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The authors discuss the disparity in African American infant mortality and suggest ways to surmount the problem. They believe the causes of the disparity are historical and biopsychosocial; racial and ethnic disparities are found in health outcomes. Eliminating factors that cause high rates of pre-term births (PTB) and low birth weight (LBW) is important as. The authors opine that a multidisciplinary approach would address the various causal factors.

Objectives: The aim of this paper is to share the results of a systematic review on the state of inequalities in access to and utilization of maternal, newborn and child health (MNCH) services in the sub-Saharan African region. The focus of the review was on urban settings where growing needs and challenges have been registered over the past few years due to rapid increase in urban populations and urban slums. Methods: The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies published in English between 2000 and 2019 were included. A narrative synthesis of both qualitative and quantitative data was undertaken. The record for registration in PROSPERO was CRD42019122066. Results: The review highlights a great variation in MNCH services utilization across urban sub-Saharan Africa (SSA). The main aspects of vulnerability to unequal and poor MNCH services utilization in urban settings of the region include poverty, low level of education, unemployment, lower socioeconomic status and poor livelihoods, younger maternal age, low social integration and social support, socio-cultural taboos, residing in slums, and being displaced, refugee, or migrant. At the health system level, persistent inequalities are associated with distance to health facility, availability of quality services and discriminating attitudes from health care personnel. Conclusion: Context-specific intervention programs that aim at resolving the identified barriers to access and use MNCH services, particularly for the most vulnerable segments of urban populations, are essential to improve the overall health of the region and universal health coverage (UHC) targets. [ABSTRACT FROM AUTHOR]

Introduction: The U.S. has the highest rate of preterm birth (PTB), of all developed countries, especially among African American women. Social determinants of health and inequalities in health outcomes are understudied areas. The intersectionality of race and socioeconomic status has been shown to contribute to chronic stress, stress has been shown to be associated with PTB, yet the mechanisms that affect pregnancy outcomes have not been explicit. Mindfulness-based Interventions that address stress reduction during pregnancy may improve quality of life during pregnancy, perhaps enhancing resilience, and be on the pathway to reducing the risk of negative pregnancy outcomes such as PTB. Methods: We over-enrolled African American women and those covered by Medicaid to reach women at higher risk for PTB and included women in substance use treatment. Participants were enrolled in a 6-week mindfulness in pregnancy (MIP) intervention at the obstetric clinic. Sociodemographic characteristics and psychosocial assessments were obtained at three time points. Results: We enrolled 35 women who self-identified as: non-white, Medicaid recipients, aged 25–35 years, with high school or less education. We found reductions in perceived stress, pregnancy specific stress, trait anxiety and depression and increases in mindfulness that sustained post-intervention at 2 and 7 months. Discussion: Social determinants and stress in particular have been associated with negative birth outcomes. This paper describes a brief intervention and results of MIP tailored to women who have significantly more stress due to race, poverty, homelessness, substance use treatment and other comorbid health risks including PTB. [ABSTRACT FROM AUTHOR]

Purpose: Protecting and advancing maternal and child health is a critical goal to both society and to the economy, given that their health is a predictor of the next generation's health. Yet despite this recognition, many of the communities aiming to improve maternal and child health still problem-solve in silos: age silos, disease silos, organizational silos, disciplinary silos, data silos, and communication silos, often created or exacerbated by the disconnected approaches to research, funding, and reporting. These silos limit discovery and spread of new solutions to important maternal and child health problems. Description: In this paper, we will discuss federal incentive prizes as a tool to break down silos and to engineer cognitive diversity and transdisciplinary collaboration. Assessment: In 2018, the United States Health Resources and Services Administration, Maternal and Child Health Bureau (HRSA MCHB) launched the "Maternal and Child Health Bureau Grand Challenges," a suite of four prize competitions totaling $1.5 million addressing critical issues in maternal and child health. These included federal challenges designed to (1) prevent childhood obesity in low-income communities, (2) improve the remote monitoring of pregnancy, (3) improve care coordination and planning for children with special health care needs, and (4) prevent opioid misuse among pregnant women and new mothers. Conclusion: The ability to incentivize innovation to address critical public health issues cannot rest in the private sector alone. Complementing other investments, the Challenge mechanism's power to catalyze the rapid development of innovative solutions can improve how we address barriers to achieve optimal maternal and child health for the families that we serve. [ABSTRACT FROM AUTHOR]

Introduction: Nepal has made considerable progress on improving child survival during the Millennium Development Goal period, however, further progress will require accelerated reduction in neonatal mortality. Neonatal survival is one of the priorities for Sustainable Development Goals 2030. This paper examines the trends, equity gaps and factors associated with neonatal mortality between 2001 and 2016 to assess the likelihood of Every Newborn Action Plan (ENAP) target being reached in Nepal by 2030. Methods: This study used data from the 2001, 2006, 2011 and 2016 Nepal Demographic and Health Surveys. We examined neonatal mortality rate (NMR) across the socioeconomic strata and the annual rate of reduction (ARR) between 2001 and 2016. We assessed association of socio-demographic, maternal, obstetric and neonatal factors associated with neonatal mortality. Based on the ARR among the wealth quintile between 2001 and 2016, we made projection of NMR to achieve the ENAP target. Using the Lorenz curve, we calculated the inequity distribution among the wealth quintiles between 2001 and 2016. Results: In NDHS of 2001, 2006, 2011 and 2016, a total of 8400, 8600, 13,485 and 13,089 women were interviewed respectively. There were significant disparities between wealth quintiles that widened over the 15 years. The ARR for NMR declined with an average of 4.0% between 2001 and 2016. Multivariate analysis of the 2016 data showed that women who had not been vaccinated against tetanus had the highest risk of neonatal mortality (adjusted odds ratio [AOR] 3.38; 95% confidence interval [CI] 1.20–9.55), followed by women who had no education (AOR 1.87; 95% CI 1.62–2.16). Further factors significantly associated with neonatal mortality were the mother giving birth before the age of 20 (AOR 1.76; CI 95% 1.17–2.59), household air pollution (AOR 1.37; CI 95% 1.59–1.62), belonging to a poorest quintile (AOR 1.37; CI 95% 1.21–1.54), residing in a rural area (AOR 1.28; CI 95% 1.13–1.44), and having no toilet at home (AOR 1.21; CI 95% 1.06–1.40). If the trend of neonatal mortality rate of 2016 continues, it is projected that the poorest family will reach the ENAP target in 2067. Conclusions: Although neonatal mortality is declining in Nepal, if the current trend continues it will take another 50 years for families in the poorest group to attain the 2030 ENAP target. There are different factors associated with neonatal mortality, reducing the disparities for maternal and neonatal care will reduce mortality among the poorest families. [ABSTRACT FROM AUTHOR]

Objectives The maternal and child health (MCH) community, partnering with women and their families, has the potential to play a critical role in advancing a new multi-sector social movement focused on creating a women's reproductive and economic justice agenda. Since the turn of the twenty-first century, the MCH field has been planting seeds for change. The time has come for this work to bear fruit as many states are facing stagnant or slow progress in reducing infant mortality, increasing maternal death rates, and growing health inequities. Methods This paper synthesizes three current, interrelated approaches to addressing MCH challenges-life course theory, preconception health, and social justice/reproductive equity. Conclusion Based on these core constructs, the authors offer four directions for advancing efforts to improve MCH outcomes. The first is to ensure access to quality health care for all. The second is to facilitate change through critical conversations about challenging issues such as poverty, racism, sexism, and immigration; the relevance of evidence-based practice in disenfranchised communities; and how we might be perpetuating inequities in our institutions. The third is to develop collaborative spaces in which leaders across diverse sectors can see their roles in creating equitable neighborhood conditions that ensure optimal reproductive choices and outcomes for women and their families. Last, the authors suggest that leaders engage the MCH workforce and its consumers in dialogue and action about local and national policies that address the social determinants of health and how these policies influence reproductive and early childhood outcomes. [ABSTRACT FROM AUTHOR]

