Relationships between self-reported smoking, household environmental tobacco smoke exposure and depressive symptoms in a pregnant minority population.

UNLABELLED: This study sought to examine relationships between depressive symptoms and prenatal smoking and/or household environmental tobacco smoke exposure (HH-ETSE) among urban minority women. We analyzed private, audio computer-assisted self interview data from a clinic-based sample of 929 minority pregnant women in Washington, DC. Depressive symptoms were assessed via the Beck Depression Inventory Fast Screen. HH-ETSE, current smoking, and former smoking were assessed via self-report. Depression levels and demographic characteristics were compared: (1) among nonsmokers, for those reporting HH-ETSE versus no HH-ETSE; and (2) among smokers, for those reporting current smoking (in last 7 days) versus former smokers. Measures associated with HH-ETSE/current smoking in bivariate analysis at P < 0.20 were included in adjusted logistic regression models. HH-ETSE, as a possible indicator of a social smoking network, was assessed as a mediator for the relationship between depression and current smoking. RESULTS: Non-smokers reporting moderate-to-severe depressive symptoms showed significantly higher adjusted odds of prenatal HH-ETSE (AOR 2.5, 95% CI [1.2, 5.2]). Smokers reporting moderate-to-severe or mild depressive symptoms showed significantly higher adjusted odds of current smoking (AOR 1.9, 95% CI [1.1, 3.5] and AOR 1.8, 95% CI [1.1, 3.1], respectively). Among smokers, HH-ETSE was a significant mediator for the association between moderate-to-severe symptoms and current smoking. In conclusion, health care providers should be aware that depressed urban minority women are at risk of continued smoking/HH-ETSE during pregnancy. Interventions designed to encourage behavior change should include screening for depression, and build skills so that women are better able to address the social environment.

African American and Latino patient versus provider perceptions of determinants of prenatal care initiation.

Few studies have compared provider and patient perceptions of barriers, motivators and facilitators of prenatal care (PNC) initiation. The current study compared these perceptions in providers and patients in Washington, DC, a city characterized by infant mortality and low birth weight rates that are among the highest in the nation, and poor utilization of PNC, particularly among minority groups. The results reported here were part of a larger study of barriers, motivators and facilitators influencing PNC utilization in Washington, DC. A convenience sample of 331 African American and Latino patients and 61 providers were interviewed to identify which of 63 motivators, facilitators, and barriers significantly influenced PNC initiation. Both sample groups were recruited at 14 PNC facilities, selected to represent all sites in DC known to serve high-risk, low-income minority women, including hospital-based clinics, community-based clinics, and private practices. Data were analyzed using Fisher exact tests and Kendall's concordance tests. Results indicated that there was good agreement between patients and providers about the relative importance of the various barriers (especially psychosocial), motivators, and facilitators. However, differences were found between patients and providers in the response frequencies. Providers were more likely to report barriers while patients were more likely to report certain motivators (especially learning better health habits and how to protect health). These results indicate that despite widespread agreement on most issues, especially psychosocial barriers, patients rated health education higher than providers.

Evaluation of a randomized intervention to delay sexual initiation among fifth-graders followed through the sixth grade.

US adolescents initiate sex at increasingly younger ages, yet few pregnancy prevention interventions for children as young as 10-12 years old have been evaluated. Sixteen Washington, DC schools were randomly assigned to intervention versus control conditions. Beginning in 2001/02 with fifth-grade students and continuing during the sixth grade, students completed pre-intervention and post-intervention surveys each school year. Each year, the intervention included 10-13 classroom sessions related to delaying sexual initiation. Linear hierarchical models compared outcome changes between intervention and control groups by gender over time. Results show the intervention significantly decreased a rise over time in the anticipation of having sex in the next 12 months among intervention boys versus control boys, but it had no other outcome effects. Among girls, the intervention had no significant outcome effects. One exception is that for both genders, compared with control students, intervention students increased their pubertal knowledge. In conclusion, a school-based curriculum to delay sexual involvement among fifth-grade and sixth-grade high-risk youths had limited impact. Additional research is necessary to outline effective interventions, and more intensive, comprehensive interventions may be required to counteract adverse circumstances in students' lives and pervasive influences toward early sex.ClinicalTrials. gov identifier: NCT00341471.

