Research Roundtables: Study Findings

May 2002 - Study Assesses Adolescents' Overweight Status and Eating Patterns

"The findings clearly indicate large gaps between current prevalence rates of overweight status and nutrient and food intake among adolescents and targeted levels in Healthy People 2010," state the authors of a study published in the May 2002 issue of the American Journal of Public Health. This study assessed the prevalence of obesity and the eating behaviors targeted in Healthy People 2010 among 4,746 adolescents between the ages of 11 and 18 attending public middle schools and high schools in Minnesota. Percentages of adolescents meeting the year 2010 objectives for obesity and intake of total fat, saturated fat, calcium, fruits, vegetables, and grains were examined and compared across sex, school level, race, ethnicity, and socioeconomic status (SES).

The authors found that "a large percentage of the population was overweight, and the percentages of youths consuming the recommended amounts of fat, calcium, fruits, vegetables, and grains were considerably lower than the targeted percentages."

Specifically, they found that

  • Higher percentages of boys, compared with girls, were overweight;
  • Higher percentages of girls, compared with boys, were consuming the recommended amount of fat; however, lower percentages of girls were consuming the recommended amounts of calcium and grains;
  • Middle school girls and boys reported higher intakes of fruits and vegetables than did those in high school;
  • Among girls, the highest prevalence in overweight status was among African Americans, whereas among boys, the highest prevalence was among Native Americans;
  • African Americans were the least likely to consume the recommended amount of fat, while calcium and grain intake was lowest among Asian
  • Americans, and fruit and vegetable intake was lowest among whites;
  • The percentages of overweight adolescents with low SES were almost twice those of overweight adolescents with high SES; and
  • Adolescent girls and boys with low SES were less likely to consume the recommended amounts of fat, calcium, fruits, vegetables, and grains than were adolescents with high SES.

"To achieve and assess some of the Healthy People 2010 targets, changes may be necessary in both interventions and assessment tools," state the authors. Findings from this and other studies, conclude the authors, "point to the importance of developing interventions that meet the needs of youth from different backgrounds."

Neumark-Sztainer D, Story M, Hannan PJ, et al. 2002. Overweight status and eating patterns among adolescents: Where do youths stand in comparison with the Healthy People 2010 objectives? American Journal of Public Health 92(5):844-851.

(Source: MCH Alert, 5/10/02)

May 2002 - Authors Examine Race as a Moderator of Parent and Family Outcomes Following Pediatric Traumatic Brain Injury

"The findings indicate that race was a significant moderator of parent and family outcomes [following pediatric traumatic brain injury]," state the authors of an article published in the May 2002 issue of the Journal of Pediatric Psychology. The authors note that differences in coping styles may lead black parents to respond differently to pediatric traumatic brain injury (TBI) than white parents. The specific aim of this study, which used data from a prospective, longitudinal study of the effects of pediatric TBI on children and families, was to determine whether race moderates parent and family outcomes following pediatric TBI independently of socioeconomic status (SES). Measures of parent and family outcomes were examined, as were coping strategies shown to predict parent and family outcomes.

The sample for this study consisted of 145 participants and their families recruited from consecutive admissions to four hospitals in central and northeastern Ohio: 72 white and 18 black children who had sustained a blunt head trauma resulting in a moderate to severe TBI, and 32 white and 23 black children with orthopedic injuries (OI) only. All children were between 6 and 12 years of age at the time of injury. Information about parent adjustment and family stress and burden associated with the children's injuries was provided by caregivers at baseline, 6 months, and 12 months.

The authors found that

  • In general, differences between the TBI and OI groups in ratings of parent distress and family burden were of lesser magnitude for parents of black children than for parents of white children at baseline, but of greater magnitude for parents of black children at the 6- and 12-month follow-ups;
  • The main effect of race was significant for several coping strategies, with blacks reporting more use of religion, denial, and mental disengagement and less use of acceptance than whites; and
  • SES accounted for significant variance in several coping strategies, with higher SES associated with more use of active coping, planning, seeking social support for instrumental reasons, and humor and with less use of behavioral disengagement and denial.

"SES generally was related to coping strategies different from those related to race," state the authors. They continue, "Our findings suggest that socioeconomic factors are related to whether parents of children with traumatic injuries will utilize coping strategies that emphasize active problem solving, whereas cultural differences associated with race are likely to be associated with whether parents rely on avoidant, as opposed to emotion-focused, coping strategies after their children are injured." Future research is needed to determine whether psychosocial interventions focused on parental coping strategies can reduce distress and burden in at-risk families after pediatric TBI.

Yeates KW, Taylor HG, Woodrome SE, et al. 2002. Race as a moderator of parent and family outcomes following pediatric traumatic brain injury. Journal of Pediatric Psychology 27(4):393-403.

(Source: MCH Alert, 5/17/02)

May 2002 - At-Risk Children Born to Adolescent Mothers are More Likely to Experience Behavior Problems When They Live in Three-Generation Households, Study Finds

"In attempts to help young families with multiple risks, policymakers and health care providers have often looked to grandmothers for support and stability. However, findings from this investigation showed that children confronted by multiple risks had more behavior problems when they lived in three-generational households [i.e., with their mothers and grandmothers], compared with children who lived in independent households," state the authors of an article published in the April 2002 issue of Pediatrics. For the analyses highlighted in this article, the authors examined the main effects of grandmother presence, the child's maltreatment history, and maternal depressive symptoms on internalizing behavior problems, externalizing behavior problems, and cognitive performance.