Objectives In low-income settings, neonatal mortality rates (NMR) are higher among socioeconomically disadvantaged groups. Institutional deliveries have been shown to be protective against neonatal mortality. In Gujarat, India, the access of disadvantaged women to institutional deliveries has increased. However, the impact of increased institutional delivery on NMR has not been studied here. This paper examined if institutional childbirth is associated with lower NMR among disadvantaged women in Gujarat, India. Methods A community-based prospective cohort of pregnant women was followed in three districts in Gujarat, India (July 2013-November 2014). Two thousand nine hundred and nineteen live births to disadvantaged women (tribal or below poverty line) were included in the study. Data was analyzed using multivariable logistic regression. Results The overall NMR was 25 deaths per 1000 live births. Multivariable analysis showed that institutional childbirth was protective against neonatal mortality only among disadvantaged women with obstetric complications during delivery. Among mothers with obstetric complications during delivery, those who gave birth in a private or public facility had significantly lower odds of having a neonatal death than women delivering at home (AOR 0.07 95% CI 0.01-0.45 and AOR 0.03, 95% CI 0.00-0.33 respectively). Conclusions for Practice Our findings highlight the crucial role of institutional delivery to prevent neonatal deaths among those born to disadvantaged women with complications during delivery in this setting. Efforts to improve disadvantaged women's access to good quality obstetric care must continue in order to further reduce the NMR in Gujarat, India. [ABSTRACT FROM AUTHOR]

Objectives Few Indian studies have examined the relationship between birth size and stunting in children. Studies on recovery from stunting in India are even fewer. This study, thus, investigates the relationship between birth size and stunting in Andhra Pradesh, India. This study further examines the factors associated with recovery from stunting using a longitudinal data. Methods We used data from the three waves of Young Lives Study (YLS) conducted in Andhra Pradesh in the years 2002, 2006-2007, and 2009 respectively. We used data from 1965 children in wave 1 to examine the association between birth size and stunting. For examining the factors associated with recovery from stunting between 1 and 5 years of age, and between 5 and 8 years, we use data from 582 and 670 children who were stunted at age 1 and age 5 respectively. We use multivariable logistic regression models to fulfil the objectives of the paper. Results The children who were of average- or large- size at birth were significantly less likely to be stunted than children who were of small size at birth (OR 0.61 and 0.47 respectively). Children of average/tall mothers were 0.41 times less likely to be stunted than children of shorter mothers. Severely stunted children were less likely than other stunted children to recover from stunting between 1 and 5 years of age, and between 5 and 8 years. Mother's height was statistically associated with recovery. Change in wealth status of the household was statistically associated with recovery between 1 and 5 years of age. In comparison, child immunization was associated with recovery between 5 and 8 years. Conclusions for Practice This study contributes to the understanding of the impact of birth size on childhood stunting, and to the extent of recovery from stunting in India. Further follow-up is necessary to demonstrate the impact during adolescence and adulthood. [ABSTRACT FROM AUTHOR]

Background Black, Hispanic, and low income children bear a greater burden of chronic health conditions compared to wealthier white counterparts. Under federal law, schools provide services to children when their health conditions impair learning. These school services, called individualized education programs (IEPs) can reduce disparities in school outcomes. This paper examines the extent to which children with health conditions have an IEP plan, an important first step in understanding service utilization. Method Andersen's Behavioral Model was used to examine IEP plan presence by using the 2012 National Survey of Children's Health. School aged children (6-17), with at least one health condition (N = 16,496) were examined using multivariable logistic regression analysis to understand predisposing (age, sex, race/ethnicity), enabling (family and neighborhood), and need (health related) factors as predictors of having an IEP plan. Race/ethnicity interaction terms tested for moderating effects of race/ethnicity on the relationship between predisposing, enabling and need factors and having an IEP plan. Results Hispanic children were 93.4 % (OR = .066) less likely and Black children were 87.9 % (OR = .121) less likely to have an IEP plan compared to White children. Black, Hispanic, and Multiracial children were more likely to have an IEP plan if they had more family and neighborhood resources (OR range 1.37-1.62) and greater health needs and health care needs (OR range 1.29-2.57). Conclusion The Behavioral Model was useful in predicting the presence of IEP plans among racially/ethnically diverse children with health conditions as an important step in understanding disparities in healthcare access in schools. [ABSTRACT FROM AUTHOR]

In 2003 Alyans Sante Borgne's (ASB) conducted the first week-long mobile hospital in Molas, a poor mountain community a 10-h walk from the main hospital in the town of Borgne in North Haiti. ASB is a partnership between Haiti Outreach-Pwoje Espwa (H.O.P.E.), a US-based NGO, and Haiti's Ministry of Health. The paper reflects on this first experience and the evolution of an indigenous model of health care delivery, Sante Nan Lakou (SNL)/Health at the Extended Family Level, a model that prioritizes the needs of patients over those of the institution. It highlights the challenges of providing quality care to a much neglected segment of our population and documents the impact of this event for the community and for ASB. Lessons learned during that week shaped ASB's response to the root causes of women and children's poor health in the commune of Borgne. The response is articulated in a holistic grassroots program called Sante/Health, Edikasyon/Education, Ekonomi/Economy for Fanm/Women (SEE Fanm). SEE Fanm is a constellation of programs and initiatives that together brings quality care to women and seeks to empower them to take charge of their health and wellbeing and, by extension, that of their families and communities. [ABSTRACT FROM AUTHOR]

Introduction: Childhood maltreatment is a well-established risk factor for health problems in adulthood and may also have intergenerational consequences for infant health. Childhood maltreatment may confer risk for infant health by undermining caregiver capacities for sensitive and responsive caregiving. However, associations among childhood maltreatment, maternal sensitivity, and infant health are not well understood. These processes may be of particular importance among low-income and ethnic minority populations for whom disparities in maltreatment exposure and poorer health outcomes are well-established. Method: The current study drew data from a sample of low-income, Mexican American families to examine whether maternal childhood maltreatment would be associated with more infant health concerns, and whether lower maternal sensitivity would explain their associations. Data were collected from 322 mother-infant dyads during home visits completed during pregnancy and when infants were 12, 18, and 24 weeks old. Results: Maternal childhood maltreatment exposure and lower maternal sensitivity were both associated with more infant health concerns. Maternal childhood maltreatment was not associated with maternal sensitivity. Discussion: These findings highlight potential intergenerational consequences of maternal childhood maltreatment for infant health and underscore a need for evaluating pre- and postnatal mechanisms through which these effects may be perpetuated. Furthermore, results indicate that maternal sensitivity may represent a promising target for interventions seeking to counteract intergenerational transmission processes. Clarification about underlying risk processes and potentiating resiliency characteristics may elucidate ways to better support mothers and infants across the lifespan. Significance: Childhood maltreatment is associated with a variety of health outcomes across an individual's lifespan and may have intergenerational consequences as well. The present study is among the first to investigate maternal co-regulatory behaviors (i.e., sensitivity) as a potential mechanism through which maternal exposure to childhood maltreatment may influence infant health concerns. Results suggest that both maternal childhood maltreatment history and sensitivity may shape infant outcomes before 24 weeks of age. Increasing understanding of the mechanisms through which maternal childhood maltreatment may exert cascades of influence on infant health may help to inform the development of early intervention services. [ABSTRACT FROM AUTHOR]

Participation in women, infants and children (WIC), supplemental nutritional assistance program (SNAP), temporary assistance for needy families (TANF), and medical assistance program (MAP) programs provide critical nutrition and health benefits to low-income families. Concurrent enrollment in these programs provides a powerful safety net, yet simultaneous participation is reported to be low. Underutilization undermines program objectives, client well-being and food security. This paper examines concurrent participation among the most needy WIC clients, those at/below 100 % of the federal poverty level (FPL), in SNAP, TANF and MAP. We examined the Maryland state WIC program infant electronic database (N = 34,409) for the 12-month period ending September 2010. Our analysis focused on two-thirds of these infants (N = 23,065) who were at/below the 100 % FPL. Mothers' mean age was 26.8 ± 6 years; 20.6 % White; 52.7 % African American, and 23.4 % Hispanic. Approximately 10 % of infants weighed <2,500 g and 1.5 % weighed <1,500 g at birth. Average household income was $10,160; 55.7 % were at/below 50 % FPL. Two-thirds (68.4 %) participated in MAP, 31 % in SNAP and 9 % in TANF. Only 8 % were enrolled in all three programs whereas 28 % were not enrolled in any. There was a statistically significant difference in mean age and household income between multi-program beneficiaries and mothers who solely participated in WIC: 25.6 ± 5 years and $7,298 ± $4,496 compared with 27.2 ± 6 years and $12,216 ± $6,920, respectively ( p < 0.001). Among WIC families at or below 100 % FPL, only 8 % received multi-program benefits. Specific factors responsible for participation on an individual level are not available. To optimize enrollment, a coordinated effort is essential to identify and overcome barriers to concurrent participation among these families. [ABSTRACT FROM AUTHOR]

