Parent Perspectives: Part 2-Considerations for the Transition Home Post-NICU Discharge.

This paper is part two of a series of papers written by the mothers of Neonatal Intensive Care Unit (NICU) graduates. The companion paper, "Parent Perspectives: Part 1-Considerations for Changing the NICU Culture", considers all aspects of the NICU experience and provides recommendations for interventions and improvements from a life-course perspective while families are in the NICU. In part two, the focus is the transition home post-NICU stay. The time after NICU discharge is a critical and sensitive developmental period for NICU babies and their families, and an important life course transition. This paper provides a parent's perspective of how to improve the transition home post-NICU stay. Our perspectives draw on the Life Course Health Development approach, which regards health as an active process that is developed over time based on a person's internal biologic and physiologic systems, their external environment and circumstances, and the interactions or relationships between them. This paper describes a collaborative care model where parents and their healthcare teams work together to develop shared care plans. It also describes how we can build trust and family capacity to support long-term care, ensure family well-being, and link families to needed resources and support that can ease the transition from the NICU back to the home and optimize family health trajectories.

Parent Perspectives: Part 1-Considerations for Changing the NICU Culture.

While publications that aim to reflect the parent perspective are increasingly common in the medical literature, few are authored by parents in their own words. As mothers with lived and professional experience in the Neonatal Intensive Care Unit (NICU), we believe this perspective is vital to improving health outcomes. We are writing from a life course health development framework that regards health as an active process that develops over time with the integration of physical, social, emotional, and relational components. Health development trajectories are shaped by the family and community ecosystems that surround each child. This means that the child's ability to thrive is strongly linked to the family's health and well-being. These links are not being given sufficient attention in clinical practice. Psychological distress, trauma, and grief are common family experiences in the NICU. Left unaddressed, they can negatively impact parent-child bonding. Drawing on life course principles, we make a series of recommendations for changes to practice to enable NICUs to better serve children and families, and better prepare families for the post-NICU experience. These include setting a positive tone in the NICU, creating a nurturing, personalized environment; addressing the social determinants of health; supporting families to develop a 'growth' mindset; and communicating in an optimistic, positive manner. Building trust is key to ensuring families feel supported and can be promoted through establishing equitable collaborative models of care. Peer support, doulas, and community health worker engagement can facilitate early interactions crucial to the child's developmental progress and family healing.

The Autism Intervention Research Network on Physical Health (AIR-P) Research Agenda.

OBJECTIVES: In the United States, autistic individuals experience disproportionate physical and mental health challenges relative to non-autistic individuals, including higher rates of co-occurring and chronic conditions and lower physical, social, and psychological health-related quality of life. The Autism Intervention Research Network on Physical Health (AIR-P) is an interdisciplinary, multicenter research network for scientific collaboration and infrastructure that aims to increase the life expectancy and quality of life for autistic individuals, with a focus on underserved or vulnerable populations. The current paper describes the development of the AIR-P Research Agenda. METHODS: Development of the research agenda involved an iterative and collaborative process between the AIR-P Advisory Board, Steering Committee, and Autistic Researcher Review Board. The methodology consisted of 3 phases: (1) ideation and design, (2) literature review and synthesis; and (3) network engagement. RESULTS: Six core research priorities related to the health of autistic individuals were identified: (1) primary care services and quality, (2) community-based lifestyle interventions, (3) health systems and services, (4) gender, sexuality, and reproductive health, (5) neurology, and (6) genetics. Specific topics within each of these priorities were identified. Four cross-cutting research priorities were also identified: (1) neurodiversity-oriented care, (2) facilitating developmental transitions, (3) methodologically rigorous intervention studies, and (4) addressing health disparities. CONCLUSIONS: The AIR-P Research Agenda represents an important step forward for enacting large-scale health-promotion efforts for autistic individuals across the lifespan. This agenda will catalyze autism research in historically underrepresented topic areas while adopting a neurodiversity-oriented approach to health-promotion.

Prevalence and Social and Built Environmental Determinants of Maternal Prepregnancy Obesity in 68 Major Metropolitan Cities of the United States, 2013-2016.

