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Purpose: Maternal substance use and deaths due to overdoses are increasing nationwide. Evidence suggests that the rate of resumed substance use, and fatal and non-fatal overdose is greatest in the first year after birth, particularly around six months postpartum, compared to other parts of the perinatal period. Doula care has been linked to improvements in perinatal health and outcomes. Description: In response to the opioid epidemic, the Philadelphia Department of Public Health developed and implemented the Doula Support Program (DSP), with a focus on one year of postpartum care for birthing people with a substance use disorder (SUD). In this paper, we describe the program and its formation and report on the early challenges and successes of the program implementation, based on information we received from program founders and managers in a group interview. Assessment: Early successes of the program include partnering with local community-based programs to recruit and retain doulas, supplementing traditional doula education with perinatal SUD-specific trainings, and maximizing client referrals by collaborating with local organizations and treatment centers that serve birthing people with SUD. Client retention, however, has proven to be challenging, especially during the COVID-19 pandemic. Conclusion: The DSP continues to grow, and lessons learned will facilitate program improvements. The goal of this paper is to outline the development and launch of the DSP and to act as a model for other state and local health departments interested in providing doula care for birthing people with SUD. Significance: Maternal substance use and fatal overdoses are increasing in Philadelphia, Pennsylvania. In response to this crisis, the Philadelphia Department of Public Health's Division of Maternal, Child and Family Health developed the Doula Support Program (DSP), offering doula care to pregnant people with a current or past SUD history up to one-year postpartum. To our knowledge, this is the only doula program in Pennsylvania offering one-year postpartum support to birthing people affected by SUD. [ABSTRACT FROM AUTHOR]

Background: Pregnancy and early parenthood can be challenging transitional times for many families, especially those struggling with opioid use disorder (OUD). Over 8 million children live with a parent with SUD and parental drug use has been attributed to rising rates of family instability and child welfare involvement (Lipari & Van Horn, 2017; AFCARS, 2020;). Community-based prevention programming for families with young children, such as evidence-based maternal and child home visiting (EBHV), may we well positioned to engage and support families impacted by the opioid epidemic through early childhood. This paper presents case studies to highlight promising practices for adapting EBHV models to families impacted by SUD from the perspectives of staff and administrators. Methods: Data from three pilot sites are presented as case studies. These sites were selected to represent the most innovative and developed adaptations to EBHV for families impacted by substance use from an implementation evaluation of state-funded pilot sites (N = 20) at existing home visiting agencies across Pennsylvania. Data reported here represent semi-structured interviews with 11 individuals. Data were coded to facilitators and barriers nodes to understand the process and impact of pilot implementation. Results: Systems-level collaboration and coordination were key to serving a population already engaged in multiple systems. Engagement of substance use experts allowed home visitors to focus on delivery of evidence-based curricula supporting family stability and child development. External partnerships reduced stigma among home visitors. Across sites, staff struggled with the increased acuity of social complexity of the OUD population. Conclusions for Practice: Pregnancy and early parenthood are challenging transitional times for many families, especially those with OUD. Evaluation results demonstrate the promise of systems-based adaptations to community-based prevention programming for families with young children, such as maternal and child home visiting, to better support families impacted by SUD. [ABSTRACT FROM AUTHOR]

Objectives The aim of this paper is to explore the process and impact of co-locating evidence-based maternal and child service models to inform future implementation efforts. Methods As part of a state-wide evaluation of maternal and child home visiting programs, we conducted semi-structured interviews with administrators and home visitors from home visiting agencies across Pennsylvania. We collected 33 interviews from 4 co-located agencies. We used the Consolidated Framework for Implementation Research (CFIR) to describe the key elements mitigating implementation of multiple home visiting models. Results A primary advantage of co-location described by participants was the ability to increase the agency’s base of eligible clients through the implementation of a model with different program eligibility (e.g. income, child age) than the existing agency offering. Model differences related to curriculum (e.g. content or intensity/meeting frequency) enabled programs to more selectively match clients to models. To recruit eligible clients, new models were able to build upon the existing service networks of the initial program. Co-location provided organizational opportunities for shared trainings, enabling administrative efficiencies and collaborative staff learning. Programs implemented strategies to build synergies with complementary model features, for instance using the additional program option to serve waitlisted clients and to transition services after one model is completed. Conclusions for Practice Considerable benefits are experienced when home visiting models co-locate. This research builds on literature encouraging collaboration among community agencies and provides insight on a specific facilitative approach. This implementation strategy informs policy across the social services spectrum and competitive funding contexts. [ABSTRACT FROM AUTHOR]