Proponents of life course comment that while the theory is persuasive, translating theory to practice is daunting. This paper speaks to the challenges and possibilities of intervention based on life course theory. It describes Healthy Start in Housing (HSiH), a partnership between the Boston Public Health Commission (BPHC) and the Boston Housing Authority (BHA) to reduce stress due to housing insecurity among low-income, pregnant women. HSiH seeks improved birth outcomes and long term health of mothers and infants. BHA goals are improved quality of life for participants, greater public housing stability and enhanced impact of housing on community well-being. HSiH is a 1 year pilot offering 75 housing units to pregnant women at risk of adverse birth outcomes and homelessness. BHA provides housing and expedites processing of HSiH applications; BPHC staff oversee enrollment, guide women through the application process, and provide enhanced, long-term case management. Of 130 women referred to HSiH to date, 53 were ineligible, 59 have submitted applications, 13 are preparing applications and 5 dropped out. Nineteen women have been housed. Among eligible women, 58 % had medical conditions, 56 % mental health conditions, and 14 % prior adverse outcomes; 30 % had multiple risks. Standardized assessments reflected high levels of depressive symptoms; 41 % had symptoms consistent with post-traumatic stress disorder. Life course theory provides both the framework and the rationale for HSiH. HSiH experience confirms the salience of daily social experience to women's health and the importance of addressing stressors and stress in women's lives. [ABSTRACT FROM AUTHOR]

With its independence secured on 9th July 2011, the Republic of South Sudan faces a daunting task to improve public health and primary care in one of the poorest countries in the world. Very high maternal and child mortality rates must be a major concern for the new national government and for the many international agencies working in the country. Poor maternal health outcomes are primarily due to poor prenatal, delivery and post natal care services in health facilities, coupled with low literacy, widespread poverty, and poor nutrition among the general population. Child mortality is the result of widespread malnutrition, pneumonia, malaria, vaccine preventable diseases and diarrheal diseases. National responses to HIV and AIDS with international assistance have been encouraging with relatively low rates of infection. This paper explores barriers and identifies opportunities available to work toward achieving the targets for Millennium Development Goals (MDGs) 5 and 4 to reduce maternal mortality from its current rate of 2,054 deaths per 100,000 live births, and child mortality (currently 135 deaths per 1,000 live births) respectively in the new nation. National and international organizations have a social responsibility to mobilize efforts to focus on maternal, child health and nutrition issues targeting the worst affected regions for improving access to primary care and obstetrical services. Initiatives are needed to build up community access to primary care with a well supervised community health workers program, as well as training mid level management capacity with higher levels of funding from national and international sources to promote public health than current in the new republic. [ABSTRACT FROM AUTHOR]

This paper examined the effect of Hurricane Katrina on children's access to personal healthcare providers and evaluated the use of propensity score methods to compare a nationally representative sample of children, as a proxy for an unexposed group, with a smaller exposed sample. 2007 data from the Gulf Coast Child and Family Health (G-CAFH) Study, a longitudinal cohort of households displaced or greatly impacted by Hurricane Katrina, were matched with 2007 National Survey of Children's Health (NSCH) data using propensity score techniques. Propensity scores were created using poverty level, household educational attainment, and race/ethnicity, with and without the addition of child age and gender. The outcome was defined as having a personal healthcare provider. Additional confounders (household structure, neighborhood safety, health and insurance status) were also examined. All covariates except gender differed significantly between the exposed (G-CAFH) and unexposed (NSCH) samples. Fewer G-CAFH children had a personal healthcare provider (65 %) compared to those from NSCH (90 %). Adjusting for all covariates, the propensity score analysis showed exposed children were 20 % less likely to have a personal healthcare provider compared to unexposed children in the US (OR = 0.80, 95 % CI 0.76, 0.84), whereas the logistic regression analysis estimated a stronger effect (OR = 0.28, 95 % CI 0.21, 0.39). Two years after Hurricane Katrina, children exposed to the storm had significantly lower odds of having a personal health care provider compared to unexposed children. Propensity score matching techniques may be useful for combining separate data samples when no clear unexposed group exists. [ABSTRACT FROM AUTHOR]

Surveys over 20 years have documented worsening in the dental health of preschoolers. Healthy People 2010 Midcourse Review reports the country moving away from oral health goals for young children; the slip is 57%. Exacerbating this is the inability of Medicaid to provide for those in need. Most children receive examinations only: few receive comprehensive care. We urge Head Start grantees to adopt a new approach to oral health goals and in this paper offer: (1) a review of the problem and premises preventing a solution; (2) a proposal that Head Start adopt a public health perspective; and (3) specific roles staff and dental personnel can take to mount aggressive strategies to arrest tooth decay at the grantee site. [ABSTRACT FROM AUTHOR]

Objectives: Diarrhoea is a leading cause of infant mortality with the main transmission pathways being unsafe water and contaminated food, surfaces and hands. The 'Safe Start' trial evaluated a food hygiene intervention implemented in a peri-urban settlement of Kisumu, Kenya, with the aim of reducing diarrhoeagenic enteric infections among infants. Four food hygiene behaviours were targeted: handwashing with soap before preparation and feeding, boiling infant food before feeding, storing infant food in sealed containers, and exclusive use of designated utensils during feeding. Methods: A process evaluation of the intervention was guided by a theory of change describing the hypothesised implementation and receipt of the intervention, mechanisms of change, and the context. These were assessed by qualitative and quantitative data that included debriefing sessions with the delivery teams and Community Health Volunteers (CHVs), and structured observations during food preparation. Results: The intervention achieved high coverage and fidelity with over 90% of 814 eligible caregivers participating in the intervention. Caregivers in the intervention arm demonstrated an understanding of the intervention messages, and had 1.38 (95% CI: 1.02–1.87) times the odds of washing hands before food preparation and 3.5 (95% CI: 1.91–6.56) times the odds of using a feeding utensil compared to caregivers in the control group. Contextual factors, especially the movement of caregivers within and outside the study area and time constraints faced by caregivers influenced uptake of some intervention behaviours. Conclusion: Future interventions should seek to explicitly target contextual factors such as secondary caregivers and promote food hygiene interventions as independent of each other. Significance: What is already known on this subject. Diarrhoea is known to be a significant cause of infant morbidity and mortality, mainly through unsafe water and food, and mainly from rural areas. What this study adds. This study describes the implementation of a novel food hygiene intervention to reduce diarrhoea causing enteric infections among children in low income peri urban settlements. The manuscript details the delivery of the intervention, describes the context, and explores associations influencing adoption of the intervention. Findings of the evaluation are meant to support the results of the trial. [ABSTRACT FROM AUTHOR]

Background: Low birthweight (LBW) as well as early childhood stunting are risk factors for increased childhood morbidity in low-and middle-income countries (LMIC). The Covid 19 pandemic has exacerbated food insecurity and unemployment globally, prompting concerns for maternal and child health. Objectives: We used data from the great recession of 2008 to examine the relationship between household food security and other risk factors with LBW and stunting using a longitudinal sample of South African women and their offspring. Methods: Food security indicators, alcohol use, blood pressure and other characteristics were examined in relation to LBW (≤ 2500 g), stunting (height for age ≤ 2SD) and severe stunting (height for age ≤ 3SD). Regression modelling with clustering at maternal ID level were employed to adjust for maternal characteristics and women who gave birth more than once during the reference period. Results: Birthweight data were available for 1173 children and height for age 1216 children. The prevalence of LBW was 14.7% while stunting and severe stunting was 17.8% and 14.5%. Child hunger in the household, maternal hypertension and alcohol use were associated with low birthweight. Food expenditure below the Stats SA poverty line and low dietary diversity was associated with stunting and severe stunting respectively. Maternal height and low birthweight were associated with both stunting and severe stunting. Conclusions for Practice: Interventions that can improve household food security and nutritional status during the periconceptional and antenatal period may reduce the prevalence of low birthweight and subsequent stunting in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

Objectives: Maternal postpartum depression (PPD) has been recognized as a serious and wide-spread mental health disorder that has long-term negative impacts on children's cognitive, social, and emotional development. This study extends prior research by examining the associations among predictors of PPD, including two different facets of father involvement and couple relationship quality, with a focus on testing these pathways across ethnic groups. Method: This study analyzed data from the Fragile Families and Child Wellbeing Study (FFCWS) including mothers' baseline interviews and one-year follow-up data sets (n = 2,794). Several models were tested using bootstrapping in structural equation modeling to explore the mediating paths and ethnic differences. Results: This study found that father involvement in sharing childcare responsibility had direct effects on reducing mothers' parenting stress and promoted maternal psychological adjustment, which was consistent across the three ethnic groups. The mediation pathways through couple relationship quality between father involvement (both father involvement in direct infant care and shared responsibilities) and PPD were detected significant for Black and white mothers. Conclusions for Practice: This study provided empirical evidence that father involvement in infant care is critical for mothers' perceived relationship quality. Maternal postpartum mental health may benefit from interventions and policies that encourage positive father engagement in infant care. [ABSTRACT FROM AUTHOR]