The authors studied 194 at-risk families with children who were between the ages of 4 and 5 at the time of the evaluation, who were born when their mother was age 19 or less, and who were living with their biological mother. Children and mothers were recruited from four sites across the United States. Of this overall sample, approximately 26% of the households consisted of three generations (grandmother, mother, child), over one-third of the children had been reported to Child Protective Services for maltreatment, and almost one-third of the mothers reported depressive symptoms.

The authors found that

  • Children who lived in three-generation households tended to have more internalizing and externalizing behavior problems; however, this finding did not reach significance when corrected for multiple comparisons;
  • Children who had experienced maltreatment or maternal depressive symptoms had more internalizing and externalizing behavior problems than children who had experienced neither; and
  • Children living in three-generation households who had experienced maltreatment and maternal depressive symptoms had more behavior and developmental problems than children experiencing these risks who did not live in three-generation households.

The authors caution that "in this investigation, as in others, there are many unanswered questions regarding adolescents' living situations." Nevertheless, they conclude that "there is a need to move away from stereotypes regarding children of adolescent parents and to examine theories regarding protective factors that can be built into intervention programs for pregnant and parenting teens and their children."

Black MM, Papas MA, Hussey JM, et al. 2002. Behavior and development of preschool children born to adolescent mothers: Risk and 3-generation households. Pediatrics 109(4):573-580.

(Source: MCH Alert, 5/3/02)

February 2002 - Study Suggests Need to Examine Shared Predictive Factors for Obesity and Disordered Eating Behavior in Adolescents

"Different intervention strategies that address the broad spectrum of weight-related concerns and behaviors need to be developed, implemented, and evaluated," state the authors of an article published in the February 2002 issue of the Archives of Pediatrics and Adolescent Medicine. In an effort to develop effective interventions aimed at preventing obesity and unhealthy dieting/disordered eating in adolescents, the study discussed in this article (1) examined specific weight-related concerns and behaviors in a large population-based sample of adolescent girls and boys; (2) compared weight-related concerns and behaviors among underweight, nonoverweight, moderately overweight, and very overweight adolescents, and (3) explored the overlap between overweight status and unhealthy weight-related behaviors.

Data for the study were drawn from Project EAT (Eating Among Teens), a comprehensive study of adolescent nutrition and obesity. The overall population for the present study consisted of 4,746 adolescents from 31 public middle schools and high schools in urban and suburban school districts in the St. Paul and Minneapolis, MN, area. Surveys were administered within school classes to assess a range of factors of potential relevance to nutritional health and obesity among adolescents. Height and weight measurements were also taken.

Findings are as follows:

  • Adolescents reported a high prevalence of weight-related concerns and behaviors; however, healthy weight-control practices were more commonly reported than were practices considered unhealthy or extreme;
  • Many adolescents reported using specific healthy weight-control behaviors; however, many nonoverweight and overweight adolescents reported engaging in unhealthy and extreme weight-control behaviors;
  • While overweight status was associated with increased unhealthy weight-control behaviors, many of the overweight adolescents accurately perceived themselves as overweight, reported that they cared about controlling their weight, and had engaged in healthy weight-control behaviors during the past year.

The authors point out that interventions aimed at preventing and treating obesity traditionally focus on increasing physical activity and decreasing calorie intake, while those aimed at preventing disordered eating/eating disorders tend to focus on promoting a positive body image and on dieting prevention. Basing their conclusions on these findings, they assert that predictive factors for obesity and disordered eating behaviors co-occur for many adolescents and suggest a need for interventions that identify and address the broad spectrum of weight-related disorders.

Neumark-Sztainer D, Story M, Hannan PJ, Perry CL, Irving LM. 2002. Weight-related concerns and behaviors among overweight and non-overweight adolescents: implications for preventing weight-related disorders. Archives of Pediatrics and Adolescent Medicine 156(2):171-178.

(Source: MCH Alert, 2/22/02)

December 2001 - Monograph Presents Results of 10-Year Investigation of Child Development and Family Well-Being

"The same processes appear to be central to the development of all children," state the authors of a monograph recently published in Monographs of the Society for Research in Child Development. The monograph presents the results of the Early Intervention Collaborative Study (EICS), a longitudinal investigation of the cognitive and adaptive behavior development of children with Down syndrome, motor impairment, or developmental delay, from infancy through middle childhood, and the adaptation of their parents. EICS represents the largest and longest-running study of children with a range of disabilities and their parents ever undertaken in the United States.

Data were collected from a sample of 183 children and their families. The children were assessed at five points in time, from entry into an early intervention program as infants or 1-year-olds, through their 10th birthday. The authors found the following:

  • Although the type of disability predicted some features of development, children's motivation and the quality of their relationships with their mothers and among family members were consistent predictors of the development of cognitive, social, communication, and daily living skills.
  • Both mothers and fathers reported increasing levels of stress as their children grew older.
  • Children's behavior problems were a consistent predictor of increases in parental stress levels, but parents' abilities to solve problems and garner support were ameliorating factors.

