Faculty Bibliography

INTRODUCTION/UNASSIGNED:Pregnancy represents a stressful period for both women and their families. Whether the family maintains functioning during pregnancy could have significant implications on maternal and child health. In this study, we explored individual- and family-level factors associated with family functioning in adolescent and young adult mothers. METHODS/UNASSIGNED:This study was a secondary analysis of 295 young mothers, ages between 15 and 21 years. Multivariate logistic regression models were conducted to estimate adjusted odds ratios of exploratory factors on the risk of being in high family functioning group. The parent study was approved by the Institutional Review Boards at Yale University. RESULTS/UNASSIGNED: = 0.008). DISCUSSION/UNASSIGNED:The models of care should be structured to support the continuity of maternity care in which health care providers have the opportunity to discover and utilize each family's strengths to provide the optimal caring experience for young mothers and their families as a unit.

INTRODUCTION/BACKGROUND:Symptoms of untreated depression and anxiety during pregnancy are associated with serious adverse effects for the pregnant person, birth outcomes, and child development. However, pregnant persons are less likely to be screened and treated compared with nonpregnant people. In this systematic review, we aimed to explore individual, provider, and systems factors that impact screening, identification, and treatment patterns for depression and anxiety during pregnancy. METHODS:Studies were eligible for inclusion if they were conducted within the United States and published in English between January 2012 and January 2023. Each study included analysis that compared rates of screening, identification, or treatment engagement and explicitly discussed disparities or health equity in marginalized groups. Fifteen articles met full inclusion criteria. RESULTS:Results demonstrated variation in the screening, identification, and treatment of depression and anxiety during pregnancy among diverse groups of patients. Screening rates ranged from 51.3% in Puerto Rico to 90.7% in Alaska. Among specific clinical populations, rates were as low as 2.0%. Fewer than half of patients were referred to treatment when indicated by screening or diagnoses. Patient characteristics such as age, race, ethnicity, socioeconomic and health factors, mental health history, and obesity were associated with variation in the rates of screening, diagnoses, or treatment engagement. Language factors were the most common factor associated with lower rates of screening and treatment access. DISCUSSION/CONCLUSIONS:Results suggest that many pregnant people are being overlooked and lack appropriate referrals or resources to access treatment. Results are consistent with previous findings that role confusion and lack of time, provider training, and interest contribute to low rates of screening and treatment. Future research must focus on system level factors to address perceived barriers to screening and treating depression and anxiety during pregnancy in a systematic and equitable way.

BACKGROUND/UNASSIGNED:Food insecurity is a major public health concern in the United States, particularly for pregnant and postpartum individuals. In 2020, ∼13.8 million (10.5%) U.S. households experienced food insecurity. However, the association between food security and pregnancy outcomes in the United States is poorly understood. PURPOSE/UNASSIGNED:The purpose of this review was to critically appraise the state of the evidence related to food insecurity as a determinant of health within the context of pregnancy in the United States. We also explored the relationship between food insecurity and pregnancy outcomes. METHODS/UNASSIGNED:PubMed, CINAHL, Web of Science, and Food and Nutrition Science databases were used. The inclusion criteria were peer-reviewed studies about food (in)security, position articles from professional organizations, and policy articles about pregnancy outcomes and breastfeeding practices. Studies conducted outside of the United States and those without an adequate definition of food (in)security were excluded. Neonatal health outcomes were also excluded. Included articles were critically appraised with the STROBE and Critical Appraisal Skills Program checklists. RESULTS/UNASSIGNED:Nineteen studies met the inclusion criteria. Inconsistencies exist in defining and measuring household food (in)security. Pregnant and postpartum people experienced several adverse physiological and psychological outcomes that impact pregnancy compared with those who do not. Intersections between neighborhood conditions and other economic hardships were identified. Findings regarding the impact of food insecurity on breastfeeding behaviors were mixed, but generally food insecurity was not associated with poor breastfeeding outcomes in adjusted models. CONCLUSION/UNASSIGNED:Inconsistencies in definitions and measures of food security limit definitive conclusions. There is a need for standardizing definitions and measures of food insecurity, as well as a heightened awareness and policy change to alleviate experiences of food insecurity.