Understanding the association of biomedical, psychosocial and behavioral risks with adverse pregnancy outcomes among African-Americans in Washington, DC.

This study investigates the relationship between adverse pregnancy outcomes in high-risk African American women in Washington, DC and sociodemographic risk factors, behavioral risk factors, and the most common and interrelated medical conditions occurring during pregnancy: diabetes, hypertension, preeclampsia, and Body Mass Index (BMI). Data are from a randomized controlled trial conducted in 6 prenatal clinics. Women in their 1st or 2nd trimester were screened for behavioral risks (smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) and demographic eligibility. 1,044 were eligible, interviewed and followed through their pregnancies. Classification and Regression Trees (CART) methodology was used to: (1) explore the relationship between medical and behavioral risks (reported at enrollment), sociodemographic factors and pregnancy outcomes; (2) identify the relative importance of various predictors of adverse pregnancy outcomes; and (3) characterize women at the highest risk of poor pregnancy outcomes. The strongest predictors of poor outcomes were prepregnancy BMI, preconceptional diabetes, employment status, intimate partner violence, and depression. In CART analysis, preeclampsia was the first splitter for low birthweight; preconceptional diabetes was the first splitter for preterm birth (PTB) and neonatal intensive care admission; BMI was the first splitter for very PTB, large for gestational age, Cesarean section and perinatal death; employment was the first splitter for miscarriage. Preconceptional factors strongly influence pregnancy outcomes. For many of these women, the high risks they brought into pregnancy were more likely to impact their pregnancy outcomes than events during pregnancy.

Smoking cessation and relapse among pregnant African-American smokers in Washington, DC.

Smoking is the single most preventable cause of perinatal morbidity. This study examines smoking behaviors during pregnancy in a high risk population of African Americans. The study also examines risk factors associated with smoking behaviors and cessation in response to a cognitive behavioral therapy (CBT) intervention. This study is a secondary analysis of data from a randomized controlled trial addressing multiple risks during pregnancy. Five hundred African-American Washington, DC residents who reported smoking in the 6 months preceding pregnancy were randomized to a CBT intervention. Psycho-social and behavioral data were collected. Self-reported smoking and salivary cotinine levels were measured prenatally and postpartum to assess changes in smoking behavior. Comparisons were made between active smokers and those abstaining at baseline and follow-up in pregnancy and postpartum. Sixty percent of participants reported quitting spontaneously during pregnancy. In regression models, smoking at baseline was associated with older age,

Very preterm birth is reduced in women receiving an integrated behavioral intervention: a randomized controlled trial.

This study examines whether an integrated behavioral intervention with proven efficacy in reducing psycho-behavioral risks (smoking, environmental tobacco smoke exposure (ETSE), depression, and intimate partner violence (IPV)) in African-Americans is associated with improved pregnancy outcomes. A randomized controlled trial targeting risks during pregnancy was conducted in the District of Columbia. African-American women were recruited if reporting at least one of the risks mentioned above. Randomization to intervention or usual care was site and risk specific. Sociodemographic, health risk and pregnancy outcome data were collected. Data on 819 women, and their singleton live born infants were analyzed using an intent-to-treat approach. Bivariate analyses preceded a reduced logistical model approach to elucidate the effect of the intervention on the reduction of prematurity and low birth weight. The incidence of low birthweight (LBW) was 12% and very low birthweight (VLBW) was 1.6%. Multivariate logistic regression results showed that depression was associated with LBW (OR = 1.71, 95% CI = 1.12-2.62). IPV was associated with preterm birth (PTB) and very preterm birth (VPTB) (OR 1.64, 95% CI = 1.07-2.51, OR = 2.94, 95% CI = 1.40-6.16, respectively). The occurrence of VPTB was significantly reduced in the intervention compared to the usual care group (OR = 0.42, 95% CI = 0.19-0.93). Our study confirms the significant associations between multiple psycho-behavioral risks and poor pregnancy outcomes, including LBW and PTB. Our behavioral intervention with demonstrated efficacy in addressing multiple risk factors simultaneously reduced VPTB within an urban minority population.

An intervention to reduce environmental tobacco smoke exposure improves pregnancy outcomes.