The authors conclude that 1) changes in policies and practices can improve the outcomes for children with disabilities and their parents and 2) the study of children with developmental disabilities and their families can enhance the overall science of child development.

Hauser-Cram P, Warfield ME, Shonkoff JP, Krauss MW, Sayer A, Upshur CC. 2001. Children with disabilities: a longitudinal study of child development and parent well-being. In WF Overton, ed., Monographs of the Society for Research in Child Development (Serial No. 266, Vol. 66, No. 3). Boston, MA: Blackwell Publishers.

(Source: MCH Alert, 12/14/01)

November 2001 - Study Examines Relationship Between Neighborhood Characteristics and Birthweight Among Five Ethnic Groups

Living in neighborhoods that are less socioeconomically advantaged may influence birthweight differently, depending on women's ethnicity and nativity, according to a study published in the November issue of the American Journal of Public Health. The authors note that neighborhood-level characteristics may measure a dimension of socioeconomic conditions that may not be captured by individual-level measures such as income and education. The purpose of the study was to examine relationships between selected neighborhood socioeconomic characteristics and birthweight among women in five ethnic groups: white, black, foreign-born Latinas, U.S.-born Latinas, and Asians.

The authors linked birth records to census block-group data for 22,304 women who delivered infants at 18 California hospitals during 1994-1995. Information on income and additional factors was obtained from a surveyed subset of 8,457 women. Neighborhood levels of poverty, unemployment, and education were examined.

The study indicates that the nature of the relationship between neighborhood socioeconomic characteristics and the birthweight of infants born to California residents varies greatly, depending on the ethnicity of the mother and the area-level characteristic considered. Findings include the following:

  • Among white women and U.S.-born Latinas, the neighborhood socioeconomic characteristics examined generally were unrelated to birthweight.
  • Among Asians and blacks, birthweight decreased with lower neighborhood socioeconomic status (SES), as measured by higher unemployment levels.
  • Paradoxically, among foreign-born Latinas, living in neighborhoods with the highest rates of poverty and unemployment was associated with higher mean birthweights and lower risk of low birthweight.
  • Adjustment for family income and other individual-level factors available for the surveyed subsample did not account for the observed associations between neighborhood SES and mean birthweight or risk of low birthweight.

The authors encourage researchers to consider ethnic groups separately when using neighborhood measures to adjust for socioeconomic influences. The consistency of neighborhood-level socioeconomic differences in birth outcomes in their findings suggests a small but real effect among certain ethnic groups that is not explained by several known risk factors. The authors conclude, "Searching for protective factors . . . may strengthen our understanding of the factors that determine birthweight and aid in the development of policies and interventions to improve birthweight and birth outcomes generally."

Pearl M, Braveman P, Abrams B. 2001. Relationship of neighborhood socioeconomic characteristics to birthweight among 5 ethnic groups in California. American Journal of Public Health 9111:1808-1814.

(Source: MCH Alert, 11/16/01)

November 2001 - Study Finds No Significant Impact of Welfare Reform on Perinatal Outcomes of Foreign-Born Latinas

The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 "appears to have had little immediate effect on the perinatal health and health care utilization of foreign-born Latinas in three localities with large immigrant populations," state the authors of a study published in the November issue of the American Journal of Public Health. Under PRWORA, many legal immigrants were no longer eligible for Medicaid coverage of prenatal care. State response to the withdrawal of federal eligibility and funds varied, as did immigrants' perceived and actual loss of eligibility. The authors explored the effect of the law on the perinatal health and health care utilization of foreign-born versus U.S.-born Latino women in California, New York City, and Texas.

Drawing information from birth certificates, the authors compared changes in the financing of births (Medicaid and self-pay), prenatal care utilization (early initiation of care and prenatal visits), and birth outcomes (low birthweight, very low birthweight, and preterm delivery) between U.S.-born and foreign-born Latinas in 1995 and 1998.

Changes in perinatal outcomes were broadly consistent among the three localities:

  • A steep drop in the percentage of births in which prenatal care was covered by Medicaid
  • Almost no change in the percentage of women uninsured during the prenatal period
  • An increase in prenatal care utilization
  • Essentially no variation in birth outcomes

The authors summarize by stating, "There is little evidence from vital statistics in California, New York City, and Texas that PRWORA had any substantive impact on the perinatal health and health care utilization of foreign-born relative to U.S.-born Latinas." They assert that any impact of welfare reform on perinatal outcomes was probably diminished in all three localities by 1) the effectiveness of presumptive eligibility and other mechanisms for simplifying access to prenatal care, 2) the powerful incentives that hospitals have to facilitate Medicaid applications in obstetric cases, and 3) the availability of prenatal care providers that remain accessible to all immigrants, such as those funded through Title V block grants, or the willingness of prenatal care providers to care for women regardless of their ability to pay.

Joyce T, Bauer T, Minkoff H. 2001. Welfare reform and the perinatal health and health care use of Latino women in California, New York City, and Texas. American Journal of Public Health 91(11):1857-1864.

(Source: MCH Alert, 11/9/01)

May 2001 - Home and Videotape Intervention Found to be Effective in Delaying Early Introduction of Complementary Feeding Among First-Time African-American Adolescent Mothers

An article based on the findings from a HRSA/MCHB supported study of African-American mothers appears in the May, 2001 issue of the journal Pediatrics. This is one of several articles representing the first and second wave of findings from a group of minority group-specific longitudinal studies of infant health and development first funded by the HRSA/MCHB Extramural Research Program in the early 1990s. Years earlier, the Bureau had made the decision to pursue the evolution of a minority group-specific scientific knowledge base that would allow MCHB's service programs to develop and deliver to mothers and children efficacious and culturally-based program interventions.