Objectives: To characterize demographics, birth parameters, and social determinants of health among mother-infant dyads affected by neonatal abstinence syndrome (NAS) in Pennsylvania. Methods: We linked 2018–2019 NAS surveillance data to birth record data using probabilistic methods and then geospatially linked to local social determinants of health data based on residential address. We generated descriptive statistics and used multivariable mixed-effects logistic regression to model the association between maternal characteristics, birth parameters, social determinants of health, and NAS. Results: In adjusted models maternal age > 24, non-Hispanic white race/ethnicity, low educational attainment, Medicaid as payor at delivery, inadequate or no prenatal care, smoking during pregnancy, and low median household income were associated with NAS. We found no significant associations between NAS and county-level measures of clinician supply, number of substance use treatment facilities, or urban/rural designation. Conclusions for Practice: This study characterizes mother-infant dyads affected by NAS using linked non-administrative, population data for Pennsylvania. Results demonstrate a social gradient in NAS and inequity in prenatal care receipt among mothers of infants with NAS. Findings may inform implementation of state-based public health interventions. Significance: This article is the first to characterize Pennsylvania mother-infant dyads affected by NAS that is not reliant on administrative data. Findings demonstrating a social gradient in NAS and inequity in receipt of care will inform state-based public health practice to better support pregnant people using opioids. Additionally, Pennsylvania was among the first states to initiate NAS surveillance. While data are from 2018 to 2019, they represent the first datasets available, and the methods and limitations described in the article may be instructive to other jurisdictions. [ABSTRACT FROM AUTHOR]

Considerable evidence suggests that modifiable risk factors for adverse pregnancy outcomes such as preterm birth and low birthweight include obesity, sedentary behavior, and infections. There is a growing consensus that the preconceptional and interconceptional periods may be an ideal time for preventive intervention targeting these risk factors; enhancing health before pregnancy would subsequently reduce the risk for poor pregnancy outcomes. This paper provides an overview of the development of a health behavior intervention, Strong Healthy Women, that aims to improve women’s preconceptional and interconceptional health. We describe the rationale, delivery, and targeted outcomes of the program, as well as the design of an ongoing trial currently testing program efficacy. The content areas are also discussed and include pregnancy-conception, stress, physical activity, nutrition, infection, sources of smoke in the home, and substance use. This intervention protocol may offer researchers and healthcare professionals a framework for designing other programs aiming to improve women’s preconceptional health. [ABSTRACT FROM AUTHOR]

Objectives: Technology-based outreach offers promise for providing support to a broad population of postpartum mothers while keeping costs low. However, research on the efficacy of this approach is scarce. We conducted a pre-registered randomized pilot trial of the effects of a novel technology-based approach for supporting postpartum mothers – via text-based mentoring – from infant's birth through 18 months. Methods: Mothers (n = 201) were recruited at West Penn Hospital in Pittsburgh, PA in the days immediately following delivery. Treatment mothers were matched with volunteer mentors who communicated with them entirely via text messages. Control mothers received monthly one-way texts on basic safety topics. Measures were collected via hospital records and mother surveys. We estimated treatment effects on mothers' parenting stress, mental health, knowledge of child development, engagement in language and literacy activities, and child milestones at 4- and 18-months postpartum. We used a systematic coding approach and simple descriptive statistics to analyze the treatment mother-mentor texting transcripts. Results: We found no statistically significant impacts on targeted outcomes. However, impacts for some outcomes were meaningfully large (> 0.2 SDs). Analyses of texting transcripts showed that most mothers stayed engaged for the full 18-month study period and that mother-mentor pairs primarily discussed maternal wellbeing and child-focused topics. Conclusions for Practice: Postpartum mothers will engage with mentors in a text-based mentoring program around important maternal and child health topics. More research and development on technology-based supports for parents in the early childhood years is needed. Significance: What is already known on this subject? Technology-based approaches to supporting parents of young children are proliferating, with some showing promise in rigorous trials. What this study adds? Postpartum mothers will engage with mentors in text-based format and discuss maternal and child health topics. The efficacy of this approach should be tested further in larger trials. [ABSTRACT FROM AUTHOR]