OBJECTIVE: We tested the efficacy of a cognitive-behavioral intervention in reducing environmental tobacco smoke exposure (ETSE) and improving pregnancy outcomes among black women. METHODS: We recruited 1044 women to a randomized, controlled trial during 2001-2004 in Washington, DC. Data on 691 women with self-reported ETSE were analyzed. A subset of 520 women with ETSE and salivary cotinine levels (SCLs) of <20 ng/mL were also analyzed. Individually tailored counseling sessions, adapted from evidence-based interventions for ETSE and other risks, were delivered to the intervention group. The usual-care group received routine prenatal care as determined by their provider. Logistic regression models were used to predict ETSE before delivery and adverse pregnancy outcomes. RESULTS: Women in the intervention were less likely to self-report ETSE before delivery when controlling for other covariates (odds ratio [OR]: 0.50 [95% confidence interval (CI): 0.35-0.71]). Medicaid recipients were more likely to have ETSE (OR: 1.97 [95% CI: 1.31-2.96]). With advancing maternal age, the likelihood of ETSE was less (OR: 0.96 [95% CI: 0.93-0.99]). For women in the intervention, the rates of very low birth weight (VLBW) and very preterm birth (VPTB) were significantly improved (OR: 0.11 [95% CI: 0.01-0.86] and OR: 0.22 [95% CI: 0.07-0.68], respectively). For women with an SCL of <20 ng/mL, maternal age was not significant. Intimate partner violence at baseline significantly increased the chances of VLBW and VPTB (OR: 3.75 [95% CI: 1.02-13.81] and 2.71 [95% CI: 1.11-6.62], respectively). These results were true for mothers who reported ETSE overall and for those with an SCL of <20 ng/mL. CONCLUSIONS: This is the first randomized clinical trial demonstrating efficacy of a cognitive-behavioral intervention targeting ETSE in pregnancy. We significantly reduced ETSE as well as VPTB and VLBW, leading causes of neonatal mortality and morbidity in minority populations. This intervention may reduce health disparities in reproductive outcomes.

An integrated intervention to reduce intimate partner violence in pregnancy: a randomized controlled trial.

OBJECTIVE: To estimate the efficacy of a psycho-behavioral intervention in reducing intimate partner violence recurrence during pregnancy and postpartum and in improving birth outcomes in African-American women. METHODS: We conducted a randomized controlled trial for which 1,044 women were recruited. Women were randomly assigned to receive either intervention (n=521) or usual care (n=523). Individually tailored counseling sessions were adapted from evidence-based interventions for intimate partner violence and other risks. Logistic regression was used to model intimate partner violence victimization recurrence and to predict minor, severe, physical, and sexual intimate partner violence. RESULTS: Women randomly assigned to the intervention group were less likely to have recurrent episodes of intimate partner violence victimization (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.29-0.80). Women with minor intimate partner violence were significantly less likely to experience further episodes during pregnancy (OR 0.48, 95% CI 0.26-0.86, OR 0.53, 95% CI 0.28-0.99) and postpartum (OR 0.56, 95% CI 0.34-0.93). Numbers needed to treat were 17, 12, and 22, respectively, as compared with the usual care group. Women with severe intimate partner violence showed significantly reduced episodes postpartum (OR 0.39, 95% CI 0.18-0.82); the number needed to treat was 27. Women who experienced physical intimate partner violence showed significant reduction at the first follow-up (OR 0.49, 95% CI 0.27-0.91) and postpartum (OR 0.47, 95% CI 0.27-0.82); the numbers needed to treat were 18 and 20, respectively. Women in the intervention group had significantly fewer very preterm neonates (1.5% intervention group, 6.6% usual care group; P=.03) and an increased mean gestational age (38.2+/-3.3 intervention group, 36.9+/-5.9 usual care group; P=.016). CONCLUSION: A relatively brief intervention during pregnancy had discernible effects on intimate partner violence and pregnancy outcomes. Screening for intimate partner violence as well as other psychosocial and behavioral risks and incorporating similar interventions in prenatal care is strongly recommended. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00381823. LEVEL OF EVIDENCE: I.