The article, Home and Videotape Intervention Delays Early Complementary Feeding Among Adolescent Mothers (Pediatrics, May 2001, 107(5), 1-8) evaluated the efficacy of an intervention designed to delay the early introduction of complementary feeding among first-time African-American adolescent mothers living in multigenerational households. The principal investigators of the research and authors of the article are Maureen M. Black, Ph.D., et al from the Department of Pediatrics of the University of Maryland School of Medicine at Baltimore. The intervention focused on reducing the cultural barriers to the acceptance of the recommendation of the American Academy of Pediatrics, WIC, and the World Health Organization on complementary feeding. In addition to messages about the type and timing of infant feeding, the intervention showed mothers how to read their infants' cues, provided nonfood strategies for managing infants' behavior, and addressed mother/grandmother negotiations regarding intergenerational conflicts on what and how infants should be fed. The intervention was delivered through a mentorship model in which a videotape made by an advisory group of African-American adolescent mothers was incorporated into a home-visiting program and evaluated through a randomized, controlled trial.

Study findings indicate that infant characteristics (e.g., size), infant behavior (e.g., signals of hunger or satiety), and caregiver concerns about infants not sleeping through the night or crying were salient cultural issues that shaped the adolescent mothers feeding practices. Specifically, sixty-one percent of the infants of the study received complementary foods before 3 months old. Multivariate analyses were conducted to determine which factors best predicted optimal and less optimal adolescent mother feeders. After controlling for infant age and family income, mothers of infants in the optimal feeders group were found to be more likely to report accurate messages from advice sources such as WIC regarding timing of complementary food and nearly four times more likely to be in the intervention group. The most common complementary food was cereal mixed with formula in the bottle.

The investigators of the study mention four possible reasons for the success of the intervention. First, the intervention was guided by ecological theory which assumed infants play an active role in the shaping of the caregiving process. Second, both the videotape and the home-visiting curriculum extended the focus on infant feeding to include mother/grandaughter negotiations skills. Third reason mentioned was the cultural sensitivity of the methods used to implement the intervention. By featuring adolescent mothers, fathers, and grandmothers in the videotape and by conducting the intervention in the home, the investigators tried to make the intervention culturally acceptable so that other family members would recognize the important role that they play in supporting the adolescent mother and child. Finally, the mentorship model used may have highlighted the recommendations provided by the advice sources and the pediatrician and possibly could have helped mothers determine why and how they would follow the recommendations.

There are several limitations to the study. First, results are specific to young African-American mothers living in multigenerational households. The families in the intervention received both the videotape and the home-visiting curriculum. Therefore, it is not possible to assess the unique contributions of each component of the intervention. Third, it is possible that the positive findings are the result of generalized attention from the home visitor, rather than the specifics of the intervention.

Reprints of the article are available from the HRSA/MCHB Extramural Research Program Office, telephone: (301) 443-2190; e-mail: rhaggerty@hrsa.gov. State, county and municipal MCH program offices interested in replicating/validating the intervention tested by the study are advised to contact the HRSA/MCHB Extramural Research Program Office at (301) 443-2190 to arrange contact with the Principal Investigator of the study and for technical assistance.

Prepared by Gontran Lamberty, Dr. P.H., 5/8/01

February 2001 - The Implications of Migration to the U.S. Mainland for Infant Mortality Among Puerto Ricans

It has been widely documented that foreign-born mothers of various ethnic backgrounds have better birth outcomes than their US-born counterparts. This has been attributed to the protective influence of the mother culture and the waning of that influence over time as migrants assimilate into the U.S. society. Selectivity in who migrates has also been offered as an explanation for the foreign- versus US-born differentials in birth outcomes. The contention being that migrants are more intelligent, healthy, and resourceful than the non-migrant peers they have left behind.

An NICHD/MCHB jointly supported investigation, Puerto Rican Maternal and Infant Health Study (PRMIHS), sought to test both of these assumptions using pooled vital statistics records and in person interviews, and based on a complex sample design that involved stratification by state, month, and birth outcome and the over sampling of infant deaths and low birthweight infants. Selected findings from the study are reported in an article entitled "Migration and Infant Death: Assimilation or Selective Migration Among Puerto Ricans?" that appeared in the December 2000 issue of the journal American Sociological Review (Vol. 65, pages 888-909). The authors of the article are: Nancy S. Landale, Ph.D., R.S. Oropesa, Ph.D., and Bridget K Gorman, Ph. D. from The Pennsylvania State University and the University of North Carolina at Chapel Hill.

Specifically, the PRMIHS: (1) compared the infant mortality rate of first- and second-generation Puerto Rican women residing in six states on the U.S. mainland (Connecticut, Florida, Massachusetts, New jersey, New York City, and Pennsylvania) with those of the offspring of women in Puerto Rico; (2) assessed the role of selective migration in producing the generational pattern of infant mortality observed for Puerto Rican women residing in the U.S.; and, (3) focused on the implications of the duration of the Puerto Rican mother's exposure to U.S. society for infant health as well as the mechanisms through which exposure was theorized to exert its effects. Testing of a series of logistic regression models with increasing number of explanatory and control variables characterized the statistical analyses part of the study.