Objectives: To compare the prevalence of highly effective contraceptive use by 12 weeks postpartum among participants of Centering Pregnancy®, a model of group prenatal care (GPC), and traditional prenatal care (TPC), and to investigate differences in contraceptive method choice by type of prenatal care. Methods: We performed a retrospective review of all eligible patients who participated in GPC (n = 143) and a random sample of patients participating in TPC (n = 290) who followed up at our institution within 12 weeks of delivery. Our primary outcome was the proportion of participants using a highly effective contraceptive method within 12 weeks postpartum. Contraceptives were classified in tiers (Tier 1, long-acting reversible and permanent contraception; Tier 2, oral contraceptive pills, transdermal patch, vaginal ring, or injection; Tier 3, barrier and fertility awareness methods, withdrawal, spermicide; and no method). Tier 1 and Tier 2 methods were considered highly effective. Results: The prevalence of highly effective contraceptive use by 12 weeks postpartum was 63.6% (91 of 143) and 63.1% (183 of 290) among participants in GPC and TPC, respectively (p = 0.99). We found no difference in Tier 1 versus other method use (adjusted odds ratio (aOR) 1.05, 95% CI 0.95–1.15, p = 0.34) or Tier 2 versus other method use between groups (aOR 0.98, 95% CI 0.89–1.08, p = 0.69), in a multivariable model controlling for demographic and clinical factors. Conclusions for Practice: The prevalence of highly effective contraceptive use at 12 weeks postpartum was not different between GPC and TPC participants in this study. GPC was not associated with increased use of Tier 1 or Tier 2 contraceptive methods. [ABSTRACT FROM AUTHOR]

Objectives We investigated associations of mothers' preterm birth (PTB) status with her infants' PTB risk. We also examined whether this relationship differs by mothers' race and generational socio-economic neighborhood context. Methods Participants were 6592 non-Hispanic (NH) white and NH black mother-infant pairs born in 2009-2011 and 1979-1998, respectively, in Allegheny County, Pennsylvania. Birth records were used to determine gestational age at birth, PTB status (<37 completed weeks of gestation), and PTB subgroups-late and early PTB (34-36 weeks and <34 completed weeks of gestation, respectively). Census data on tract racial composition and household income were used to characterize residential race and economic environment. Logistic regression models were used to calculate Odds Ratios (ORs), Relative Risk Ratios (RRR), and 95% confidence intervals (CIs). Stratified analyses were conducted to assess effect modification. Results Overall, 8.21, 6.63 and 1.58% infants had PTB, LPTB, and EPTB, respectively. Maternal PTB status was associated with a 46% increase in infant PTB (95% CI: 1.08-1.98), EPTB (95% CI: 0.80-2.69), and LPTB (95% CI: 1.04-2.04) risk. Maternal PTB-infant PTB associations, particularly maternal PTB-infant LPTB associations, were stronger among NH blacks, mothers in neighborhoods with a high percentage of NH black residents in both generations, or mothers who moved to neighborhoods with a higher percentage of NH black residents. Conclusions for Practice Race and generational socio-economic neighborhood context modify transgenerational transmission of PTB risk. These findings are important for identification of at-risk populations and to inform future mechanistic studies. [ABSTRACT FROM AUTHOR]

Objectives The objective of this study was to describe factors that influence the ability of state Medicaid agencies to report the Centers for Medicare & Medicaid Services' (CMS) core set of children's health care quality measures (Child Core Set). Methods We conducted a multiple-case study of four high-performing states participating in the Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program: Illinois, Maine, Pennsylvania, and Oregon. Cases were purposively selected for their diverse measurement approaches and used data from 2010 to 2015, including 154 interviews, semiannual grant progress reports, and annual public reports on Child Core Set measures. We followed Yin's multiple-case study methodology to describe how and why each state increased the number of measures reported to CMS. Results All four states increased the number of Child Core Set measures reported to CMS during the grant period. Each took a different approach to reporting, depending on the available technical, organizational, and behavioral inputs in the state. Reporting capacity was influenced by a state's Medicaid data availability, ability to link to other state data systems, past experience with quality measurement, staff time and technical expertise, and demand for the measures. These factors were enhanced by CHIPRA Quality Demonstration grant funding and other federal capacity building activities, as hypothesized in our conceptual framework. These and other states have made progress reporting the Child Core Set since 2010. Conclusion With financial support and investment in state data systems and organizational factors, states can overcome challenges to reporting most of the Child Core Set measures. [ABSTRACT FROM AUTHOR]

