Suezanne T. Orr

Maternal prenatal pregnancy-related anxiety and spontaneous preterm birth in Baltimore, Maryland.

Objective: To focus on the relationship between pregnancy-related anxiety and spontaneous preterm birth. Psychosocial factors have been the subject of inquiries about the etiology of preterm birth; a factor of recent interest is maternal prenatal pregnancy-related anxiety (worries and concerns related to the pregnancy). Methods: From 1991 to 1993, a total of 1820 women completed the study questionnaire during their first prenatal visit to clinics in Baltimore, Maryland. Pregnancy-related anxiety was assessed using six questions from the Prenatal Social Environment Inventory; scores ranged from 0 to 6. Data on pregnancy outcome and clinical and behavioral covariates were obtained from the women’s clinical records. Results: After adjustment for covariates (first or second trimester bleeding, drug use, employment, prior poor pregnancy outcome, smoking, low body mass index, maternal education, age, and race), women with higher levels of pregnancy-related anxiety (scores of 5 or 6) had a significantly increased risk of spontaneous preterm birth compared with those with scores of ≤3. Conclusions: If additional research confirms these results, then this finding may suggest the possibility of intervention to reduce maternal prenatal pregnancy-related worries and concerns, thereby reducing the risk of spontaneous preterm birth. PSEI = Prenatal Social Environment Inventory; CES-D = Center for Epidemiologic Studies Depression Scale; BMI = body mass index; OR = Odds Ratio.

Seizures and Seizure Care in an Emergency Department

Summary: We evaluated the nature and significance of seizure problems in an emergency department (ED) by studying seizures in an urban community hospital. In 6 months, there were 29,131 ED visits; of these, 200 (0.7%) were for diagnosed seizures. Among these 200 seizure visits, were 69 (34.5%) new‐onset seizures, 30 (15%) febrile seizures, and 92 (46%) seizures in epilepsy patients with prescribed antiepileptic drugs (AEDs). These seizures were often serious and complicated by medical and psychosocial problems; e.g., 37 patients (18.5%) had multiple seizures, 14 (7%) had status epilepticus, and 63 (31.5%) required hospitalization. Associated psychosocial problems included 61 patients (31%) who had no medical insurance, 62 others (31%) who were judged indigent, and 60 (30%) who abused alcohol. Of 92 epilepsy patients receiving AEDs, 52 (56.5%) had subtherapeutic blood levels and were noncompliant with AED prescription patients. Problems with continuity of care were demonstrated by the failure of the ED to communicate with primary care providers about drug levels, noncompliance, and changes in therapy in 85% of patients. A hospital ED is a major source for epilepsy and seizure care, but this care is not always optimum. EDs need to be prepared to manage common acute seizure problems. However, EDs must also place greater emphasis on significant nonemergency aspects of seizure care such as AED compliance, associated psychosocial problems, and effective communication with primary care providers.

Referrals from an emergency room to primary care practices at an urban hospital.

Three hundred ninety-eight patients treated in the emergency room for non-urgent complaints who stated that they had no regular source of primary medical care were referred to one of several medical care centers in the area. Overall, 34 per cent of such patients complied with the referral. Correlates of compliance were: age (very young and very old), patient-perceived health status, medically determined need for follow-up care, and having an appointment made by the emergency room provider. Another group of 500 successfully referred patients became excellent users of the primary care office, complying with requested health maintenance and follow-up visits. However, emergency room utilization by the successfully referred patients did not decrease more than among referred patients who did not enroll in the primary care source.

Maternal depression in an urban pediatric practice: implications for health care delivery.

A scale to measure depressive symptomatology was administered to mothers attending an urban pediatric primary care center. Over 50 per cent of the female heads of households were Black or low income and depressed. This suggests that the provider of pediatric primary care should recognize depression and make appropriate referrals or intervention, since depressed mothers may have a diminished ability to respond to the emotional needs of their children.

Psychosocial stressors and low birth weight: development of a questionnaire

Low birth weight is a major public health problem because it is a major contributor to infant mortality as well as to various types of morbidity among young children. Of particular concern is that black women have an increased risk of low birth weight babies compared with white women. Many etiologic factors for low birth weight have been identified, but even within homogeneous strata of risk, black women have a greater risk of low birth weight babies than do white women. The reasons for this excess risk are not well understood. Available evidence suggests that exposure to psychosocial stressors is associated with adverse pregnancy outcomes. However, prior work in this area has been limited by the lack of a valid and reliable tool to assess exposure to stressors among pregnant women. We report on the development and testing of such a questionnaire, the Prenatal Social Environment Inventory. In this questionnaire, exposure to stressors is conceptualized and measured in the context of chronic stressful conditions. The questionnaire is self-administered and can be used in clinical settings with pregnant women. Findings of psychometric evaluations showed that the questionnaire has acceptable levels of 30-day temporal stability (reliability), internal consistency, and construct validity.

