Nancy Dole

Psychosocial Factors and Preterm Birth Among African American and White Women in Central North Carolina

Objectives. We assessed associations between psychosocial factors and preterm birth, stratified by race in a prospective cohort study.Methods. We surveyed 1898 women who used university and public health prenatal clinics regarding various psychosocial factors.Results. African Americans were at higher risk of preterm birth if they used distancing from problems as a coping mechanism or reported racial discrimination. Whites were at higher risk if they had high counts of negative life events or were not living with a partner. The association of pregnancy-related anxiety with preterm birth weakened when medical comorbidities were taken into account. No association with preterm birth was found for depression, general social support, or church attendance.Conclusions. Some associations between psychosocial variables and preterm birth differed by race.

Sociodemographic, Perinatal, Behavioral, and Psychosocial Predictors of Weight Retention at 3 and 12 Months Postpartum

Postpartum weight retention plays an important role in the pathway leading to obesity among women of childbearing age. The objective of this study was to examine predictors of moderate (1–10 pounds) and high (>10 pounds) postpartum weight retention using data from a prospective pregnancy cohort that followed women into the postpartum period; n = 688 and 550 women at 3 and 12 months, respectively. Analysis included descriptive statistics and predictive modeling using log‐binomial techniques. The average weight retained at 3 and 12 months postpartum in this population was 9.4 lb (s.d. = 11.4) and 5.7 lb (s.d. = 13.2), respectively. At 3 months postpartum, prepregnancy weight, gestational weight gain, and hours slept during the night were associated with moderate or high weight retention, whereas having an infant hospitalized after going home and scoring in the upper 75th percentile of the Eating Attitudes Test (EAT) were associated only with high weight retention. At 12 months postpartum, prepregnancy weight, gestational weight gain, and maternal education were associated with moderate weight retention; and gestational weight gain, maternal age, race, employment status, and having an infant hospitalized at birth were associated with high weight retention. The results of this study illustrate the importance of prepregnancy weight and gestational weight gain in predicting postpartum weight retention. Furthermore, given the lack of successful intervention studies that exist to date to help women lose weight in the postpartum period, the results of this study may help to inform future interventions that focus on such aspects as hours of sleep, dealing with stress associated with a hospitalized infant, and nonclinical eating disorder symptomatology.

Smoking and pregnancy outcome among African-American and white women in central North Carolina

Despite extensive research on tobacco smoking during pregnancy, few studies address risks among African-American and white women, groups that differ in brand preference and smoking habits. The Pregnancy, Infection, and Nutrition Study is a prospective cohort study that included 2,418 women with detailed information on smoking during pregnancy, including brand, number of cigarettes per day, and changes during pregnancy. We analyzed risk of preterm birth (<37 and <34 weeks’ gestation) and small-for-gestational-age deliveries in relation to tobacco use. Pregnant African-American smokers differed markedly from whites in brand preference (95%vs 26% smoked menthol cigarettes) and number of cigarettes per day (1% of African-Americans and 12% of whites smoked 20+ cigarettes per day). Smoking was not related to risk of preterm birth overall, but cotinine measured at the time of delivery was (adjusted odds ratio = 2.2, 95% confidence interval = 1.1–4.5). A clear association and dose-response gradient was present for risk of fetal growth restriction (risk ratio for 20+ cigarettes/day = 2.4, 95% confidence interval = 1.4–4.0). Associations of tobacco use with preterm premature rupture of amniotic membrane resulting in preterm birth were notably stronger than the associations with other types of preterm birth.