Overall, findings from the PRMIHS study lend support to the waning cultural influence and selective migration hypotheses. The PRMIHS data indicate that both mainland-born women and long-standing mainland residents from Puerto Rico have higher rates of infant mortality than do recent migrants to the mainland. This pattern persists after controlling for an extensive set of demographic and socioeconomic variables. Findings also indicate that the risk of infant mortality is substantially lower among migrants with relatively few years of residence on the mainland than it is among women who remain in Puerto Rico. This latter finding enhances the validity of the selective migration hypothesis and undermines that of the protective culture one. If, argue the study investigators, beliefs and practices drawn from the origin culture are central to the favorable birth outcomes of migrants living on the mainland, then non-migrants at the origin should be similarly protected. That is not the case for the PRMIHS data. The data indicate that the risk of infant mortality for non-migrant Puerto Rican women is roughly similar to that for U.S. born mainland Puerto Rican women and considerably higher than that of recent migrant women.

Other interesting, mainly bivariate, findings reported by the study are: (1) education and income are unlikely to play key roles in explaining nativity differences in infant mortality among mainland Puerto Ricans; (2) those who live in a predominantly Latino neighborhood have higher risks of infant mortality than others, and; (3) participants of WIC program have a significantly lower rate of infant mortality than do non-participants.

A companion article focusing on the determinants of the use of prenatal care among the participants of the PRMIHS appear in the most recent issue of Social Science and Medicine (November 2000, Vol. 51, pages 1723-1739). Copies of both of these articles are available from the Research Program Office upon request: Telephone: (301) 443-2190, e-mail: rhaggerty@hrsa.gov.

Prepared by Gontran Lamberty

January 2001 - Social and Psychological Circumstances Surrounding Pregnancy Outweigh Financial Situation as Barriers to Use of Prenatal Care Among Puerto Rican Women Residing on the U.S. Mainland

Findings from a HRSA/MCHB and NICHD supported study of Puerto Rican women residing on the U.S Mainland report that barriers to prenatal care utilization are common among this group even though a single barrier did not predominate.  About half (48%) of the study participants mentioned at least one barrier and close to one-fifth (22%) mentioned at least two types of barriers that made it difficult for them to get care.  Among the most frequently mentioned barriers were those that signal uncertainty about the pregnancy, the consideration of abortion, the desire to keep the pregnancy secret, and the lack of awareness about being pregnant.  Financial and transportation considerations were mentioned as barriers but did not fare prominently; barriers related to aspects of the health care delivery system were of relatively minor importance.

The number of barriers to prenatal care were related to a host of relevant factors (i.e., pregnancy wantedness, migration status, social and financial capital, etc.) using bivariate and multinomial logistic regression models.  One variable that stands out in these analyses is pregnancy wantedness.  The odds of mentioning multiple barriers are much higher for women who did not want a baby or wanted a baby in the future than the odds for women who wanted the pregnancy at the time it occurred.  The multivariate results are less impressive for other variables, especially for indicators of migration status, financial capital and human capital. Married and cohabitating women are less likely than single mothers to mention barriers..  Access to someone who can provide emotional support and advice also reduces the likelihood of mentioning multiple barriers.

The study, "Prenatal Care Among Puerto Rican on the United States Mainland," appears in the November 2000 issue of the British Medical Journal Social Science and Medicine (Vol. 51, 1723-1739). R.S. Oropesa, N.S. Landale, M. Inkleyand B.K. Gorman are the lead authors.  Reprints of the article are available from the HRSA/MCHB Research Program Office, Telephone: (301) 443-2190, e-mail: rhaggerty@hrsa.gov.

January 2001 - Influence of Unintended First Pregnancy on Parental Postpartum Depressive Symptoms Complex/Operate Through Different Mechanisms for Men and Women

Despite the high prevalence of unintended pregnancy, little research has focused on its consequences among adult, married, or cohabitating couples.  Understanding whether unintended pregnancy contributes to maternal and paternal postpartum depressive symptoms is important, as such depression can lead to difficulties with parenting.

A HRSA/MCHB supported study published in the October 2000 issue of the American Journal of Orthopsychiatry (70, 4, pp. 523-531) sought to document the effects of unintended pregnancy on women and men levels of postpartum depressive symptoms.

Overall, study findings indicate that the influence of unintended first pregnancy on parental depressive symptoms is complex and operate via different mechanisms for men and women.  Pregnancy viewed as unintended by males and intended by their partners appeared to pose the greater risk for postpartum depressive symptoms particularly in women.  .Although most of the pregnancies in the study (N:124 couples) were mistimed rather than unwanted, they nevertheless appeared to influence women's risk for postpartum depressive symptoms.  A strong association between men's perception that a pregnancy was unintended and maternal depressive symptomatology was detected.  Although most couples agreed about whether their pregnancies were intended, 13.7% of women reported an intended pregnancy that their partners reported as mistimed or unwanted.  For these women, pregnancy intendedness was associated with an increase of over five points in the CES-D scale measuring depressive symptoms, an increased risk of approximately two depressive symptoms. 