Objective: Maternal prepregnancy obesity is related to increased maternal morbidity and mortality and poor birth outcomes. However, prevalence and risk factors for prepregnancy obesity in US cities are not known. This study examines the prevalence and social and environmental determinants of maternal prepregnancy obesity (BMI ≥30), overweight/obesity (BMI ≥25), and severe obesity (BMI ≥40) in the 68 largest metropolitan cities of the United States. Methods: We fitted logistic and Poisson regression models to the 2013-2016 national vital statistics birth cohort data (N = 3,083,600) to derive unadjusted and adjusted city differentials in maternal obesity and to determine social and environmental determinants. Results: Considerable disparities existed across cities, with the prevalence of prepregnancy obesity ranging from 10.4% in San Francisco to 36.6% in Detroit. Approximately 63.0% of mothers in Detroit were overweight or obese before pregnancy, compared with 29.2% of mothers in San Francisco. Severe obesity ranged from 1.4% in San Francisco to 8.5% in Cleveland. Women in Anchorage, Buffalo, Cleveland, Fresno, Indianapolis, Louisville, Milwaukee, Oklahoma City, Sacramento, St Paul, Toledo, Tulsa, and Wichita had >2 times higher adjusted odds of prepregnancy obesity compared to those in San Francisco. Race/ethnicity, maternal age, parity, marital status, nativity/immigrant status, and maternal education were important individual-level risk factors and accounted for 63%, 39%, and 72% of the city disparities in prepregnancy obesity, overweight/obesity, and severe obesity, respectively. Area deprivation, violent crime rates, physical inactivity rates, public transport use, and access to parkland and green spaces remained significant predictors of prepregnancy obesity even after controlling for individual-level covariates. Conclusions: Substantial disparities in maternal prepregnancy obesity among the major US cities remain despite risk-factor adjustment, with women in several Southern and Midwestern cities experiencing high risks of obesity. Sound urban policies are needed to promote healthier lifestyles and favorable social and built environments for obesity reduction and improved maternal health.

Maternal and Child Health Bureau's Autism Research Program.

OBJECTIVES: To provide an overview and quantitatively demonstrate the reach of the Health Resources and Services Administration's Maternal and Child Health Bureau autism research program. METHODS: We reviewed program reports and internal data from 59 autism research grantees. The US federal Interagency Autism Coordinating Committee's strategic plan questions were used as a framework to highlight the contributions of the autism research program in advancing the field. RESULTS: The autism research program grantees advance research in several ways. Grantees have strengthened the evidence for autism interventions by conducting 89 studies at 79 distinct research sites. A total of 212 708 participants have enrolled in autism research program studies and 361 researchers have contributed to furthering autism research. The program addresses topics that align with the majority of the Interagency Autism Coordinating Committee's priority topic areas, including advancements in treatments and interventions, services and supports, and identifying risk factors. Grantee products include 387 peer-reviewed publications, 19 tools, and 13 practice guidelines for improving care and intervention practices. CONCLUSIONS: The autism research program has contributed to medical advances in research, leveraged innovative training platforms to provide specialized training, and provided access to health services through research-based screening and diagnostic procedures. Autism research program studies have contributed to the development of evidence-based practice guidelines, informed policy guidelines, and quality improvement efforts to bolster advancements in the field. Although disparities still exist, the Health Resources and Services Administration's Maternal and Child Health Bureau can reduce gaps in screening and diagnosis by targeting interventions to underserved populations including minority and rural communities.

Associations Between Maternal Body Mass Index, Gestational Weight Gain, Maternal Complications, and Birth Outcome in Singleton, Term Births in a Largely Non-Hispanic White, Rural Population.

Background: In 2009, the Institute of Medicine (IOM) published guidance on gestational weight gain (GWG) modified by body mass index (BMI). GWG outside of IOM recommendations negatively affects birth outcomes and child health. This study examined the relationship between BMI, GWG, birth complications, and birth outcomes in a rural, non-Hispanic white population over 10 years. Materials and Methods: We examined maternal BMI, GWG, birth weight, birth complications, and Apgar score in 18,217 term singleton births from medical records at Geisinger, PA from 2006 to 2015. Primary outcomes were GWG, delivery mode, Apgar score, and infant birth weight. Results: A majority of women (74.2%) had GWG outside of recommendations. Prevalence of cesarean delivery was highest for women with GWG above recommendations regardless of BMI. One in five neonates of obese women with GWG above recommendations had Apgar scores below eight. Although most births were normal for gestational age (88%), underweight women who gained below recommendations had the highest percentage of small for gestational age (SGA) births (10.4%) and obese women who gained above recommendations had the highest percentage of large for gestational age (LGA) births (22.2%). Among women with BMIs above 35 kg/m2 and GWG within recommendations, 18.9% of births were LGA. Conclusions: Most pregnant women are not gaining weight within recommendations. GWG outside of IOM recommendations resulted in poorer birth outcomes, particularly in underweight and obese women. Underweight women with GWG below recommendations are at increased risk for SGA neonates. We suggest reducing GWG recommendations for women above 35 kg/m2 to decrease LGA births and pregnancy complications.