Direct observation of neighborhood attributes in an urban area of the US south: characterizing the social context of pregnancy

BackgroundNeighborhood characteristics have been associated with poor maternal and child health outcomes, yet conceptualization of potential mechanisms is still needed. Census data have long served as proxies for area level socioeconomic influences. Unique information captured by neighborhood inventories, mostly conducted in northern US and Canadian urban areas, has shown important aspects of the community environment that are not captured by the socioeconomic and demographic aggregated individual statistics of census data. In this paper, we describe a neighborhood data collection effort tailored to a southern urban area.MethodsThis study used data from the Pregnancy, Nutrition and Infection (PIN) prospective cohort study to describe neighborhoods where low- and moderate-income pregnant women reside. Women who participated in the PIN study and who resided in Raleigh, NC and its surrounding suburbs were included (n = 703). Neighborhood attributes captured by the inventory included litter, housing condition, road condition, and social interactions that informed theoretical constructs of physical incivility, territoriality and social spaces. US Housing and Population Census 2000 data at the block group level were also assessed to identify the unique contribution of directly observed data. We hypothesize that neighborhood environments can influence health through psychosocial mediated pathways that lead to increased stress, or through disadvantage leading to poor neighborhood resources, or by protective attributes through increased social control.ResultsFindings suggest that directly observed neighborhood attributes distinguished between different types of areas in which low-income pregnant non-Hispanic white and non-Hispanic black women lived. Theoretically informed scales of physical incivilities, territoriality and social spaces were constructed and found to be internally consistent. Scales were weakly associated indicating that these constructs capture distinct information about these neighborhoods. Physical incivilities, territoriality and social spaces scales were poorly explained by traditional census variables used to proxy neighborhood environment.ConclusionIf neighborhoods influence health through psychosocial mediated pathways then careful detailing of neighborhood attributes that contribute to stress or deterioration, beyond traditional socioeconomic status, are needed. We believe that measuring physical incivility, territoriality and social spaces as expressions of underlying issues of maintenance and social communication make important contributes to this field.

A prospective study of maternal anxiety, perceived stress, and depressive symptoms in relation to infant cognitive development

AIM Our objective was to examine the associations between maternal psychological health (trait anxiety, perceived stress, and depressive symptoms) during pregnancy or postpartum and infant visual, language, motor, and overall cognitive development. STUDY DESIGN AND METHODS In the prospective Pregnancy, Infection, and Nutrition Study (2001-2006), central North Carolina women completed self-administered questionnaires during pregnancy to assess trait anxiety and depressive symptoms. An in-person interview assessed maternal perceived stress and depressive symptoms in the 4th postpartum month. Infant development was assessed at 12 months using the Mullen Scales of Early Learning (n=358). Multiple linear regression with restricted cubic splines was used to examine potential non-linear associations between trait anxiety, perceived stress, and depressive symptoms in relation to Mullen sub-scales and Composite scores. RESULTS Increasing maternal anxiety was associated with poorer overall cognition (adjusted β for Composite=-0.2, 95% CI: -0.4, 0.0). Postpartum stress was positively associated with language development and general cognition (adjusted β for Expressive Language=0.2, 95% CI: 0.0, 0.4; adjusted β for Composite=0.3, 95% CI: 0.0, 0.6). Elevated depressive symptoms throughout pregnancy and postpartum were associated with better fine motor skills (adjusted β=9.7, 95% CI: 3.9, 15.5). Anxiety, postpartum depressive symptoms and stress were associated with gross motor skills in a non-linear fashion, as were postpartum depressive symptoms and stress with expressive language. CONCLUSIONS Maternal trait anxiety, depressive symptoms and stress had little negative influence on infant cognitive development. In fact, moderate psychosocial distress may slightly accelerate motor development in particular, and some aspects of language.

Violent crime exposure classification and adverse birth outcomes: a geographically-defined cohort study.