Limitations of the study reported by investigators are: (1) relatively small sample; (2) sample representativeness unknown; (3) instrument used ( Center for Epidemiological Studies Depression Scale (CES-D) does not measure clinical depression.

May 2000 - Home Visits Compared with Pediatric Clinic Visits on the Third and Fourth Postpartum Hospital Day After Discharge From the Hospital Found to Be Higher in Maternal Satisfaction, Equivalent in Clinical Outcomes, But More Costly

National guidelines recommend a follow-up visit on the third or fourth postpartum day after the mother/infant pair has been discharged from the hospital. Little scientific evidence exists on what the clinical approach to postdischarge should be nor about the cost or degree of clinical effectiveness associated with the various approaches currently in use.

An HRSA/MCHB-supported randomized clinical trial investigation sought to do just that for home compared to clinic postdischarge follow-up visits. Study sample were medically and socially low-risk mother-newborn pairs with uncomplicated deliveries who were delivered at the Kaiser Foundation Hospital in Sacramento, CA. and who were being cared for by 5 Kaiser Permanente Plan outpatient clinics.

Findings from the study indicate that no significant differences occurred in clinic outcomes between the mother-infant groups assigned randomly to home or to clinic visits as measured by maternal or newborn rehospitalization within 10 days postpartum. No significant differences were also found in maternal or newborn urgent clinic visits within 10 days postpartum, maternal or newborn urgent clinic visits within 10 days postpartum, or breastfeeding discontinuation or maternal depressive symptoms at the 2-week interviews. In contrast, higher proportions of mothers in the home visit group rated as excellent or very good the preventive advice delivered (80% vs. 44%), the provider's skills and abilities (87% vs 63%), the newborn's postospital care (87% vs. 59%), and their own posthospital care (75% vs. 47%). On average, a home visit cost the study $255 and a pediatric clinic visit cost $120. Because the pediatric clinic visits did not formally address the medical needs of the mother, the investigators also evaluated the cost of a 10-minute visit to the obstetric-gynecologic clinic; this was estimated at $82.

There are limitations to the study. Participants were from low-risk populations. They were of diverse backgrounds, but nearly two-thirds had at least some college education and less than 10% had less than a high school degree. The health maintenance organization in the study primarily serves families with employment-based, comprehensive health insurance coverage; the study population's median income was higher than that of the general population. Social and medical screening criteria for the study were fairly stringent; only about half of all births at the facility during the study period were considered eligible. Moreover, the study had limited statistical power to identify group differences in rehospitalization and may not be generalizable to less affluent or otherwise higher-risk populations without comparable access to integrated hospital and outpatient care.

For home visits, argued the investigators, the value of higher maternal satisfaction with the postpartum experience will need to be weighed against their additional cost. Decisions among alternative postpartum, follow-up services ideally should incorporate the perspectives of all parties in these decision, including clinicians, insurers, and the mothers and families themselves. The study entitled " A Randomized Comparison of Home and Clinic Follow-up Visits After Early Postpartum Hospital Discharge," appears in the May 2000 issue of the medical journal Pediatrics ( Vol.105, No 5, pp. 1058-1065), Tracy, A. Lieu and Patricia Braveman, lead authors.

April 2000 - Study Provides Evidence That the Quality of Child Care in Community-Based Centers is Related to the Cognitive and Language Development of Young Children

Findings from an HRSA/MCHB-supported study indicate that the quality of community-based center child care is a modest to moderate predictor of cognitive and languagte development in young children. Even after adjusting for child and family characteristics, analyses indicate that infants and toddlers in classes with better quality tend to have better cognitive and communication skills at one, two, and three years of age. Furthermore, the analyses provide evidence that the rate at which children acquire expressive language skills is slower for children in poorer than for those in higher quality classrooms.

As it has been the case in randomized clinical trials of early intervention programs, the results of the HRSA/MCHB study also show that children who attended classrooms with child-adult ratios within the recommended guidelines tend to have somewhat higher receptive and overall communication language scores at all ages. This association is consistent with the belief that scaffolded conversations with adults are especially important for language development during early childhood and that the teacher who has more children per adult in her/his class than is recommended will not have enough time to provide the individual language models and responsive turn-taking interactions that are required to enhance language development. Somewhat surprising, the study found that the child outcomes were higher for girls in classes whose lead teachers met recommendations regarding education, but not for boys. These findings may reflect the fact that preschool girls may be likelier to seek out the attention of adults than are preschool boys, eliciting more conversations with them.

The study is unique in three respects: (1) subjects were African-American infants and toddlers from predominantly low-income families; (2) children were followed longitudinally from 6 months to 36 months of age; and, (3) study variables included whether the care rendered at the centers met or did not meet professional recommendations on classroom child-adult ratios and teacher education. These regulable aspects of center child care have been found in prior studies to promote child care quality.

The findings of the study are reported in an article entitled, "Relating Quality of Center Child Care to Early Cognitive and Language Development Longitudinally," which appears in the March/April 2000 issue of the journal Child Development (Vol. 71 , No. 2 ,pp 339-357 ). Lead authors of the article are Margaret R. Burchinal, Joanne E. Roberts, Rhodeus Riggins, Jr., et al. from the Frank Porter Graham Child Development Center of the University of North Carolina, Chapel Hill, NC. Reprints of the article are available from the HRSA/MCHB Research Program Office, Telephone: (301) 443-2190;
e-mail:kwadhwan@hrsa.gov or rhaggerty@hrsa.gov.