BACKGROUND:Perceived insufficient milk is a primary reason for early breastfeeding cessation. Some breastfeeding mothers may use galactagogues (ie, foods, beverages, herbal supplements, and pharmaceuticals) to try to increase milk supply. However, milk production requires frequent and effective milk removal, and there is limited evidence on the safety and efficacy of galactagogues. Additional research on the use of galactagogues is needed to inform breastfeeding support. OBJECTIVE:Describe the prevalence of use and perceived effects of galactagogues and compare galactagogue use by maternal characteristics. DESIGN:Cross-sectional online survey. PARTICIPANTS/SETTING:A convenience sample of 1,294 adult women breastfeeding a singleton child and living in the United States were recruited using paid Facebook advertisements between December 2020 and February 2021. MAIN OUTCOME MEASURES:Self-reported current or previous use of galactagogues and their perceived effects on milk production. STATISTICAL ANALYSES PERFORMED:test of independence and independent t tests compared galactagogue use by select maternal characteristics. RESULTS:More than half of participants (57.5%) reported using any galactagogues, 55.4% reported consuming foods or beverages, and 27.7% reported using herbal supplements. Few participants (1.4%) reported using pharmaceuticals. Participants reported varying effects of specific galactagogues on milk production. Reported galactagogue use was higher among participants who reported first-time breastfeeding (yes: 66.7% vs no: 49.3%; P < 0.001), breastfeeding pumped milk (yes: 63.1% vs no: 50.4%; P < 0.001), formula supplementation (yes: 66.8% vs no: 50.4%; P < 0.001), and perceived insufficient milk (yes: 78.8% vs no: 53.8%; P < 0.001). CONCLUSIONS:Breastfeeding mothers in the United States commonly reported using galactagogues to increase milk production, highlighting the need for research on the safety and efficacy of galactagogues and enhanced breastfeeding support.

BACKGROUND:Analyses of factors that determine quality of perinatal care consistently rely on clinical markers, while failing to assess experiential outcomes. Understanding how model of care and birth setting influence experiences of respect, autonomy, and decision making, is essential for comprehensive assessment of quality. METHODS:We examined responses (n = 1771) to an online cross-sectional national survey capturing experiences of perinatal care in the United States. We used validated patient-oriented measures and scales to assess four domains of experience: (1) decision-making, (2) respect, (3) mistreatment, and (4) time spent during visits. We categorized the provider type and birth setting into three groups: midwife at community birth, midwife at hospital-birth, and physician at hospital-birth. For each group, we used multivariate logistic regression, adjusted for demographic and clinical characteristics, to estimate the odds of experiential outcomes in all the four domains. RESULTS:Compared to those cared for by physicians in hospitals, individuals cared for by midwives in community settings had more than five times the odds of experiencing higher autonomy (aOR: 5.22, 95% CI: 3.65-7.45), higher respect (aOR: 5.39, 95% CI: 3.72-7.82) and lower odds of mistreatment (aOR: 0.16, 95% CI: 0.10-0.26). We found significant differences across birth settings: participants cared for by midwives in the community settings had significantly better experiential outcomes than those in the hospital settings: high- autonomy (aOR: 2.97, 95% CI: 2.66-4.27), respect (aOR: 4.15, 95% CI: 2.81-6.14), mistreatment (aOR: 0.20, 95% CI: 0.11-0.34), time spent (aOR: 8.06, 95% CI: 4.26-15.28). CONCLUSION/CONCLUSIONS:Participants reported better experiential outcomes when cared for by midwives than by physicians. And for those receiving midwifery care, the quality of experiential outcomes was significantly higher in community settings than in hospital settings. Care settings matter and structures of hospital-based care may impair implementation of the person-centered midwifery care model.