BackgroundArea-level socioeconomic disparities have long been associated with adverse pregnancy outcomes. Crime is an important element of the neighborhood environment inadequately investigated in the reproductive and public health literature. When crime has been used in research, it has been variably defined, resulting in non-comparable associations across studies.MethodsUsing geocoded linked birth record, crime and census data in multilevel models, this paper explored the relevance of four spatial violent crime exposures: two proximal violent crime categorizations (count of violent crime within a one-half mile radius of maternal residence and distance from maternal residence to nearest violent crime) and two area-level crime categorizations (count of violent crimes within a block group and block group rate of violent crimes) for adverse birth events among women in living in the city of Raleigh NC crime report area in 1999–2001. Models were adjusted for maternal age and education and area-level deprivation.ResultsIn black and white non-Hispanic race-stratified models, crime characterized as a proximal exposure was not able to distinguish between women experiencing adverse and women experiencing normal birth outcomes. Violent crime characterized as a neighborhood attribute was positively associated with preterm birth and low birth weight among non-Hispanic white and black women. No statistically significant interaction between area-deprivation and violent crime category was observed.ConclusionCrime is variably categorized in the literature, with little rationale provided for crime type or categorization employed. This research represents the first time multiple crime categorizations have been directly compared in association with health outcomes. Finding an effect of area-level violent crime suggests crime may best be characterized as a neighborhood attribute with important implication for adverse birth outcomes.

Elevated Corticotropin Releasing Hormone (CRH) during Pregnancy and Risk of Postpartum Depression (PPD)

CONTEXT Perinatal depression has a prevalence of 10% with devastating consequences for mother and baby. The prospective identification of those at risk for postpartum (PPD) or prenatal (PND) depression has led to biomarker searches in pregnancy. There are conflicting reports of associations between midpregnancy placental CRH (pCRH) and PPD or PND. OBJECTIVE The objective of the study was to quantify the association of maternal pCRH with PPD and PND. DESIGN This was a prospective cohort study (the Pregnancy, Infection, and Nutrition Study). SETTING The study was conducted at a prenatal clinics at the University of North Carolina at Chapel Hill. PATIENTS Patients included 1230 pregnant women. MAIN OUTCOME MEASURES The relationship between pCRH at less than 20 wk and 24-29 wk and maternal depression assessed in pregnancy [Center for Epidemiologic Studies Depression Scale (CES-D)] and postpartum (12 wk and 1 yr) with the Edinburgh Postnatal Depression Scale (EPDS). RESULTS At 24-29 wk, 24.8% of women had CES-D score of 17 or greater, and 9.7% had a CES-D score of 25 or greater. At 12 wk postpartum, 18.2% of women had an EPDS score of 10 or greater and 7.6% had an EPDS score of 13 or greater. CRH measures at less than 20 wk and 24-29 wk were inversely correlated with a CES-D score at 24-29 wk (n = 1080, P < 0.05 and P < 0.01, respectively). Pregnancy pCRH was not correlated with the EPDS score at 12 wk (n = 484) or 1 yr postpartum (n = 391). In covariate-adjusted models, higher pCRH was not associated with a CES-D of 17 or greater at 24-29 wk (odds ratio 0.88 per sd change in pCRH at 24-29 wk, 95% confidence interval 0.76-1.03). There was no association between log CRH at 24-29 wk and PPD (covariate-adjusted odds ratio per sd 0.99, 95% confidence interval 0.69-1.42). CONCLUSION Higher midpregnancy pCRH was not associated with an increased risk of PND or PPD.

A Prospective Cohort Study of Modifiable Risk Factors for Gestational Diabetes among Hispanic Women: Design and Baseline Characteristics