Acceptance, Communication Mode and Use of Audio Computer-Assisted Self Interview Using Touchscreen to Identify Risk Factors among Pregnant Minority Women.

This paper evaluates the acceptability, communication mode and use of audio computer-assisted self-interview (A-CASI) among minority pregnant women receiving prenatal care in six Washington, DC sites. A total of 2,913 women were screened for demographic eligibility (18+ years old, <29 weeks gestation, Black/African-American or Hispanic) and risk (smoking, environmental tobacco smoke exposure, depression, intimate partner violence). Questions were displayed on touch screen laptop monitors and heard through earphones. The mean length of time to complete the screener was almost 6 minutes.A-CASI experience, which included difficulty in using the computer, acceptability (enjoyment), and preferred communication mode, was compared across sites, the eligibility and risk groups and a subset of 878 enrolled women for whom educational attainment and receipt of WIC (a proxy for income) were available. Respondents thought A-CASI was not difficult to use and liked using the computer. Black/African-American or Hispanic respondents enjoyed it significantly more than did respondents of other race/ethnicities. Respondents who were demographically eligible, Black/African-American or Hispanic, or with lower education levels listened to questions significantly more than did their counterparts. Mainly listening or listening and reading does not impact burden in terms of the length of time it took to complete the screener.The acceptance of A-CASI as a screening tool opens the door for more uses of this technology in health-related fields. The laptop computer and headphones provide privacy and mobility so the technology can be used to ask sensitive questions in almost any locale, including busy clinic settings.

Prediction of birth weight by cotinine levels during pregnancy in a population of black smokers.

OBJECTIVE: The goal was to investigate the association between maternal salivary cotinine levels (SCLs) and pregnancy outcomes among black smokers. METHODS: In a randomized, controlled trial conducted in 2001-2004 in Washington, DC, 714 women (126 active smokers [18%]) were tested for SCLs at the time of recruitment and later in pregnancy. Sociodemographic health risks and pregnancy outcomes were recorded. RESULTS: Birth weights were significantly lower for infants born to mothers with baseline SCLs of > or =20 ng/mL in comparison with <20 ng/mL (P = .024), > or =50 ng/mL in comparison with <50 ng/mL (P = .002), and > or =100 ng/mL in comparison with <100 ng/mL (P = .002), in bivariate analyses. In linear regression analyses adjusting for sociodemographic and medical factors, SCLs of > or =20 ng/mL were associated with a reduction in birth weight of 88 g when SCLs were measured at baseline (P = .042) and 205 g when SCLs were measured immediately before delivery (P < .001). Corresponding results were 129 g (P = .006) and 202 g (P < .001) for > or =50 ng/mL and 139 g (P = .007) and 205 g (P < .001) for > or =100 ng/mL. Gestational age was not affected significantly at any SCL, regardless of when SCLs were measured. CONCLUSIONS: Elevated SCLs early in pregnancy or before delivery were associated with reductions in birth weight. At any cutoff level, birth weight reduction was more significant for the same SCL measured in late pregnancy. Maintaining lower levels of smoking for women who are unable to quit may be beneficial.

Reducing psychosocial and behavioral pregnancy risk factors: results of a randomized clinical trial among high-risk pregnant african american women.

OBJECTIVES: We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, secondhand smoke exposure, depression, and intimate partner violence). METHODS: Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-up. RESULTS: Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021). CONCLUSIONS: In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.

Environmental tobacco smoke avoidance among pregnant African-American nonsmokers.