Introduction: While the city offers economic opportunities for women in many countries, their safety and security remain vulnerable to urban violence, especially in poor areas. In Haiti, poor urban women may be subjected to multiple forms of physical, sexual, and structural violence leading to adverse birth outcomes. We explored some of the complexities of how pregnancy is experienced under the reality and threat of urban violence in Haiti. Methods: We examined data from focus group discussions with fourteen women who lived in severely disenfranchised neighborhoods in Port au Prince and who were pregnant or had recently delivered at the time of the study. Results: We report on three recurring themes that emerged from the discussion: (a) ways in which the threat or experience of violence affected women's ability to access maternal healthcare, (b) ways in which women altered their behavior to accommodate everyday violence, and (c) the extent to which violence was embedded in women's consensual and non-consensual sexual encounters with perpetrators. We found that Haitian women considered violence, labeled ensekirite (insecurity), to be an everyday threat in their lives and that they strategized ways to access maternal health care and other services while navigating ensekirite. Discussion: Pregnancy adds another layer of vulnerability that may necessitate further negotiations with the threat and presence of violence. The pervasiveness and impact of urban violence in women's daily lives needs to be better evaluated in maternal and newborn health research and programs. [ABSTRACT FROM AUTHOR]

Objectives: We estimate the effect of the Affordable Care Act's (ACA) Medicaid expansions on Medicaid coverage of reproductive-aged women at varying childbearing stages. Methods: Using data from the American Community Survey (ACS) (n = 1,977,098) and a difference-in-differences approach, we compare Medicaid coverage among low-income adult women without children, postpartum mothers, and mothers of children older than one year in expansion states to non-expansion states, before and after the expansions. Results: The ACA's Medicaid expansion increased Medicaid coverage among adult women with incomes between 101 and 200% of the federal poverty line (FPL) without children by 10.7 percentage points (54 percent, p < 0.01). Coverage of mothers with children older than one year increased by 9.5 percentage points (34 percent, p < 0.01). Coverage of mothers with infants rose by 7.9 percentage points (21 percent, p < 0.01). Conclusions for Practice: Within the population of adult reproductive-aged women, we find a "fanning out" of effects from the ACA's Medicaid expansions. Childless women experience the largest gains in coverage while mothers of infants experience the smallest gains; mothers of children greater than one year old fall in the middle. These results are consistent with ACA gains being the smallest among the groups least targeted by the ACA, but also show substantial gains (one fifth) even among postpartum mothers. [ABSTRACT FROM AUTHOR]

Objective: To develop, implement, and assess implementation outcomes for a developmental monitoring and referral program for children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Methods: Based on Centers for Disease Control and Prevention's Learn the Signs. Act Early. campaign, the program was developed and replicated in two phases at 20 demographically diverse WIC clinics in eastern Missouri. Parents were asked to complete developmental milestone checklists for their children, ages 2 months to 4 years, during WIC eligibility recertification visits; WIC staff referred children with potential concerns to their healthcare providers for developmental screening. WIC staff surveys and focus groups were used to assess initial implementation outcomes. Results: In both phases, all surveyed staff (n = 46) agreed the program was easy to use. Most (≥ 80%) agreed that checklists fit easily into clinic workflow and required ≤ 5 min to complete. Staff (≥ 55%) indicated using checklists with ≥ 75% of their clients. 92% or more reported referring one or more children with potential developmental concerns. According to 80% of staff, parents indicated checklists helped them learn about development and planned to share them with healthcare providers. During the second phase, 18 of 20 staff surveyed indicated the program helped them learn when to refer children and how to support parents, and 19 felt the program promoted healthy development. Focus groups supported survey findings, and all clinics planned to sustain the program. Conclusions: Initial implementation outcomes supported this approach to developmental monitoring and referral in WIC. The program has potential to help low-income parents identify possible concerns and access support. [ABSTRACT FROM AUTHOR]

To systematically review the literature on the relationship between early childhood low income/socioeconomic status (SES) and physical health in later childhood/adolescence, to identify gaps in the literature and to suggest new avenues for research. A systematic search of electronic databases from their start date to November 2011 was conducted to identify prospective longitudinal studies in industrialized countries with a measure of low income/SES in the first 5 years of life and physical health outcomes in later childhood or adolescence. STROBE criteria were used to assess study quality. Risk estimates were expressed as odds ratios with 95 % confidence intervals where possible. Heterogeneity of studies precluded meta-analysis. Nine studies fulfilled the inclusion criteria. Significant associations of early childhood low income/SES with activity-limiting illness, parent-reported poor health status, acute and recurrent infections, increasing BMI percentile and hospitalization were reported. Results for parent-reported asthma were less consistent: there was a significant association with low income/SES in early childhood in 2 studies but null findings in 3 others. This systematic review of the association of early childhood low income/SES with physical health status in later childhood and adolescence shows that, in contrast to the extensive literature on the impact of poor childhood social circumstances on adult health, the evidence base is limited. The literature points to some associations of early low income/SES with later poor health status, but many key research questions remain unanswered. Implications for further research are considered. [ABSTRACT FROM AUTHOR]

Background and Objective: Folate and vitamin B12 deficiencies can impair proper growth and brain development in children. Data on the folate and vitamin B12 status of children aged 6–59 months in Guatemala are scarce. Identification of factors associated with higher prevalence of these micronutrient deficiencies within the population is needed for national and regional policymakers. Objective: To describe national and regional post-fortification folate and vitamin B12 status of children aged 6–59 months in Guatemala. Methods: A multistage, cluster probability study was carried out with national and regional representation of children aged 6–59 months. Demographic and health information was collected for 1246 preschool children, but blood samples for red blood cell (RBC) folate and vitamin B12 were collected and analyzed for 1,245 and 1143 preschool children, respectively. We used the following deficiency criteria as cutoff points for the analyses: < 305 nmol/L for RBC folate, < 148 pmol/L for vitamin B12 deficiency, and 148–221 pmol/L for marginal vitamin B12 deficiency. Prevalence of RBC folate deficiency and vitamin B12 deficiency and marginal deficiency were estimated. Prevalence risk ratios of RBC folate and vitamin B12 deficiency were estimated comparing subpopulations of interest. Results: The national prevalence estimates of RBC folate deficiency among children was 33.5% [95% CI 29.1, 38.3]. The prevalence of RBC folate deficiency showed wide variation by age (20.3–46.6%) and was significantly higher among children 6–11 months and 12–23 months (46.6 and 37.0%, respectively), compared to older children aged 48–59 months (20.3%). RBC folate deficiency also varied widely by household wealth index (22.6–42.0%) and geographic region (27.2–46.7%) though the differences were not statistically significant. The national geometric mean for RBC folate concentrations was 354.2 nmol/L. The national prevalences of vitamin B12 deficiency and marginal deficiency among children were 22.5% [95% CI 18.2, 27.5] and 27.5% [95% CI 23.7, 31.7], respectively. The prevalence of vitamin B12 deficiency was significantly higher among indigenous children than among non-indigenous children (34.5% vs. 13.1%, aPRR 2.1 95% CI 1.4, 3.0). The prevalence of vitamin B12 deficiency also significantly varied between the highest and lowest household wealth index (34.3 and 6.0%, respectively). The national geometric mean for vitamin B12 concentrations was 235.1 pmol/L. The geometric means of folate and B12 concentrations were significantly lower among children who were younger, had a lower household wealth index, and were indigenous (for vitamin B12 only). Folate and vitamin B12 concentrations showed wide variation by region (not statistically significant), and the Petén and Norte regions showed the lowest RBC folate and vitamin B12 concentrations, respectively. Conclusions: In this study, a third of all children had RBC folate deficiency and half were vitamin B12 deficient. Folate deficiency was more common in younger children and vitamin B12 deficiency was more common in indigenous children and those from the poorest families. These findings suggest gaps in the coverage of fortification and the need for additional implementation strategies to address these gaps in coverage to help safeguard the health of Guatemalan children. [ABSTRACT FROM AUTHOR]