OBJECTIVE:This study aimed to explore the association of nurses' perceptions of patient safety climate with missed nursing care in labor and delivery (L&D) units. METHODS:We recruited nurse respondents via email distribution of an electronic survey between February 2018 and July 2019. Hospitals with L&D units were recruited from states with projected availability of 2018 state inpatient data in the United States. Measures included the Safety Attitudes Questionnaire Safety Climate Subscale and the Perinatal Missed Care Survey. We estimated the relationship between safety climate and missed care using Kruskal-Wallis tests and mixed-effects linear regression. RESULTS:The analytic sample included 3429 L&D registered nurses from 253 hospitals (response rate, 35%). A majority of respondents (65.7%) reported a perception of good safety climate in their units, with a mean score of 4.12 (±0.73) out of 5. The mean number of aspects of care occasionally, frequently, or always missed on respondents' units was 11.04 (±6.99) out of 25. χ2 Tests showed that six mostly commonly missed aspects of care (e.g., timely documentation) and three reasons for missed care (communications, material resources, and labor resources) were associated with safety climate groups (P < 0.001). The adjusted mixed-effects model identified a significant association between better nurse-perceived safety climate and less missed care (β = -2.65; 95% confidence interval, -2.97 to -2.34; P < 0.001) after controlling for years of experience and highest nursing education. CONCLUSIONS:Our findings suggest that improving safety climate-for example, through better teamwork and communication-may improve nursing care quality during labor and birth through decreasing missed nursing care. Conversely, it is also possible that strategies to reduce missed care-such as staffing improvements-may improve safety climate.

BACKGROUND:Evidence is limited on nurse staffing in maternity units. PURPOSE/OBJECTIVE:To estimate the relationship between hospital characteristics and adherence with Association of Women's Health, Obstetric and Neonatal Nurses nurse staffing guidelines. METHODS:We enrolled 3,471 registered nurses in a cross-sectional survey and obtained hospital characteristics from the 2018 American Hospital Association Annual Survey. We used mixed-effects linear regression models to estimate associations between hospital characteristics and staffing guideline adherence. FINDINGS/RESULTS:Overall, nurses reported strong adherence to AWHONN staffing guidelines (rated frequently or always met by ≥80% of respondents) in their hospitals. Higher birth volume, having a neonatal intensive care unit, teaching status, and higher percentage of births paid by Medicaid were all associated with lower mean guideline adherence scores. DISCUSSION AND CONCLUSIONS/CONCLUSIONS:Important gaps in staffing were reported more frequently at hospitals serving patients more likely to have medical or obstetric complications, leaving the most vulnerable patients at risk.

BACKGROUND:Social determinants of health, including neighborhood context, may be a key driver of severe maternal morbidity and its related racial and ethnic inequities; however, investigations remain limited. OBJECTIVE:This study aimed to examine the associations between neighborhood socioeconomic characteristics and severe maternal morbidity, as well as whether the associations between neighborhood socioeconomic characteristics and severe maternal morbidity were modified by race and ethnicity. STUDY DESIGN/METHODS:This study leveraged a California statewide data resource on all hospital births at ≥20 weeks of gestation (1997-2018). Severe maternal morbidity was defined as having at least 1 of 21 diagnoses and procedures (eg, blood transfusion or hysterectomy) as outlined by the Centers for Disease Control and Prevention. Neighborhoods were defined as residential census tracts (n=8022; an average of 1295 births per neighborhood), and the neighborhood deprivation index was a summary measure of 8 census indicators (eg, percentage of poverty, unemployment, and public assistance). Mixed-effects logistic regression models (individuals nested within neighborhoods) were used to compare odds of severe maternal morbidity across quartiles (quartile 1 [the least deprived] to quartile 4 [the most deprived]) of the neighborhood deprivation index before and after adjustments for maternal sociodemographic and pregnancy-related factors and comorbidities. Moreover, cross-product terms were created to determine whether associations were modified by race and ethnicity. RESULTS:Of 10,384,976 births, the prevalence of severe maternal morbidity was 1.2% (N=120,487). In fully adjusted mixed-effects models, the odds of severe maternal morbidity increased with increasing neighborhood deprivation index (odds ratios: quartile 1, reference; quartile 4, 1.23 [95% confidence interval, 1.20-1.26]; quartile 3, 1.13 [95% confidence interval, 1.10-1.16]; quartile 2, 1.06 [95% confidence interval, 1.03-1.08]). The associations were modified by race and ethnicity such that associations (quartile 4 vs quartile 1) were the strongest among individuals in the "other" racial and ethnic category (1.39; 95% confidence interval, 1.03-1.86) and the weakest among Black individuals (1.07; 95% confidence interval, 0.98-1.16). CONCLUSION/CONCLUSIONS:Study findings suggest that neighborhood deprivation contributes to an increased risk of severe maternal morbidity. Future research should examine which aspects of neighborhood environments matter most across racial and ethnic groups.