BACKGROUND: Environmental tobacco smoke (ETS) exposure during pregnancy contributes to adverse infant health outcomes. Limited previous research has focused on identifying correlates of ETS avoidance. This study sought to identify proximal and more distal correlates of ETS avoidance early in pregnancy among African-American women. METHODS: From a sample of low-income, black women (n=1044) recruited in six urban, prenatal care clinics (July 2001-October 2003), cotinine-confirmed nonsmokers with partners, household/family members, or friends who smoked (n=450) were identified and divided into two groups: any past-7-day ETS exposure and cotinine-confirmed ETS avoidance. Bivariate and multivariate logistic regression analyses identified factors associated with ETS avoidance. Data were initially analyzed in 2004. Final models were reviewed and revised in 2007 and 2008. RESULTS: Twenty-seven percent of pregnant nonsmokers were confirmed as ETS avoiders. In multivariate logistic regression analysis, the odds of ETS avoidance were increased among women who reported household smoking bans (OR=2.96; 95% CI=1.83, 4.77; p<0.0001), that the father wanted the baby (OR=2.70; CI=1.26, 5.76; p=0.01), and that no/few family members/friends smoked (OR=3.15; 95% CI=1.58, 6.29; p<0.001). The odds were decreased among women who had a current partner (OR=0.42; 95% CI=0.23, 0.76; p<0.01), reported any intimate partner violence during pregnancy (OR=0.43; 95% CI=0.19, 0.95; p<0.05), and reported little social support to prevent ETS exposure (OR=0.50; 95% CI=0.30, 0.85; p=0.01). Parity, emotional coping strategies, substance use during pregnancy, partner/household member smoking status, and self-confidence in avoiding ETS were significant in bivariate, but not multivariate analyses. CONCLUSIONS: Social contextual factors were the strongest determinants of ETS avoidance during pregnancy. Results highlight the importance of prenatal screening to identify pregnant nonsmokers at risk, encouraging household smoking bans, gaining support from significant others, and fully understanding the interpersonal context of a woman's pregnancy before providing behavioral counseling and advice to prevent ETS exposure.

An intervention to improve postpartum outcomes in African-American mothers: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of an integrated multiple risk intervention, delivered mainly during pregnancy, in reducing such risks (cigarette smoking, environmental tobacco smoke exposure, depression, and intimate partner violence) postpartum. METHODS: Data from this randomized controlled trial were collected prenatally and on average 10 weeks postpartum in six prenatal care sites in the District of Columbia. African Americans were screened, recruited, and randomly assigned to the behavioral intervention or usual care. Clinic-based, individually tailored counseling was delivered to intervention women. The outcome measures were number of risks reported postpartum and reduction of these risks between baseline and postpartum. RESULTS: The intervention was effective in significantly reducing the number of risks reported in the postpartum period. In bivariate analyses, the intervention group was more successful in resolving all risks (47% compared with 35%, P=.007, number needed to treat=9, 95% confidence interval [CI] 5-31) and in resolving some risks (63% compared with 54%, P=.009, number needed to treat=11, 95% CI 7-43) as compared with the usual care group. In logistic regression analyses, women in the intervention group were more likely to resolve all risks (odds ratio 1.86, 95% CI 1.25-2.75, number needed to treat=7, 95% CI 4-19) and resolve at least one risk (odds ratio 1.60, 95% CI 1.15-2.22, number needed to treat=9, 95% CI 6-29). CONCLUSION: An integrated multiple risk factor intervention addressing psychosocial and behavioral risks delivered mainly during pregnancy can have beneficial effects in risk reduction postpartum.

Pregnancy intentions and happiness among pregnant black women at high risk for adverse infant health outcomes.

CONTEXT: Unintended pregnancy is associated with risk behaviors and increased morbidity or mortality for mothers and infants, but a woman's feelings about pregnancy may be more predictive of risk and health outcomes than her intentions. METHODS: A sample of 1,044 black women who were at increased risk were enrolled at prenatal care clinics in the District of Columbia in 2001-2003. Bivariate and multivariate analyses assessed associations between pregnancy intentions or level of happiness about being pregnant and multiple psychosocial and behavioral risk factors, and identified correlates of happiness to be pregnant. RESULTS: Pregnancy intentions and happiness were strongly associated, but happiness was the better predictor of risk. Unhappy women had higher odds than happy women of smoking, being depressed, experiencing intimate partner violence, drinking and using illicit drugs (odds ratios, 1.7-2.6). The odds of being happy were reduced among women who had other children or a child younger than two, who were single or did not have a current partner, who had had more than one sexual partner in the past year and who reported that the baby's father did not want the pregnancy (0.3-0.6). In contrast, the odds of being happy were elevated among women who had better coping strategies (1.03), who had not used birth control at conception (1.6) and who had 1-2 household members, rather than five or more (2.1). CONCLUSIONS: Additional psychosocial screening for happiness about being pregnant and for partner characteristics, particularly the father's desire to have this child, may help improve prenatal care services and prevent adverse health outcomes.