OBJECTIVES Women diagnosed with gestational diabetes mellitus (GDM) are at high risk for future diabetes, with rates of GDM consistently higher in Hispanic than non-Hispanic white women. Currently recognized risk factors for GDM are absent in up to half of affected women, and studies addressing modifiable risk factors for GDM in Hispanic women are sparse. METHODS Proyecto Buena Salud is an ongoing prospective cohort study of Hispanic women in Massachusetts designed to assess physical activity, psychosocial stress, and GDM risk. Bilingual interviewers recruit prenatal care patients early in pregnancy and assess activity, trait anxiety, perceived stress, and depressive symptoms using validated questionnaires. RESULTS Baseline characteristics of the first 632 participants are presented. Women were predominantly young (69% <24 years), were unmarried (87%), and had low levels of education (48% had less than high school). Women with high acculturation were less likely to live with a partner (OR: 0.6, 95% CI 0.4-0.8) than women with low acculturation. Few participants met physical activity guidelines during pregnancy (5.2%). Levels of perceived stress (mean 26.9 +/- 7.1), trait anxiety (mean 41.6 +/- 10.4), and depressive symptoms (33.2%) were high. CONCLUSIONS Proyecto Buena Salud represents a high-risk population of pregnant Hispanic women who are predominantly inactive, with higher levels of perceived stress, trait anxiety, and depressive symptoms compared to predominantly non-Hispanic white cohorts studied earlier. Therefore, Proyecto Buena Salud provides a unique opportunity to prospectively evaluate modifiable risk factors for GDM. Findings will inform prenatal behavioral intervention programs designed to address modifiable GDM risk factors.

Patterns of salivary cortisol secretion in pregnancy and implications for assessment protocols.

Cortisol is used in research as a biomarker of psychological stress. Logistical considerations argue for collecting as few samples as possible, balanced against diurnal rhythms and intra-individual variations. 100 pregnant women gave five saliva samples a day for 3 days, at waking, 30 min after waking, and 11:00 a.m., 5:00 p.m., and 9:00 p.m. Timing of collection was confirmed by monitors. Another sample was taken during a clinic visit. Using the 15 measures as the gold standard, correlations and mean area under the curve (AUC) were compared with subsets and the single clinic sample to evaluate alternate collection protocols. Five samples in 1 day, or protocols involving morning and night samples, had the highest correlations with mean AUC (correlation coefficient ranging from 0.82 to 0.88). Standardizing the clinic measurement to a single time of day did not substantially improve correlations with mean AUC. Correlations with measures of reported stress were also not strong.

Prenatal stress, anxiety, and depressive symptoms as predictors of intention to breastfeed among Hispanic women

BACKGROUND Studies on the relationship between prenatal psychosocial risk factors and breastfeeding are sparse, particularly in Hispanic women. METHODS We evaluated this association among 424 participants in Proyecto Buena Salud, an ongoing prospective cohort of pregnant Hispanic women in Western Massachusetts. The Perceived Stress Scale (PSS), the State-Trait Anxiety Inventory (STAI), and the Edinburgh Postnatal Depression Scale (EPDS) were administered by bilingual interviewers in early pregnancy (mean 13.6 weeks gestation) and midpregnancy (mean 25.7 weeks gestation). Information on sociodemographic, behavioral, and acculturation factors was also collected. Breastfeeding intention was abstracted from medical records. Poisson regression was used to calculate prevalence risk ratios (PRR) and 95% confidence intervals (CI). RESULTS A total of 274 (64.6%) women reported a positive intention to breastfeed. In multivariate analyses, women in the highest quartile of perceived stress (PRR 0.76, 95% CI 0.62-0.94) in early pregnancy and highest quartile of anxiety in early pregnancy (PRR 0.66, 95% CI 0.54-0.81) and midpregnancy (PRR 0.80, 95% CI 0.64-1.00) were less likely to intend to breastfeed compared to women in the lowest quartile. Women who had at least probable minor depression (EPDS score ≥13) (PRR 0.79, 95% CI 0.65-0.95) or probable major depression (EPDS score ≥15) (PRR 0.77, 95% CI 0.62-0.96) during midpregnancy were less likely to intend to breastfeed compared to women without depressive symptoms. Similarly, women with persistent depressive symptoms over pregnancy were 24%-33% less likely to intend to breastfeed compared to women without depressive symptoms. CONCLUSIONS Psychosocial risk factors during pregnancy are important predictors of breastfeeding intention among Hispanic women.