To evaluate the association between economic indicators (unemployment and mortgage foreclosure rates) and volume of investigated and substantiated cases of child maltreatment at the county level from 1990 to 2010 in the Commonwealth of Pennsylvania. County-level investigated reports of child maltreatment and proportion of investigated cases substantiated by child protective services in the Commonwealth of Pennsylvania were compared with county-level unemployment rates from 1990 to 2010, and with county-level mortgage foreclosure rates from 2000 to 2010. We employed fixed-effects Poisson regression modeling to estimate the association between volume of investigated and substantiated cases of maltreatment, and current and prior levels of local economic indicators adjusting for temporal trend. Across Pennsylvania, annual rate of investigated maltreatment reports decreased through the 1990s and rose in the early 2000s before reaching a peak of 9.21 investigated reports per 1,000 children in 2008, during the recent economic recessionary period. The proportion of investigated cases substantiated, however, decreased statewide from 33 % in 1991 to 15 % in 2010. Within counties, current unemployment rate, and current and prior-year foreclosure rates were positively associated with volume of both investigated and substantiated child maltreatment incidents ( p < 0.05). Despite recent increases in investigations, the proportion of investigated cases substantiated decreased by more than half from 1990 to 2010 in Pennsylvania. This trend suggests significant changes in substantiation standards and practices during the period of study. Economic indicators demonstrated strong association with investigated and substantiated maltreatment, underscoring the urgent need for directing important prophylactic efforts and resources to communities experiencing economic hardship. [ABSTRACT FROM AUTHOR]

The objective of this study is to determine the influence of maternal health literacy and child's age on participation in social welfare programs benefiting children. In a longitudinal prospective cohort study of 560 Medicaid-eligible mother-infant dyads recruited in Philadelphia, maternal health literacy was assessed using the test of functional health literacy in adults (short version). Participation in social welfare programs [Temporary Assistance to Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), child care subsidy, and public housing] was self-reported at child's birth, and at the 6, 12, 18, 24 month follow-up interviews. Generalized estimating equations quantified the strength of maternal health literacy as an estimator of program participation. The mothers were primarily African-Americans (83 %), single (87 %), with multiple children (62 %). Nearly 24 % of the mothers had inadequate or marginal health literacy. Children whose mothers had inadequate health literacy were less likely to receive child care subsidy (adjusted OR = 0.54, 95 % CI 0.34-0.85) than children whose mothers had adequate health literacy. Health literacy was not a significant predictor for TANF, SNAP, WIC or housing assistance. The predicted probability for participation in all programs decreased from birth to 24 months. Most notably, predicted WIC participation declined rapidly after age one. During the first 24 months, mothers with inadequate health literacy could benefit from simplified or facilitated child care subsidy application processes. Targeted outreach and enrollment efforts conducted by social welfare programs need to take into account the changing needs of families as children age. [ABSTRACT FROM AUTHOR]

Appropriate measurement of socioeconomic status (SES) in health research can be problematic. Conventional SES measures based on 'objective' indicators such as income, education, or occupation may have questionable validity in certain populations. The objective of this investigation was to determine if a relatively new measurement of SES, subjective social status (SSS), was more consistently and strongly associated with multiple health outcomes for low income mothers. Data available from a large scale community-based study examining maternal and infant health for a low income urban population were used to examine relationships between SSS and a wide range of postpartum physical and emotional health outcomes. Crosstabulations and multivariate analyses focused on the breadth and depth of these relationships; in addition, the relative strength of the relationships between SSS and the health outcomes was compared to that of conventional measures of SES, including both income and education. SSS was significantly related to all physical and emotional health outcomes examined. The overall pattern of findings indicated that these relationships were independent of, as well as more consistent and stronger than, those between conventional measures of SES and postpartum health outcomes. SSS represents an important dimension of the relationship between SES and postpartum physical and emotional health. In low income populations the failure to account for this dimension likely underestimates the influence of SES on postpartum health. This has important implications for the interpretation of findings in empirical studies which seek to control for the effects of SES on maternal health outcomes. [ABSTRACT FROM AUTHOR]

Objective: To examine maternal pre-pregnancy (preconception) predictors of birthweight and fetal growth for singleton live births occurring over a 2-year period in a prospective study. Methods: Data are from a population-based cohort study of 1,420 women who were interviewed at baseline and 2-years later; self-report data and birth records were obtained for incident live births during the followup period. The analytic sample includes 116 singleton births. Baseline preconception maternal health status and health-related behaviors were examined as predictors of birthweight and fetal growth, controlling for prenatal and sociodemographic variables, using multiple regression analysis. Results: Preconception BMI (overweight or obese) and vegetable consumption (at least one serving per day) had statistically significant independent and positive effects on birthweight and fetal growth. Maternal weight gain during pregnancy, a prenatal variable, was an additional independent predictor of birthweight and fetal growth. Sociodemographic variables were not significant predictors after controlling for preconception and prenatal maternal characteristics. Conclusions: Findings confirm that preconception maternal health status and health-related behaviors can affect birthweight and fetal growth independent of prenatal and socioeconomic variables. Implications for preconception care are discussed. [ABSTRACT FROM AUTHOR]