Background: Social history (SH) makes it possible to learn the social environment of children in pediatric practice and enables interventions into social risks such as poverty. While SH has been evolving in use as an advocacy practice in high-income countries, that seems not to be the case in low- and middle-income countries. We explored pediatricians' and pediatric residents' opinions and experiences of SH with an aim to promote advocacy-based SH practices in Turkey. Methods: A qualitative study conducted involving interviews with pediatrics residents, pediatricians and educators, and a focus group with residents. Interviews and the focus group were transcribed and reviewed for themes using qualitative content analysis. Results: The principal objective of SH was found to be diagnosis rather than advocacy. Although all participants expressed opinions about socioeconomic conditions' vital influence on child health, most reported limited use of SH. When asked about social needs screening with SH, most participants opposed with various reasons, primarily time concerns and doubts about the necessity for each child. Lack of time was reported as the leading barrier to SH by participants. Other barriers were identified as lack of structured SH education, problems regarding referrals and interdisciplinary work, and the biomedical health approach which defines the physician's role within the physical health domain. Conclusions for Practice: To achieve an advocacy-based SH practice, the biomedical health approach should be questioned. Action is needed to implement a social determinants of health approach and equity focus to health policies and to medical and residency education. [ABSTRACT FROM AUTHOR]

Objectives: The aim of our study is to explore the relationships between neighborhood context, perceived social support, and parenting for low-income mothers with young infants. Methods: Data were collected during the first three time points from the Kids in Columbus Study, a 5-year longitudinal study on low-income families. Mother–child dyads (n = 228) were recruited from five Women, Infants, and Children Centers located in a Midwestern Metropolitan area. Data for the present study represents mother–child dyads that had completed time point 1 (infant age birth to 3-months), time point 2 (infant age 4 to 7 months), and 3 (infant age 9- to 12-months old). Results: Social support and neighborhood quality were associated with both maternal perceptions and observed parenting outcomes. Social support positively predicted maternal perceptions of self-efficacy whereas neighborhood quality was positively related to parent involvement. Discussion: Overall, social support and neighborhood quality were related to aspects of parenting in the first year of children's lives. There was no evidence that the association between social support and parenting varied as a function of neighborhood quality. This finding suggests the neighborhood qualities captured in our study do not influence mothers' ability to access social support during infancy. [ABSTRACT FROM AUTHOR]

Objectives mHealth interventions for MNCH have been shown to improve uptake of antenatal and neonatal services in low- and middle-income countries (LMICs). However, little systematic analysis is available about their impact on infant health outcomes, such as reducing low birth weight or malnutrition among children under the age of five. The objective of this study is to determine if an age- and stage-based mobile phone voice messaging initiative for women, during pregnancy and up to 1 year after delivery, can reduce low birth weight and child malnutrition and improve women's infant care knowledge and practices. Methods We conducted a pseudo-randomized controlled trial among pregnant women from urban slums and low-income areas in Mumbai, India. Pregnant women, 18 years and older, speaking Hindi or Marathi were enrolled and assigned to receive mMitra messages (intervention group N = 1516) or not (Control group N = 500). Women in the intervention group received mMitra voice messages two times per week throughout their pregnancy and until their infant turned 1 year of age. Infant's birth weight, anthropometric data at 1 year of age, and status of immunization were obtained from Maternal Child Health (MCH) cards to assess impact on primary infant health outcomes. Women's infant health care practices and knowledge were assessed through interviews administered immediately after women enrolled in the study (Time 1), after they delivered their babies (Time 2), and after their babies turned 1 year old (Time 3). 15 infant care practices self-reported by women (Time 3) and knowledge on ten infant care topics (Time 2) were also compared between intervention and control arms. Results We observed a trend for increased odds of a baby being born at or above the ideal birth weight of 2.5 kg in the intervention group compared to controls (odds ratio (OR) 1.334, 95% confidence interval (CI) 0.983–1.839, p = 0.064). The intervention group performed significantly better on two infant care practice indicators: giving the infant supplementary feeding at 6 months of age (OR 1.4, 95% CI 1.08–1.82, p = 0.009) and fully immunizing the infant as prescribed under the Government of India's child immunization program (OR 1.531, 95% CI 1.141–2.055, p = 0.005). Women in the intervention group had increased odds of knowing that the baby should be given solid food by 6 months (OR 1.89, 95% CI 1.371–2.605, p < 0.01), that the baby needs to be given vaccines (OR 1.567, 95% CI 1.047–2.345, p = 0.028), and that the ideal birth weight is > 2.5 kg (OR 2.279, 95% CI 1.617–3.213, p < 0.01). Conclusions for Practice This study provides robust evidence that tailored mobile voice messages can significantly improve infant care practices and maternal knowledge that can positively impact infant child health. Furthermore, this is the first prospective study of a voice-based mHealth intervention to demonstrate a positive impact on infant birth weight, a health outcome of public health importance in many LMICs. [ABSTRACT FROM AUTHOR]

Objectives: To examine the association between changes in contextual economic factors on childhood obesity in the US. Methods: We combined data from 2003, 2007, and 2011/2012 National Surveys of Children's Health for 129,781 children aged 10–17 with 27 state-level variables capturing general economic conditions, labor supply, and the monetary or time costs of calorie intake, physical activity, and cigarette smoking. We employed regression models controlling for demographic factors and state and year fixed effects. We also examined heterogeneity in economic effects by household income. Results: Obesity risk increased with workforce proportion in blue-collar occupations, urban sprawl, female labor force participation, and number of convenience stores but declined with median household income, smoking ban in restaurants, and full service restaurants per capita. Most effects were specific to low income households, except for density of supercenters/warehouse clubs which was significantly associated with higher overweight/obesity risk only in higher income households. Conclusions for Practice: Changes in state-level economic factors related to labor supply and monetary or time cost of calorie intake may affect childhood obesity especially for children in low-income households. Policymakers should consider these effects when designing programs aimed at reducing childhood obesity. [ABSTRACT FROM AUTHOR]

Objectives To investigate the association of residential mobility with flourishing among school-age children. Methods Data from the 2011/2012 National Survey of Children's Health were used to examine parent/caregiver-reported information on flourishing and residential mobility for children age 6–17 (N = 63,333). Residential mobility was the number of times the child moved categorized as: none, 1–2, and 3+. Children who were reported to show interest/curiosity, finish tasks, stay calm/in control, care about doing well in school, and do all homework were coded as flourishing. Sex-specific multivariable models were used to model the relative risk of mobility on flourishing. Interactions of mobility with age and poverty were tested. Results Among US school-age children, 22% had no moves, 39% had 1–2 moves and 39% had 3+ moves in their lifetime. Nearly half (45%) were flourishing. Both boys and girls who moved 3+ times were less likely to flourish compared to children with no moves. Among poor boys moving 3+ times was associated with less flourishing (aRR 0.83, 95% CI 0.71, 0.98) with no association for non-poor boy. Among girls the pattern was reversed (aRR 0.88, 95% CI 0.81, 0.95 for non-poor girls and no association for poor girls). Conclusions for Practice Residential mobility may lead to lower rates of flourishing. The patterns, when stratified by age or poverty, are different for boys and girls. [ABSTRACT FROM AUTHOR]

Objectives Household stressors, such as food insecurity, contribute to the home emotional environment and negatively affect child development. Little research on this topic has been conducted among very young children. This study aimed to examine the relationship between food insecurity and the home emotional environment, as well the extent to which the relationship may be mediated by maternal symptoms of depression. Frequency of praise, affection, and discipline of young children by mothers were examined as markers of the home emotional environment. Methods Data were collected in a cross-sectional study of mothers of children under the age of five (N = 4231). Logistic regression was used to assess the relationship between level of food security and frequency of praise and discipline of children. Mediation analysis using the KHB method was conducted to test whether maternal mental health mediated the relationship between food insecurity and each outcome. Results Low and very low food security were significantly associated with higher odds of disciplining children with high frequency. Controlling for all covariates, frequency of praise was not significantly associated with level of household food insecurity. Differences in praise and discipline frequency were found by language of interview, maternal education, and employment. Conclusions for Practice Parent-child interactions, specifically related to discipline, are related to food insecurity. Further research should consider cultural patterns and mechanisms behind the relationship between food insecurity and the home environment. Household stressors begin affecting children at young ages, and early intervention is essential to prevent further negative sequelae as children grow older. [ABSTRACT FROM AUTHOR]