Recruitment and retention of low-income minority women in a behavioral intervention to reduce smoking, depression, and intimate partner violence during pregnancy.

BACKGROUND: Researchers have frequently encountered difficulties in the recruitment and retention of minorities resulting in their under-representation in clinical trials. This report describes the successful strategies of recruitment and retention of African Americans and Latinos in a randomized clinical trial to reduce smoking, depression and intimate partner violence during pregnancy. Socio-demographic characteristics and risk profiles of retained vs. non-retained women and lost to follow-up vs. dropped-out women are presented. In addition, subgroups of pregnant women who are less (more) likely to be retained are identified. METHODS: Pregnant African American women and Latinas who were Washington, DC residents, aged 18 years or more, and of 28 weeks gestational age or less were recruited at six prenatal care clinics. Potentially eligible women were screened for socio-demographic eligibility and the presence of the selected behavioral and psychological risks using an Audio Computer-Assisted Self-Interview. Eligible women who consented to participate completed a baseline telephone evaluation after which they were enrolled in the study and randomly assigned to either the intervention or the usual care group. RESULTS: Of the 1,398 eligible women, 1,191 (85%) agreed to participate in the study. Of the 1,191 women agreeing to participate, 1,070 completed the baseline evaluation and were enrolled in the study and randomized, for a recruitment rate of 90%. Of those enrolled, 1,044 were African American women. A total of 849 women completed the study, for a retention rate of 79%. Five percent dropped out and 12% were lost-to-follow up. Women retained in the study and those not retained were not statistically different with regard to socio-demographic characteristics and the targeted risks. Retention strategies included financial and other incentives, regular updates of contact information which was tracked and monitored by a computerized data management system available to all project staff, and attention to cultural competence with implementation of study procedures by appropriately selected, trained, and supervised staff. Single, less educated, alcohol and drug users, non-working, and non-WIC women represent minority women with expected low retention rates. CONCLUSION: We conclude that with targeted recruitment and retention strategies, minority women will participate at high rates in behavioral clinical trials. We also found that women who drop out are different from women who are lost to follow-up, and require different strategies to optimize their completion of the study.

Determinants of inadequate prenatal care utilization by African American women.

A convenience sample of city-dwelling African American women (n=246) was interviewed during each woman's postpartum stay at one of five hospitals in Washington, D.C. to determine their perceptions of factors influencing their prenatal care utilization. The Kotelchuck Adequacy of Prenatal Care Utilization Index was used to classify prenatal care utilization as either adequate (Adequate Plus and Adequate groups combined) or inadequate (Intermediate and Inadequate groups combined). Of the 246 women studied, 40% (99) had adequate prenatal care utilization. Using Classification and Regression Trees analysis, the following risk groups for inadequate prenatal care utilization were identified: women who reported psychosocial problems as barriers and who were not participants in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) (percent adequate=8.8); women who reported psychosocial problems as barriers, were participants of the WIC program, and reported substance use (percent adequate=13.8); and women who reported psychosocial problems as barriers, were participants of the WIC program, denied substance use, and reported childcare problems as barriers (percent adequate=20.0).

Low-income minority mothers' reports of infant health care utilisation compared with medical records.