In populations where the majority of pregnancies occur to unmarried women, exploring the quality of partner relationships and reproductive health is warranted. This study assesses differences in psychosocial characteristics, health behaviors, and birth outcomes between unmarried pregnant women who reported having a ‘good’ relationship with their baby’s father, compared to those who reported having a ‘fair’ or ‘poor’ relationship with their baby’s father. This research was part of a prospective study of low-income urban women. All unmarried women ( n = 3,633) enrolled during their first prenatal visit were asked questions designed to differentiate between being in a good, fair or poor relationship with the baby’s father. The worse the quality of the relationship, the worse the outcome, with dose–response associations between the quality of the relationship, emotional health, health behaviors, and birthweight. Compared to women in good relationships, those in poor relationships were more likely to have depressive symptoms (aPR 1.93; 95% CI: 1.65, 2.25), stress (aPR 1.24; 95% CI: 1.14, 1.35), use drugs (aPR 1.34; 95% CI: 1.11, 1.61) and smoke (aPR 1.28; 95% CI: 1.10, 1.49). Although infants born to mothers in poor relationships had the highest rate of low birth weight, the differences were not significant. Delving beyond marital status to assess the quality of partner relationships among unmarried mothers is important. Further research is needed to understand the complex interplay of individual, social and environmental factors promoting or hindering stable and supportive partner relationships among socially disadvantaged populations of pregnant women. [ABSTRACT FROM AUTHOR]

Objective Our objective was to determine whether intention for future pregnancy affects selected preconception health behaviors that may impact pregnancy outcomes. Methods Analyses are based on data from a population-based cohort study of women ages 18–45 residing in Central Pennsylvania. A subsample of 847 non-pregnant women with reproductive capacity comprise the analytic sample. We determined the associations between intention for future pregnancy and the pattern in the following health behaviors over a 2-year period: nutrition (fruit and vegetable consumption), folic acid supplementation, physical activity, binge drinking, smoking, and vaginal douching. Multivariable analyses controlled for pregnancy-related variables, health status, health care utilization, and sociodemographic variables. Results At baseline, 9% of women were considering pregnancy in the next year, 37% of women were considering pregnancy some other time in the future, and 53% of women were not considering future pregnancy. In multivariable analyses, there were no associations between intention for future pregnancy and maintaining healthy behavior or improving behavior for any of the seven longitudinal health behaviors studied. Conclusions The importance of nutrition, folic acid supplementation, physical activity, avoiding binge drinking, not smoking, and avoiding vaginal douching in the preconception period needs to be emphasized by health care providers and policy makers. [ABSTRACT FROM AUTHOR]

Objectives In the United States, significant ethnic and racial health and healthcare disparities exist among our most vulnerable populations, new mothers and newborns. We sought to determine disparities in socioeconomic status, perinatal health, and perinatal healthcare for black mothers and their newborns cared for in well-baby nurseries compared with white mother/baby pairs in Pennsylvania. Methods A retrospective analysis of a merged data set containing birth and clinical discharge records was conducted. Perinatal data from 44,105 black mothers and their singleton newborns, ≥35 weeks gestational age cared for in Pennsylvania well-baby nurseries from 1998–2002 were compared with 88,210 white mother/baby pairs. Results Black mothers were younger and were much more likely to receive Medicaid or be uninsured compared with white mothers. They were less likely to be college-educated, married, or have prenatal care beginning in the first trimester. Infants born to black mothers were less likely to be delivered via Cesarean section, but were more likely to be born between 35 and 38 weeks gestation and be of low birth weight. Conclusions Numerous significant disparities exist for black mothers and their newborns cared for in well-baby nurseries in Pennsylvania. Since most newborns are cared for in this setting as opposed to intensive care environments, recognition of the differences that exist for this group when compared to well newborns of white mothers can help to improve healthcare and its delivery to this population. Federal and local initiatives must continue efforts to eliminate racial disparities. [ABSTRACT FROM AUTHOR]