Marked Disparities in Pre-Pregnancy Obesity and Overweight Prevalence among US Women by Race/Ethnicity, Nativity/Immigrant Status, and Sociodemographic Characteristics, 2012-2014.

This study examines racial/ethnic, nativity, and sociodemographic disparities in the prevalence of pre-pregnancy obesity and overweight in the United States. Logistic regression was fitted to the 2012-2014 national birth cohort data to derive unadjusted and adjusted differentials in pre-pregnancy obesity (BMI ≥30), severe obesity (BMI ≥40), and overweight/obesity (BMI ≥25) prevalence among 10.4 million US women of childbearing age. Substantial racial/ethnic differences existed, with pre-pregnancy obesity rates ranging from 2.6% for Chinese and 3.3% for Vietnamese women to 34.9% for American Indians/Alaska Natives (AIANs) and 60.2% for Samoans. Pre-pregnancy overweight/obese prevalence ranged from 13.6% for Chinese women to 61.7% for AIANs and 86.3% for Samoans. Compared to non-Hispanic whites, women in all Asian subgroups had markedly lower risks of pre-pregnancy obesity, severe obesity, and overweight/obesity, whereas Samoans, Hawaiians, AIANs, blacks, Mexicans, Puerto Ricans, and Central/South Americans had significantly higher risks. Immigrant women in each racial/ethnic group had lower rates of pre-pregnancy obesity than the US-born. Sociodemographic risk factors accounted for 33-47% of racial/ethnic disparities and 12-16% of ethnic-immigrant disparities in pre-pregnancy obesity and overweight/obesity. Further research is needed to assess the effects of diet, physical inactivity, and social environments in explaining the reported ethnic and nativity differences in pre-pregnancy obesity.

Use of postpartum care: predictors and barriers.

This study aimed to identify actual and perceived barriers to postpartum care among a probability sample of women who gave birth in Los Angeles County, California in 2007. Survey data from the 2007 Los Angeles Mommy and Baby (LAMB) study (N = 4,075) were used to identify predictors and barriers to postpartum care use. The LAMB study was a cross-sectional, population-based study that examined maternal and child health outcomes during the preconception, prenatal, and postpartum periods. Multivariable analyses identified low income, being separated/divorced and never married, trying hard to get pregnant or trying to prevent pregnancy, Medi-Cal insurance holders, and lack of prenatal care to be risk factors of postpartum care nonuse, while Hispanic ethnicity was protective. The most commonly reported barriers to postpartum care use were feeling fine, being too busy with the baby, having other things going on, and a lack of need. Findings from this study can inform the development of interventions targeting subgroups at risk for not obtaining postpartum care. Community education and improved access to care can further increase the acceptability of postpartum visits and contribute to improvements in women's health. Postpartum care can serve as a gateway to engage underserved populations in the continuum of women's health care.

Menopause and lead body burden among US women aged 45-55, NHANES 1999-2010.

BACKGROUND: Environmental factors in menopause have received limited attention. Lead is a known reproductive toxicant associated with delayed puberty in girls that may also affect menopause. METHODS: The odds of menopause among US women aged 45-55 were estimated in the National Health and Nutrition Examination Survey, 1999-2010, in relation to quartiles of blood lead. Women still menstruating (n=2158) were compared to women with natural menopause (n=1063). Logistic regression models included age, race/ethnicity, current hormone use, poverty, smoking and where available, bone density or bone alkaline phosphatase. RESULTS: Lead levels (ug/dL) were higher in menopausal women, geometric mean (standard error)=1.71 (0.04) vs. 1.23 (0.02). Adjusted odds of menopause and 95% confidence intervals for lead quartiles (lowest quartile referent) were 1.7 (1.0-2.8), 2.1 (1.2-3.6), and 4.2 (2.5-7.0) respectively. Results adjusting for bone markers were generally similar but had less precision. CONCLUSIONS: Blood lead was associated with natural menopause in US women even after adjustment for bone turnover. This raises concern that lead exposure, even at low levels, may shorten women's reproductive lifespan.