Objectives Pakistan is one of five nations contributing to half of the world's child mortality and holds under-five mortality rates which are nearly double global targets. Reasons for this shortfall include civil conflicts, political uncertainty, low education, poverty, rural-urban disparities, and limited health care access. The aim of this study was to explore associations between individual characteristics, community factors, and child mortality in Pakistan. Methods Data were derived from the 2012 to 2013 Pakistan Demographic and Health Survey, and included 7399 live births and 380 child deaths. Multivariate, multilevel logistic regression was used to model risk of neonatal, infant and under-five child deaths. Results Seventy-one percent of child deaths occurred during the neonatal period. Significant factors ( p < 0.05) associated with lower odds of child mortality included adhering to recommended minimum of 24 months interpregnancy interval and higher household wealth. These were significant for neonatal (OR 0.448; 0.871), infancy (OR 0.465; 0.881), and under-five deaths (OR 0.465; 0.879). Employed mothers had higher odds of neonatal (OR 1.479), infant (OR 1.506), and child mortality (OR 1.459). Likewise, women living in consanguineous marriages had higher odds of infant (OR 1.454) and under-five deaths (OR 1.381). Children in Balochistan, Punjab, and Sindh, regions disproportionately poor, rural with low levels of education, were at highest risk of dying. Conclusions for Practice Findings may assist in designing targeted interventions, developing appropriate public health messaging, and implementing policies designed to lower child mortality. Focusing on lowering rates of maternal poverty, increasing opportunities for education, and improving access to health care could assist in reducing child mortality in Pakistan. [ABSTRACT FROM AUTHOR]

Objectives This systematic review identifies and reviews both peer-reviewed and 'grey' literature, across a range of disciplines and from diverse sources, relating to the condition of children living in mountain communities in low- and middle-income countries. Findings The literature on poverty in these communities does not generally focus on the particular vulnerabilities of children or the impact of intersecting vulnerabilities on the most marginalised members of communities. However, this literature does contribute analyses of the broader context and variety of factors impacting on human development in mountainous areas. The literature on other areas of children's lives-health, nutrition, child mortality, education, and child labour-focuses more specifically on children's particular vulnerabilities or experiences. However, it sometimes lacks the broader analysis of the many interrelated characteristics of a mountainous environment which impact on children's situations. Themes Nevertheless, certain themes recur across many disciplines and types of literature, and point to some general conclusions: mountain poverty is influenced by the very local specificities of the physical environment; mountain communities are often politically and economically marginalised, particularly for the most vulnerable within these communities, including children; and mountain communities themselves are an important locus for challenging and interrupting cycles of increasing inequality and disadvantage. While this broad-scale review represents a modest first step, its findings provide the basis for further investigation. [ABSTRACT FROM AUTHOR]

Objective: Analyze the association between household food security status and diet quality during pregnancy. Methods: Cross-sectional analysis of pregnant women from the National Health and Nutrition Examination Survey from 1999 to 2008. Of the 1158 pregnant women with complete household food security information, we analyzed 688 women who had complete dietary information and household incomes ≤300 % of the Federal Poverty Level (FPL). Diet quality was measured by the Alternate Healthy Eating Index modified for Pregnancy (AHEI-P) from 1 to 2 24 h dietary recalls. Multivariate linear and logistic regression models were implemented to assess the association between household food security status and AHEI-P, adjusting for age, nativity, marital status, race/ethnicity, education, and household income. Results: Among women with household incomes ≤300 % of the FPL, 19 % were food insecure and 4 % were marginally food secure. The mean AHEI-P score was 41.9 (95 % CI 40.4, 43.3). Household food insecurity was not associated with overall diet quality. However, living in a food insecure household compared to a food secure household was associated with a 2.3 (1.3, 4.1) greater odds of having a calcium component score greater than the median intake of calcium scores among food secure women in the sample. Conclusions for Practice: In a nationally representative sample of pregnant women, 80 % lived in a fully food secure household. Improving household food security during pregnancy is a public health opportunity to improve health outcomes; however household food security status may not be associated with overall diet quality. [ABSTRACT FROM AUTHOR]

Objective Evaluate variation in fruit and vegetable intake by Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation and poverty status among pregnant, and postpartum women participating in the Infant Feeding Practice Study II (IFPSII). Methods IFPSII (2005-2007) followed US women from third trimester through 1 year postpartum through mailed questionnaires measuring income, WIC participation, breastfeeding; and dietary history questionnaires (DHQ) assessing prenatal/postnatal fruit and vegetable consumption. Poverty measurements used U.S. Census Bureau Federal Poverty thresholds to calculate percent of poverty index ratio (PIR) corresponding to WIC's financial eligibility (≤185 % PIR). Comparison groups: WIC recipients; WIC eligible (≤185 % PIR), but non-recipients; and women not financially WIC eligible (>185 % PIR). IFPSII participants who completed at least one DHQ were included. Intake variation among WIC/poverty groups was assessed by Kruskal-Wallis tests and between groups by Mann-Whitney Wilcoxon tests and logistic regression. Mann-Whitney Wilcoxon tests examined postnatal intake by breastfeeding. Results Prenatal vegetable intake significantly varied by WIC/poverty groups ( p = 0.04) with WIC recipients reporting significantly higher intake than women not financially WIC eligible ( p = 0.02); association remained significant adjusting for confounders [odds ratio 0.66 (95 % confidence interval: 0.49-0.90)]. Prenatal fruit and postnatal consumption did not significantly differ by WIC/poverty groups. Postnatal intake was significantly higher among breastfeeding than non-breastfeeding women (fruit: p < 0.0001; vegetable: p = 0.006). Conclusions for Practice Most intakes did not significantly differ by WIC/poverty groups and thus prompts research on WIC recipient's dietary behaviors, reasons for non-participation in WIC, and the influence of the recent changes to the WIC food package. [ABSTRACT FROM AUTHOR]

Objective Adverse childhood experiences (ACEs) are associated with myriad health conditions and risk behaviors in both adolescents and adults. In this study we examine the association between ACEs and specific physical, mental, and developmental conditions, as well as their comorbidity, in a nationally representative sample of children 0-17 years. Methods Data from the 2011-2012 National Survey for Child Health (NSCH) were used. A total of 95,677 random-digit-dial interviews with parents of children 0-17 years were conducted across all 50 states and the District of Columbia. Outcomes included singular condition domains (physical, mental, and developmental) as well as combinations of condition domains (e.g., physical plus mental, mental plus developmental, etc.). Results Twenty-three percent of parents reported that their child experienced 1 ACE; 9.2 % experienced 2 ACEs, and 10.3 % experienced three or more. Across all three condition domains and combinations of domains, children who experienced at least one ACE were more likely than children who experienced 0 ACEs to have at least one condition. Additionally, greater ACEs was associated with increased likelihood of at least one condition in each domain and in multiple domains. Conclusions for practice These findings support the extension of existing family environment screening tools in pediatric practices as well as the establishment of a system for monitoring ACEs in families with multiple or complex conditions. [ABSTRACT FROM AUTHOR]

Objectives The patient centered medical home is now widely supported as a strategy for delivering high quality primary care. The objective of this study was to examine whether children's primary care experiences nationally have become more aligned with the medical home model over time, and how this may have varied for vulnerable children. Methods This study analyzed data on 289,672 children, aged 0-17 years, of families responding to one of three iterations of National Survey of Children's Health from 2003, 2007 and 2011-2012. Each year, we assessed indicators of four medical home features (access, continuity, comprehensiveness, and family-centeredness) and a total medical home score for children nationally and for those with a set of social and demographic risk factors. Results Indicators of access and continuity, and total medical home scores fluctuated but improved overall from 2003 to 2012 (7.1, 6.7 and 1.4 % point increases, respectively), while indicators of comprehensiveness and family-centered care measures declined (2.4 and 1.8 % point decreases, respectively). Children with the highest levels of social and demographic risk experienced larger fluctuations in these measures over time. Conclusions for Practice There were improvements in the extent to which children's primary care experiences aligned with a medical home model, though not linearly or for all component features. Children with more risk factors experienced more volatile changes, suggesting a particular need to attend to the primary care experiences of the most vulnerable children. [ABSTRACT FROM AUTHOR]