This study aimed to investigate mothers' reporting of the nature, location, frequency and content of health care visits for their infants, as compared with data abstracted from the infants' medical records. It was part of a community-based parenting intervention designed to improve preventive health care utilisation among minority mothers in Washington, DC. Mothers >or=18 years old with newborn infants and with poor or no prenatal care were enrolled in the study. A total of 160 mother-infant dyads completed the 12-month study. Mothers were interviewed when the infants were 4, 8 and 12 months old, and were asked to recall infant visits to all health care providers. Medical records from identified providers were used for verification. The number and type of immunisations given, types of providers visited, and reason for the visits were compared. Only about a quarter of mothers agreed with their infants' medical records on the number of specific immunisations received. The mothers reported fewer polio (1.8 vs. 2.1, P = 0.006), diphtheria and tetanus toxoids and pertussis (DTP) (1.8 vs. 2.2, P = 0.002), and Haemophilus influenzae type b (HiB) (1.3 vs. 2.1, P < 0.0001) immunisations than were recorded. Similarly, about a quarter of the mothers were unaware of any polio, DTP or hepatitis B immunisations given, as documented in the medical records, and 38% did not know that their infant was immunised for HiB. Nearly half of the mothers recalled more infant doctors' visits than were recorded in the medical records (4.1 vs. 3.6 visits, P = 0.017). The mothers generally disagreed with the providers about the reason for a particular visit and reported fewer sick-baby visits (1.5 vs. 3.3, P < 0.0001) than the providers recorded. Mothers' reports and medical records matched in only 19% of the cases. In 47%, mothers under-reported and in 34% over-reported the total number of visits. The strongest agreement between mothers' reports and medical records was in the case of emergency room visits (63%). In conclusion, in this population, mothers' reporting did not match that of providers with respect to specific information: the number of immunisations, the location where services were provided, and the classification of sick- vs. well-baby visits. Future studies that evaluate health care utilisation data should take these discrepancies into consideration in their selection of information source, and in their interpretation of the data.

Determinants of late prenatal care initiation by African American women in Washington, DC.

OBJECTIVES: The objective of this study was to identify the determinants of late prenatal care (PNC) initiation among minority women in Washington, DC. METHODS: DC-resident, African American women (n = 303) were recruited at 14 PNC facilities, representing the various types of PNC facilities located in DC: 4 hospital-based clinics, 5 community-based clinics, and 5 private practices. The women were interviewed at their first prenatal care visits to determine their perceptions of 63 barriers, motivators and facilitators influencing PNC initiation; substance use; and sociodemographic background. PNC initiation was classified as early (prior to the 20th week of gestation) or late (after the 20th week of gestation). The responses of women who initiated PNC early versus late were compared using bivariate and multivariate statistical procedures. Classification and Regression Trees analysis was used to identify groups at risk of late initiation. RESULTS: Variables contributing to late PNC initiation included maternal age not between 20 and 29 years, unemployment, no history of previous abortions, consideration of abortion, lack of money to pay for PNC, and no motivation to learn how to protect ones health. Three risk groups for late PNC initiation included 1) women consideringabortion and not employed outside their homes; 2) women not considering abortion who had no previous abortion experience; and 3) teenagers not considering abortion and with no previous abortions. CONCLUSIONS: The results of this study indicate that psychosocial barriers are more important than structural barriers. Of the psychosocial barriers, the major determinants of late PNC initiation were consideration of abortion and previous abortion experience.

The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: a randomized, controlled study.

OBJECTIVE: To determine if a community-based intervention program focusing on parenting education will have an impact on preventive health care utilization behaviors among low-income, minority mothers in Washington, DC. DESIGN: The experimental design was a randomized, controlled study in which 286 mother-infant dyads were assigned to either the standard social services (control) group or to the intervention group. Women and their newborn infants were recruited during the immediate postpartum period in 4 Washington, DC, hospital sites from April 1995 to April 1997. The year-long multicomponent intervention included home visits and hospital-based group sessions in addition to the standard social services available at the hospital sites. A total of 286 postpartum women with inadequate prenatal care were assigned randomly to the control or the intervention group. Women and their infants were followed for 1 full year. Outcome measures included usage of preventive health care services including well care infant visits and adherence to immunization schedules during the first year of the infant's life. RESULTS: Infants in the intervention group initiated well care at an earlier age than controls (by 6 weeks, 62.5% vs 50% had received their first well infant visit). Infants in the intervention group had more frequent well visits (by 12 months of age, 3.5 vs 2.7 visits). Multivariate analyses showed infants in the intervention group to be more likely to complete their scheduled immunizations (by 9 months, odds ratio = 2.2, 95% confidence interval: 1.09-4.53). Those in the intervention group with more frequent contacts (30+ visits) with study personnel were most likely to have followed age-appropriate immunization schedules when compared with controls (at 9 months odds ratio = 3.63, 95% confidence interval: 1.58-8.33). CONCLUSIONS: It is possible to influence health care usage patterns of high-risk minority populations through public health interventions that are global in their perspective. Focusing on parental knowledge and beliefs regarding health-related issues and life skills in a self-efficacy model is associated with improved usage of infant health care resources.