records of 50 young children who had been hospitalized with failure to thrive of nonorganic etiology were reviewed in regard to clinical picture, physical and laboratory findings, and hospital course. Extensive clinical studies were generally unrevealing. Lengthy and expensive hospitalizations often did not effect clinical improvement. Follow-up evaluation of 40 of the 50 hospitalized patients showed a substantial incidence of continued growth deficits. Mental retardation, emotional disturbance, and family dysfunction were also observed. A minority of children, from favorable home environments, appeared to have recovered spontaneously.

The types of families that use an emergency clinic.

UTILIZATION of hospital emergency clinics is increasing constantly. At the Childrens Hospital Medical Center, for example, use of the emergency clinic has grown in ten years from 4,500 visits per year (1957) to more than 50,000 visits per year in 1967. The lack of available physicians in the community, the increase in insurance coverage for hospital emergency room visits, the constant availability of the emergency service, and the use of the emergency service by the physician are suggested explanations for this increased use.4 Not all families, however, use the emergency clinic for the same reasons or with the same degree of consistency. Some use it for true emergencies, others as a

Prospective study of human immunodeficiency virus 1-related disease among 512 infants born to infected women in New York City

OBJECTIVE To determine the incidence of HIV-1-related clinical findings, mortality and predictors of death in a cohort of HIV-exposed infants followed from birth. METHODS Data were collected approximately bimonthly during the first and second year of life and used in Kaplan-Meier and Cox proportional hazards survival analyses to predict time to the development of symptoms and death. RESULTS One hundred sixteen infected and 396 uninfected infants were followed for a median of 26 months at 7 New York City hospitals from 1986 to 1995. Two or more nonspecific HIV-related symptoms, AIDS or death occurred in 83% of infected children by the first year. Fifty infected infants (43%) developed AIDS and 19 (38%) of these had Pneumocystis carinii pneumonia. Estimated median age at AIDS/death was 30 months and 64% of infected children remained alive and AIDS-free at 1 year. Estimated infant mortality among infected children was 160/1000 live births, and median survival after AIDS was 21 months; 55% of infected children survived > 12 months after diagnosis of AIDS. P. carinii pneumonia was the most common cause of death. Although birth CD4 values did not predict AIDS or death, CD4 counts as early as 6 months of age were highly correlated with both. Thirteen (68%) of 19 infants who remained AIDS-free up to 3 to 6 months of age with CD4 count < or = 1500 cells/microliters subsequently developed AIDS vs. 18 (30%) of 61 with CD4 count > 1500 (P = 0.0001). CONCLUSIONS Most HIV-1-infected infants develop disease in the first year of life. AIDS or death can be predicted by a threshold CD4 count of 1500 cells/microliters at 3 to 6 months of age.

Outreach as case finding: its effect on enrollment in prenatal care.

One mechanism proposed for encouraging use of prenatal services in lowincome communities involves the employment of community residents to encourage and support individuals in the use of available medical care. This study examines the effect of such workers on the start of prenatal care among a cohort of women receiving prenatal services at clinics affiliated with Harlem Hospital. Of the 599 women enrolling for prenatal care during the intake period for the study, only 52 had had an outreach contact before the start of prenatal care despite extensive field activity. No difference in the week of gestation at the start of prenatal care was noted between those with and without outreach contacts. Controlling for factors associated both with trimester of initiation of prenatal care in this population and with outreach contact did not account for this lack of difference. This type of outreach, known as case-finding, proved to be very labor intensive. Other less costly techniques for encouraging use of services in mobile, urban populations should be sought.

The planning of pregnancy among low-income women in central Harlem

A planned pregnancy is considered desirable, in part because of the potential of a better pregnancy outcome. Since the improvement of pregnancy outcome is of particular relevance in low-income populations, we have compared the characteristics of women with planned and unplanned pregnancies in central Harlem with regard to those factors that might affect pregnancy planning such as sociodemographic factors, attitudes toward child-rearing, environmental stress, social support, and maternal mental health. Of the 416 women in the study, a minority (27%) reported their pregnancy as being planned. They differed from the remainder in being more likely to be married and/or living with a boyfriend or husband and to have been born outside New York City. The two groups did not differ in any other risk factor or in outcome in terms of birth weight and gestational age. The results provide little support for the lack of planning of pregnancy as an indicator of risk in a low-income population and suggest that improvement of perinatal outcome must involve more broadly based interventions that are not confined to the periconceptional period.

Factors associated with maternal rating of infant health in central Harlem.

Maternal perceptions of infant health are strongly associated with the use of health services and may influence the childs future health and development. The extent to which such perceptions reflect infant health problems or a response to environmental stress in the mothers life is unclear. Because this issue may be especially important in disadvantaged groups for which both high levels of infant morbidity and environmental stress are common, we have explored the correlates of maternal perceptions of infant health among 367 mothers of 12-month-olds in central Harlem. Lower ratings of infant health were associated with such indicators of morbidity as problems in the neonatal period, hospitalization, and one or more episodes of illness. They were also associated with lower family income and the mothers rating of her own health in the bivariate analyses, but not in multivariate analyses. Neither maternal mental health, social support, nor enviromental stress appeared to influence maternal rating of child health. These findings indicate that a mothers ratings of her infants health relate specifically to the childs morbidity, independent of her own health and environmental stress. Moreover, within disadvantaged communities, infants of the poorest mothers may experience greater levels of morbidity.

Outreach as case finding. The process of locating low-income pregnant women.

This article documents the process of an outreach program for locating disadvantaged women who, as a group, do not receive prenatal care early and have adverse pregnancy outcomes. Three full-time community residents searched for pregnant women for a year, being paid a commission for each woman that they found who enrolled for antenatal care. Outreach workers spent more than half of their time in the field, contacted 20 to 25 people per day, and used a variety of strategies to locate women. Fifty-two women entered the Harlem Hospital Medical Center health care system through the outreach process, with 104 pregnant women not already receiving antenatal care being identified by the outreach workers. Their effort, conversion rate, and yield were comparable to private sector salespeople. The cost per enrollee was high (although not higher than the cost of additional low-birthweight births). Alternatives for locating pregnant women are suggested.

Caring for HIV-Infected Women and Children

WHEN the acquired immunodeficiency syndrome (AIDS) first appeared in 1981, it was considered a disease of homosexual and drug-using men. Only later did it become evident that AIDS could also strike...

Preventing infant mortality and morbidity: developmental perspectives.

Developmental approaches to the etiology of low birthweight and to the design and evaluation of antenatal programs are reviewed. Examples are presented of interventions focusing on family planning, educational program content, modification of health-related behavior, and improvement of access to antenatal care. A Harlem Hospital program, designed to alter pregnant womens behavior, is discussed as an exemplar of possible collaboration among pediatricians, obstetricians, and developmentally oriented mental health professionals.