Based on the findings of the study the investigators advocate that community child care or other early intervention for children, especially for those from families living in poverty, should focus on the qualitjy of the child care received by the children. Results of this study, the investigators assert, in conjunction with the early intervention literature, suggest that policy-makers should ensure that low-income African-American infants who are at risk for developmental problems because of poverty and its associated problems receive good quality care beginning in infancy to reduce the likelihood of school failure. High quality child care requires child-adult ratios such as recommended by the American Public Health and American Pediatric Associations to permit the extensive teacher-child interactions that promote infant responsiveness to people and objects. In addition, high quality care also require training teachers in infant and toddler classrooms to be responsive and contingent in interaction with babies and young children.

January 2000 - Formal Evaluation of Hawaii's Healthy Start Program Documents How An Original Demonstration Program Model Fares When Expanded or Taken to Scale

Home visiting today enjoys widespread endorsement as a way to promote child health and development and prevent child abuse and neglect. Many home visiting models have been developed. Some use nurses, baccalaureate- or graduate-school trained, as the deliverers of service; others use para-professionals with varying degrees of training and professional supervision. The supplement to the January 2000 issue of the journal Pediatrics (Vol. 105, No.1, pp250-259) has an article that reports on the findings of a process- and experimental design-based evaluation of Hawaii's Healthy Start Program (HSP) that was jointly funded by HRSA/MCHB, the Robert Wood Johnson Foundation, and the Hawaii Department of Health . The model underlying the Hawaii Healthy Start Program was piloted in a single community in Hawaii during 1985-1988 and has since expanded to cover about two-thirds of the state. The Pediatrics January 2000 article reports on the findings of the paraprofessional home visiting component of the program. It seeks to describe how closely the implemented home visiting component of the program mirrored the specifications of the original demonstration model. Evaluation study results are a mixed bag of positives and negatives. Overall, results indicate that actual service delivery departed in many ways from the demonstration model tested several years ago. Community agencies, for example, implemented the same model differently, even when following the same contracts for service provisions. Screening coverage, was more complete when performed by program, rather than hospital, staff. In person assessment greatly increased a family's willingness to enroll in home visiting. The investigators conclude by accentuating the underlying complexities inherent in taking a program from the demonstration phase to system wide implementation. They exhort states and communities establishing home visiting programs to include a technically strong and concurrent evaluation component as part of the overall implementation of such programs. A technically strong and concurrent evaluation component, they suggest, ensures that programs reach and engage the families most likely to benefit.

December 1999 - Extremely Low Birth Weight Infants Treated Early With a Low Dose of Hydrocortisone Found to Have a Greater Chance of Surviving Without Chronic Lung Disease

Findings from a Health Resources and Services Administration's Maternal and Child Health Bureau-funded pilot study support the early administration of a low dose of hydrocortisone ( an anti-inflammatory drug) to very low birth weight infants as a way to increase their chances of survival without chronic lung disease (CLD). The pilot study main findings are reported in an article entitled "Prophylaxis Against Early Adrenal Insufficiency to Prevent Chronic Lung Disease in Premature Infants" which appears in the December 1999 issue of Pediatrics (Vol. 104, and No. 6,pp1258-1263). This two-center, randomized, double-masked, controlled pilot study was designed to provide a preliminary assessment of treatment efficacy and safety and to estimate the sample size needed for a much larger multi-center clinical trial. Overall, the study findings indicate that early hydrocortisone therapy significantly improved the chances of survival without oxygen dependence at 36 weeks of postconceptional age in very low premature infants. The beneficial effects of hydrocortisone therapy were seen in the two study centers and was more pronounced in infants whose mothers had experienced a condition called chorioamnionitis, a prenatal inflamation of the embryonic sac in and through which the baby develops and is nourished. In this latter group, the hydrocortisone treatment was associated not only with better respiratory outcome,but also improved early feeding and increased weight at 36 weeks of postconceptional age. The investigators conclude that the pilot study findings justify a larger multi-center randomized trial to test the benefits and assess the risks of low-dose hydrocortisone therapy to prevent chronic lung disease in extremely premature infants. Chronic lung disease develops frequently in small premature infants and results in increased health care costs, prolonged hospsital stay with frequent hospitalization, and possible harmful effects on future growth and development. Many factors contribute to chronic lung disease in very low birth weight infants such as: (1) oxygen therapy;(2) prenatal inflammation; (3) trauma resulting from the process of intubation; (4) and trauma resulting from prolonged use of feeding tube. Many treatments other than early administration of low-dose hydrocortisone have been tried with few successes and/or without significant harmful effects.