Introduction: Exclusive breastfeeding (EBF) benefits the life course health development of infants, families, and society. Professional health associations recommend EBF for 4 months, and many now recommend EBF for 6 months. Yet only 18.8 % of US infants born in 2011 were exclusively breastfed. Numerous studies on breastfeeding are published, but few describe EBF. This study describes characteristics of women who initiated EBF and examines the associations of those factors with EBF lasting ≥4 months. The Life Course Health Development (LCHD) framework was used to structure the analysis and interpret results. Methods: Data collected through the Infant Feeding Practices Study II survey (2005-2007) were used to identify a cohort of women ( n = 1226) practicing EBF at the time of hospital discharge and their sociodemographic, health, work, and childcare characteristics. Associations of these characteristics with EBF lasting ≥4 months were studied by bivariate and logistic regression analyses. Results: College education [odds ratio (OR) 2.14, 95 % confidence interval (CI) 1.58-2.89] and marriage (OR 2.19, 95 % CI 1.43-3.37) were associated with greater odds of EBF lasting ≥4 months, whereas the plan to return to work after birth (OR 0.57, 95 % CI 0.43-0.74), living in the south (OR 0.67, 95 % CI 0.47-0.95), and postpartum depression risk (OR 0.43, 95 % CI 0.28-0.66) were associated with lower odds of EBF lasting ≥4 months. Discussion: Several factors associated with disparities in continued EBF were identified. The application of the LCHD framework furthers understanding of the multiple and interacting risks associated with early discontinuation of EBF. [ABSTRACT FROM AUTHOR]

Objectives: Researchers often examine neighborhood socioeconomic environment and health during the perinatal period using geocoded addresses recorded on birth certificates at the time of delivery. Our objective was to assess the potential for post-partum neighborhood misclassification by examining whether women move neighborhoods during the immediate post-partum period, whether they move to neighborhoods of different socioeconomic status (SES), and whether mobility differs by maternal characteristics. Methods: We used data from the 2003-2007 California Maternal and Infant Health Assessment (MIHA), an annual, statewide-representative survey of post-partum women, to examine women's neighborhood mobility patterns between giving birth and completing a survey 2-7 months post-partum. We examined whether women changed neighborhoods, whether moves were to neighborhoods of higher, lower, or similar socioeconomic status (SES), and whether these patterns differed by maternal race/ethnicity, maternal SES, or other demographic characteristics. Results: Overall, 93 % of women either did not move neighborhoods or moved to a neighborhood of similar SES post-partum. Only 4 % of women moved to a neighborhood of lower SES and 3 % to an area of higher SES. Mothers who were non-Hispanic black or US-born Hispanic, young, unmarried, primiparous, or lower SES were slightly more likely to move overall and more likely to move to neighborhoods with different SES, compared to other women. Conclusions: These findings suggest that geocoded addresses from birth certificates can be used to estimate women's neighborhood SES during the early post-partum period with little misclassification, an especially relevant finding for researchers using post-partum surveys. [ABSTRACT FROM AUTHOR]

Early childhood home visiting (HV) services are expanding broadly across the United States. Supported by federal policy, HV is now an integral part of maternal and child health services. However, no nationally representative estimate of HV use is available and no research has compared HV use across states. The 2011/12 National Survey on Children's Health was used to estimate the national and state prevalence of HV use for children 0-3 years. Generalized linear mixed modeling was used to predict HV use. An estimated 2,137,044 US children and families received HV during pregnancy and up to child age of 3 years. State HV prevalence range was 3.7-30.6 %. Nationally, 19.1 % of children below the federal poverty line received HV services. Although family poverty increased the odds of receiving HV services, higher rates of child poverty at the state level predicted less use of HV services. Important predictors of HV use include infant/child need factors (health risk, adverse experiences), predisposing factors (family size), and enabling factors (insurance type). This study provides the first estimates of national and state HV service use. Although findings indicate HV services are targeted to children at elevated risk for poor physical or developmental outcomes, our estimates show the vast majority of at-risk children did not receive HV services, including more than 80 % of low-income children, 76 % of preterm infants, and 57 % of very low birth weight infants. Increasing HV service availability could decrease negative health outcomes for young children. [ABSTRACT FROM AUTHOR]

Objectives: Racial and ethnic groups in the US exhibit major differences in low birthweight (LBW) rates. While previous studies have shown that community level social indicators associated with LBW vary by race and ethnicity, it is not known whether these differences exist among racial or ethnic groups who live in the same neighborhood or community. To address this question, we examined the association of community level features with LBW among African American, White and Hispanic women who live in similar geographic areas. Methods: The analysis is based on geocoded birth certificates for all singleton live births in the year 2000 to women residing in 805 California ZIP codes. Community level social and demographic data were obtained from U.S. Census data files for the year 2000 and surrogate indices of population level alcohol and drug abuse and dependence were derived from hospital discharge data (HDD). Tobit and bootstrap analyses were used to test associations with birth outcomes, maternal characteristics, and community level social and demographic features within and across the three groups of women living in similar geographic areas. Results: The results demonstrate major racial and ethnic differences in community level correlates of LBW. Rates of LBW among African Americans were lower if they lived in areas that were more densely populated, had greater income disparities, were more racially segregated, and had low rates of alcohol abuse or dependence. These associations were different or absent for Hispanic and White women. Conclusions for Practice: The results suggest that despite living in the same areas, major differences in neighborhood features and social processes are linked to birth outcomes of African American women compared to Hispanic and White women. Further research, especially using multilevel approaches, is needed to precisely identify these differences to help reduce racial and ethnic disparities in LBW. [ABSTRACT FROM AUTHOR]

This study examines whether orphan and vulnerable children (OVC) primary caregivers are facing absolute household wealth (AWI) disparities, the association between AWI and women's overweight status, and the modifying role of OVC primary caregiving status on this relationship. Demographic Health Surveys data (2006-2007) from 20 to 49 year old women in Namibia (n = 6,305), Swaziland (n = 2,786), and Zambia (n = 4,389) were analyzed using weighted marginal means and logistic regressions. OVC primary caregivers in Namibia and Swaziland had a lower mean AWI than other women in the same country. In Zambia, OVC primary caregivers had a lower mean AWI score than non-primary caregivers living with an OVC but a higher mean AWI score than non-OVC primary caregivers. In Swaziland and Zambia, even small increases in household wealth were associated with higher odds for being overweight regardless of women's caregiving status. Only in Namibia, OVC primary caregiving modified the effect of the previous association. Among Namibian OVC primary caregivers, women who had at least medium household wealth (4 or more AWI items) were more likely to be overweight than their poorest counterparts (0 or 1 AWI items). OVC primary caregivers are facing household wealth disparities as compared to other women from their communities. Future studies/interventions should consider using population-based approaches to reach women from every household wealth level to curb overweight in Swaziland and Zambia and to focus on specific household wealth characteristics that are associated with OVC primary caregivers' overweight status in Namibia. [ABSTRACT FROM AUTHOR]

This research determined the levels and odds ratios for low birth weight (LBW) infants delivered under the National Health Insurance Scheme (NHIS) compared to LBW infants delivered under the previous 'Cash and Carry' system in Northern Ghana. Birth records of infants delivered before and after implementation of the NHIS in Northern Ghana were examined. Records of each day's births during the identified periods were abstracted. Days with fewer or no births were accommodated by oversampling from days before or after. Chi squared tests of independence were used to examine the bivariate association between categorical independent variables and LBW. Multiple logistic regression models were used to examine the relationships among selected variables for mothers and infants and the odds ratios for LBW. Infants delivered under NHIS had lower rates of LBW (16.8 %) compared to infants born under Cash and Carry (23.3 %). Mothers who delivered under NHIS were significantly less likely to have infants at LBW (unadjusted OR 0.65; 95 % CI 0.49, 0.86). The rate of LBW among infants delivered under NHIS is significantly lower than among infants delivered under Cash and Carry. The rate of LBW under Cash and Carry in 2000 fell by 27 % in relation to the NHIS in 2010. These findings confirm that the NHIS, which gives pregnant women in Northern Ghana four antenatal visits and access to skilled health professionals for delivery at no cost to the mother, significantly improved birth weight outcomes. [ABSTRACT FROM AUTHOR]

Educational achievement and attainment are associated with health outcomes across the entire life span. The objective of this study was to determine whether racial/ethnic disparities in academic achievement and educational aspirations have changed over time. The study used data from the Minnesota Student Survey (MSS) from 1998, 2001, 2004, 2007, and 2010. The MSS is administered to adolescents in public secondary schools, charter schools, and tribal schools. Measures of academic achievement and educational aspirations were examined by race/ethnicity, poverty status, and family structure. Chi square tests evaluated differences in the above proportions. The analytic sample included 351,510 adolescents (1998, N = 67,239; 2001, N = 69,177; 2004, N = 71,084; 2007, N = 72,312; and 2010, N = 71,698). Study participants ranged in age from 13 to 19 years (mean = 15.9, SD = 1.6). Most were white (81.7 %), followed by 5.4 % Asian American/Pacific Islander, 4.3 % Black/African American, 2.7 % Hispanic/Latino, 1 % American Indian, and 4.9 % mixed race. Results showed that academic achievement fluctuated amongst all the racial/ethnic groups, but there were significant race/ethnic disparities at every time point. Overall, academic aspirations increased over time among the adolescents. Poverty was associated with poorer academic indicators for white youth, but not consistently for other racial/ethnic groups of youth. Family structure, however, was significantly associated with the educational indicators across all racial and ethnic groups. Despite many efforts to improve educational outcomes, there remain significant disparities in educational achievement and aspirations related to race-ethnicity and social status. Findings have implications for efforts to improve adolescent health at both individual and community levels. [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]