Unintended Pregnancy and Prenatal Behaviors Among Urban, Black Women in Baltimore, Maryland : The Baltimore Preterm Birth Study

PURPOSE We explored associations between intendedness of pregnancy with maternal prenatal behaviors, including smoking, use of alcohol, use of illicit drugs, and late initiation of prenatal care. METHODS Pregnant black women ages 18 years or older (N = 913) were enrolled in the study at their first visit to prenatal clinics in Baltimore, Maryland, at which time data were obtained from the women about intendedness of pregnancy. Data on behavioral risks were abstracted from clinical records. Logistic regression was used to adjust analyses for maternal demographic characteristics. RESULTS Women with unwanted pregnancies were significantly more likely than women with wanted or mistimed pregnancies, or who were unsure about intendedness, to smoke (odds ratio [OR], 2.0; 95% CI, 1.2-3.3), use alcohol (OR, 2.1; 95% CI, 1.1-3.9), and use illicit drugs (OR, 1.8; 95% CI, 1.0-2.9) during pregnancy, and to initiate prenatal care in the third trimester (OR, 5.7; 95% CI, 3.5-9.4). CONCLUSIONS Unwanted pregnancy is associated with prenatal behaviors that increase the risk of poor pregnancy outcomes. The facilitation of wanted pregnancies and reduction of harmful maternal behaviors may result in improved pregnancy outcomes in the United States.

Factors Associated with Prenatal Smoking Among Black Women in Eastern North Carolina

Objectives: The objective of this research was to explore prenatal smoking behaviors among Black women attending prenatal clinics. Despite the racial disparities in poor pregnancy outcomes, and the well-known association of smoking with harmful outcomes, little research has been conducted about prenatal smoking among Black women. Methods: Women were enrolled in the study and interviewed at the time of the first prenatal visit. The interview contained items to assess prenatal smoking and cessation, depressive symptoms, demographic factors, and beliefs about smoking. Reports of smoking cessation were verified using urinary cotinine. Results: The sample consisted of 811 Black women. Fourteen percent of the women were self-reported smokers, 12.6% reported cessation and 73% were nonsmokers. Twenty percent of the self-reported quitters had elevated cotinine; when these women were reclassified, 17% of the women were smokers. Factors associated with smoking in logistic regression analysis included elevated maternal depressive symptoms (OR = 1.7, 95% CI: 1.1–2.6), maternal age 20 years or older (OR = 1.94; 95% CI: 1.1, 3.3), less than a high school education (OR = 2.2; 95% CI: 1.2, 3.8), unmarried/not living with a partner (OR = 1.9; 95% CI: 1.0, 3.6), and allowing smoking in the home (OR = 5.5; 95% CI: 3.4, 8.6). Conclusions: The prevalence of maternal prenatal smoking was much higher among women in this sample than has been previously reported. The rate of nondisclosure of smoking among self-reported quitters was also high. Maternal behavioral (allowing smoking in the home) and psychosocial factors (depressive symptoms) were associated with prenatal smoking.

Emergency room use by low income children with a regular source of health care.

problematic by many hospital administrators and providers of emergency care. The hospital emergency room is primarily designed for the prompt treatment of victims of accidents/trauma and sudden emergent illnesses. In that setting it is difficult to address chronic and psychosocial problems of patients. Moreover, the care is expensive, and the presence of those seeking primary care contributes to crowding and long waits for all patients. With the advent of Medicaid in 1966, it was assumed that emergency room use by persons needing primary care would decrease. The Medicaid program was designed

Maternal Prenatal Depressive Symptoms, Nicotine Addiction, and Smoking-Related Knowledge, Attitudes, Beliefs, and Behaviors

Maternal smoking is a key preventable cause of poor pregnancy outcomes, such as low birthweight. In many areas of the United States, including Eastern North Carolina, rates of prenatal smoking are high. Prenatal depressive symptoms are associated with maternal smoking, but there remains much to learn about this relationship, especially among Black women, who have double the risk of poor pregnancy outcomes of White women. In the study reported in this paper, we investigated the relationship between maternal prenatal depressive symptoms with smoking behaviors, beliefs and attitudes, environmental factors which promote smoking and nicotine addiction. Pregnant women were enrolled in the study at the first prenatal visit to the clinics of the Departments of Obstetrics and Gynecology and Family Medicine of the Brody School of Medicine, East Carolina University. An interviewer administered a questionnaire to each woman about smoking, smoking-related attitudes, knowledge, beliefs and behaviors, nicotine addiction, and home environmental factors that encourage smoking. The CES-D was used to measure depressive symptoms. We used the cut-point score of 23 or greater to indicate elevated depressive symptoms, which is thought to represent major depressive disorder. The sample consisted of 810 Black women, of whom 18% were smokers. CES-D score was associated with nicotine addiction, not thinking of quitting smoking, and not expecting support from family and friends if they decided to quit. Prenatal depressive symptoms may be a barrier to smoking cessation.

A Social Environment Inventory for the pediatric office.

Exposure to psychosocial stressors is associated with deleterious physical and mental health outcomes among children adn adults, as well as with school-related and behavioral problems among children. However, research and intervention in this area have been hampered by the lack of a valid measurement tool to assess exposure to stressors among mothers. This paper reports on the development and testing of a self-administered questionnaire for use in the pediatric setting to assess maternal exposure to stressors. The questionnaire was developed to facilitate the early identification of mothers exposed to high levels of stressors, since exposure to stressors often precedes the onset of problems. Early identification of mothers and children, in the pediatric office, could facilitate the prevention of various behavioral, school, and other problems among children.