December 1999 - Intestinal Blood Loss in Infancy Due to Cow Milk Consumption Found to Disappear Gradually Between 7-1/2 and 12 Months of Age

Previous studies have clearly established the tendency of young infants to respond to cow's milk with increased intestinal blood loss. The response of older infants remain less well defined. Iron deficiency, with or without anemia attributable to the feeding of cow's milk has been demonstrated in a number of studies. Although in some of the studies infants intestinal blood loss was of a magnitude that could have explained the anemia, there were also infants who had iron deficiency but no blood loss. The opposite, blood loss without iron deficiency, may occur. Previous studies also have shown that infants who had been breast fed early in life showed a much greater propensity to respond to cow's milk with blood loss than infants who had not been breast fed. The findings of a HRSA/MCHB-supported study on cow's milk feeding in infancy are reported in an article titled, "Cow's Milk and Intestinal Blood Loss in Late Infancy," which appears in the December 1999 issue of The Journal of Pediatrics (Vol. 135, No.6, pp.720-726). The study sought to document whether older infants may react differently to cow's milk than young infants and to ascertain what is the contributions of intestinal blood loss to the poor iron status associated with feeding of cow's milk. Findings from the study clearly showed that intestinal blood loss provoked by exposure to cow's milk is a phenomenon of the young child as it gradually disappears in the second half o the first year of life. The study also confirmed earlier observations that increased intestinal blood loss in response to cow's milk is more common among infants who were breast fed early in life than in infants who were never breast fed. The duration of breastfeeding did not seem to make a difference. The study was not able to detect an association between intestinal blood loss and iron status. The investigators conclude that based on their findings, intestinal blood loss associated with milk consumption should cease to be a source of concern as the infant approaches the end of the first year of life. Although they fully support the recommendation of the Committee on Nutrition of the American Academy of Pediatrics that cow's milk not be fed during the first year of life, they see little reason for withholding cow's milk beyond the age of 12 months.

October 1999 - HRSA/MCHB Supported Research Explores the Link Between a Mother's Birth-Weight and the Risk of Pre-term Delivery and Low-Birth Weight in Her Own Pregnancies

A large population-based inter-generational database that links vital statistics, hospital obstetrical and neonatal discharge summaries and motor vehicle licencing information is exploring birth characteristics across generations under the support of a HRSA/MCHB research grant. Two articles based on this unique database were published in 1999 under the authorship of Irvin Emanuel, M.D. and colleagues from the University of Washington, Seattle. The two articles, The Washington State Inter-generational Study of Birth Outcomes: Methdology and Some Comparisons of Maternal Birth-weight and Infant Birth-weight and Gestion in Four Race/ethnic Groups, and, A Population-based Cohort Study of the Relation Between Maternal Birth-weight and Risk of Gestational Diabetes Mellitus in Four Racial/ethnic Groups, have been published in the British journal Paediatric and Perinatal Epidemiology (1999, 13, 352-371 & 13, 670-682). An additional third article, Respiratory Distress Syndrome and Maternal Birth Weight Effects, will appear in the U.S. journal Obstetrics and Gynecology as part of one of the journal's year 2000 issues. All three articles are noted for their racial- and ethnic-specific analyses and are representative of cutting-edge research that seeks to elucidate the pre-natal, fetal and natal antecedents of adult-onset diseases such as hypertension, gestational and adult onset diabetes. Study 1 presents data supportive of an inverse dose-response association between maternal birth weight and four adverse infant outcomes: low birth-weight, very low birth-weight, pre-term birth and very pre-term birth. Besides the association between maternal birth-weight and adverse outcomes, the most important findings of the study concern the pattern of risks and outcomes found among the four race/ethnic groups studied (i.e., non-Hispanic whites, Hispanics, African-American and Native American). In general, non-Hispanic whites had lowest rates of adverse birth outcomes and African-Americans had the highest. But maternal birth-weight was an important mediator of adverse outcomes in each of the four groups. Study 2 looked at the association between what a mothers weight when she is born (i.e., maternal birth weight) and the risk of developing gestational diabetes mellitus (GDM) later in life. Women who develop GDM, a relatively common maternal medical complication of pregnancy, are thought to have a compromised physiological capacity to adapt to the metabolic challenges of late pregnancy. Findings from Study 2 indicate that maternal birth-weight of 2000 grams or less is associated with an almost doubling in the risk for GDM among non-Hispanic white, African American, Native American and Hispanic women. African-American women with a birth-weight of 4000 grams or more also experienced a two-fold increased risk of GDM.

January 1999 - Recovery From Serious Traumatic Brain Injury in Children Found To Be In Part Determined by the Post-Injury Family Environment

Many studies have shown that families of children with serious traumatic brain injuries (TBI) experience greater stress and impaired functioning than do families of chldren who have sustained mild TBI or other forms of traumatic injuries. The possible influences of the post-injury family environment on children's recovery from TBI, however, have not been studied and until recently have remained unsubstantiated. Findings from a Health Resourcews and Services Administration's Maternal and Child Health Bureau-funded study confirm the suspected relevance of the post-injury family environment for the recovery process of traumatic brain injured children. The findings are reported in an article which appears in the journal Neuropsychology, 1999, Vol. 13, No. 1, pp76-89. For the study group as a whole, post-injury measurements of family burden, parental psychological distress, and family dysfunction predicted several child outcomes. In all instances, more favorable family circumstances were associated with better child outcomes, and these associations were found even after controlling for socio-economic status, race, and group effects. Family factors were more consitently associated with measures of child behavior than with those of cognitive skills. The investigators of the study conclude that, based on these findings, there seems to be a clear need for rehabilitation efforts aimed at the family system of children with TBI and that careful follow-up of these children and their families is additionally warranted to illuminate processes of recovery and identify factors that contribute to risk or resiliency.