Estimates suggest that over 90 % of population increase in the least developed countries over the next four decades will occur in urban areas. These increases will be driven both by natural population growth and rural-urban migration. Moreover, despite its status as the world's least urbanized region, the urban population in the sub-Saharan Africa region is projected to increase from under 40 % currently to over 60 % by 2050. Currently, approximately 70 % of all urban residents in the region live in slums or slum-like conditions. Sexual and reproductive health (SRH) risks for the urban poor are severe and include high rates of unwanted pregnancies, sexually transmitted infections, and poor maternal and child health outcomes. However, the links between poverty, urbanization, and reproductive health priorities are still not a major focus in the broader development agenda. Building on theoretical and empirical data, we show that SRH in urban contexts is critical to the development of healthy productive urban populations and, ultimately, the improvement of quality of life. We posit that a strategic focus on the sexual and reproductive health of urban residents will enable developing country governments achieve international goals and national targets by reducing health risks among a large and rapidly growing segment of the population. To that end, we identify key research, policy and program recommendations and strategies required for bringing sexual and reproductive health in urban contexts to the forefront of the development agenda. [ABSTRACT FROM AUTHOR]

Few studies examined breastfeeding initiation and duration among mothers who were eligible for the Women Infants Children (WIC) program and did not participate. This study is sought to understand the role of WIC participation and poverty level in breastfeeding initiation and duration in South Carolina. The data came from the 2009-2010 South Carolina Pregnancy Risk Assessment Monitoring System (unweighted N = 1,796). All participants were classified as WIC participants, income-eligible non-WIC participants, and income-ineligible non-WIC participants. Logistic regression models were used to analyze the association between breastfeeding initiation and WIC participation. The Kaplan-Meier method and Cox proportional hazards models were used to determine whether the continuation of breastfeeding and hazards of discontinuing breastfeeding differed by WIC participation groups. In South Carolina, two out of three women (67.2 %) initiated breastfeeding. The breastfeeding initiation rate was higher among income-ineligible (84.0 %) and income-eligible (78.9 %) non-WIC participants than among WIC participants (55.5 %). Compared to WIC participants, both income-ineligible [odds ratio (OR) = 2.1, 95 % confidence interval (CI) 1.2-4.0] and income-eligible (OR = 2.6, 95 % CI 1.1-4.3) non-WIC participants were more likely to initiate breastfeeding. Among mothers who already initiated breastfeeding, after adjusting covariates, the hazard ratios for weaning within 34 weeks postpartum were not significantly different by WIC participation groups. This study confirmed WIC participants were less likely to initiate breastfeeding. Once initiated, WIC participation did not significantly impact breastfeeding duration in the early postpartum period. Poverty status may not play an important role in explaining disparities in breastfeeding initiation between WIC and non-WIC participants. [ABSTRACT FROM AUTHOR]

The objectives of this study were to evaluate the association between caregiver burden and preventive dental care use for children with special health care needs (CSHCN) and assess if caregiver burden explains the relationship between child- and family-level characteristics and preventive dental care use. Samples of US CSHCN ages 3-17 years with a functional limitation (n = 7,559) and those without (n = 26,345) were derived from the 2005-2006 National Survey of CSHCN. We generated structural equation models, stratified by functional limitation, to describe the relationships between caregiver burden and preventive dental utilization. We measured caregiver burden using six items on whether the child's health condition impacted work, time spent on health management, and finances. About 80.9 % of CSHCN used preventive dental care. Higher levels of caregiver burden were associated with significantly lower odds of preventive dental care use for CHSCN with a functional limitation (β = −0.06; P < 0.001) and those without (β = −0.07; P < 0.001). For CSHCN with a functional limitation, family poverty and being uninsured were significantly associated with greater caregiver burden and less preventive dental use. Findings were similar for CSHCN without a functional limitation, except that lower caregiver education was also associated with greater caregiver burden and less preventive dental care use. Caregiver burden is potential barrier to preventive dental care use for CSHCN and explains the relationship between child- and family-level characteristics and preventive dental care use. Interventions to improve the oral health of CSHCN should include strategies to reduce caregiver burden, especially within socioeconomically vulnerable families. [ABSTRACT FROM AUTHOR]

In recent years, maternal and child health professionals have been seeking approaches to integrating the Life Course Perspective and social determinants of health into their work. In this article, we describe how community input, staff feedback, and evidence from the field that the connection between wealth and health should be addressed compelled the Contra Costa Family, Maternal and Child Health (FMCH) Programs Life Course Initiative to launch Building Economic Security Today (BEST). BEST utilizes innovative strategies to reduce inequities in health outcomes for low-income Contra Costa families by improving their financial security and stability. FMCH Programs' Women, Infants, and Children Program (WIC) conducted BEST financial education classes, and its Medically Vulnerable Infant Program (MVIP) instituted BEST financial assessments during public health nurse home visits. Educational and referral resources were also developed and distributed to all clients. The classes at WIC increased clients' awareness of financial issues and confidence that they could improve their financial situations. WIC clients and staff also gained knowledge about financial resources in the community. MVIP's financial assessments offered clients a new and needed perspective on their financial situations, as well as support around the financial and psychological stresses of caring for a child with special health care needs. BEST offered FMCH Programs staff opportunities to engage in non-traditional, cross-sector partnerships, and gain new knowledge and skills to address a pressing social determinant of health. We learned the value of flexible timelines, maintaining a long view for creating change, and challenging the traditional paradigm of maternal and child health. [ABSTRACT FROM AUTHOR]

A life course conceptual framework for MCH research demands new tools for understanding population health and measuring exposures. We propose a method for measuring population-based socio-environmental trajectories for women of reproductive age. We merged maternal longitudinally-linked births to Georgia-resident women from 1994 to 2007 with census economic and social measures using residential geocodes to create woman-centered socio-environmental trajectories. We calculated a woman's neighborhood deprivation index (NDI) at the time of each of her births and, from these, we calculated a cumulative NDI. We fit Loess curves to describe average life course NDI trajectories and binomial regression models to test specific life course theory hypotheses relating cumulative NDI to risk for preterm birth. Of the 1,815,944 total live births, we linked 1,000,437 live births to 413,048 unique women with two or more births. Record linkage had high specificity but relatively low sensitivity which appears non-differential with respect to maternal characteristics. Georgia women on average experienced upward mobility across the life course, although differences by race, early life neighborhood quality, and age at first birth produced differences in cumulative NDI. Adjusted binomial models found evidence for modification of the effect of history of prior preterm birth and advancing age on risk for preterm birth by cumulative NDI. The creation of trajectories from geocoded maternal longitudinally-linked vital records is one method to carry out life course MCH research. We discuss approaches for investigating the impact of truncation of the life course, selection bias from migration, and misclassification of cumulative exposure. [ABSTRACT FROM AUTHOR]

Given the existing evidence linking parental depression with infant and early child development, our aim was to describe the burden of mental health disorders among caregivers of young children aged 4-6 years living in an environment of poverty and high HIV seroprevalence. We analyzed baseline data from an epidemiologic study of the health and psychosocial needs of preschool-aged children. Primary caregivers of index children recruited from a household survey were screened for common mental disorders using the Client Diagnostic Questionnaire (CDQ). Sociodemographic, HIV and general health surveys were also conducted. Many caregivers (449/1,434; 31.3 %) screened positive for at least one psychiatric disorder on the CDQ, with post-traumatic-stress-disorder being the most common. Caregivers who screened positive for any disorder were more likely to be older, to have no individual sources of income and to have less formal education. Presence of a disorder was also significantly associated with lower employment levels within the household and death of a young child within the household. Known HIV-infected caregivers were more likely to have any mood disorder than caregivers who previously tested negative. The data support the need for mental health treatment interventions in South Africa, particularly interventions directed at PTSD and depression, and that take into account the high burden of poverty, HIV and childhood mortality. Given the limited formal mental health structure in South Africa to address these highly prevalent disorders; community-based mental health supports, available through decentralized health systems many be critical to delivering accessible interventions. [ABSTRACT FROM AUTHOR]