A Path Towards Reproductive Justice: Incorporating a RJ Framework into North Carolina's Improving Community Outcomes for Maternal and Child Health Initiative.

PURPOSE: Long-acting reversible contraception (LARC) is encouraged as a strategy to address racial disparities in birth outcomes. Black woman-led organizations and stakeholders recommend a thoughtful integration of Reproductive Justice for any LARC programs. This paper will describe how one state-funded maternal and child health program reconceptualized an evidence-based strategy (EBS) focused on increasing access to LARC, to a broader strategy that incorporated principles of Reproductive Justice to improve birth outcomes. DESCRIPTION: In 2016, North Carolina established the Improving Community Outcomes for Maternal and Child Health (ICO4MCH) program. As part of this program, five county health departments were awarded funding to "increase access to LARC". Noting community partners' concerns with this strategy, ICO4MCH leadership revised the strategy to focus on using the Reproductive Justice framework to improve utilization of reproductive life planning and access to LARC. Leaders modified the strategy by changing performance measures and scope of work/deliverables required by grantees. ASSESSMENT: Using quarterly reports and focus group data from ICO4MCH grantees, we identified key steps communities have taken to prioritize Reproductive Justice. Key findings include that sites hosted Reproductive Justice trainings for team members and changed language describing family planning services. These activities were tailored to fit community context and existing perceptions about reproductive health services. CONCLUSION: The ICO4MCH program was able to modify a LARC EBS to better emphasize Reproductive Justice. Local agencies desiring to shift their LARC programs should include and value feedback from those with lived experience and partner with organizations committed to Reproductive Justice.

Black Perinatal Mental Health: Prioritizing Maternal Mental Health to Optimize Infant Health and Wellness.

Infant mental health is interconnected with and affected by maternal mental health. A mother or birthing person's mental health before and during pregnancy and the postpartum period is essential for a child's development. During the first year of life, infants require emotional attachment and bonding to strive. Perinatal mood disorders are likely to hinder attachment and are associated with an increased risk of adverse mental health effects for children later in life. The Black community is faced with a crisis as Black mothers experience a higher prevalence of perinatal mood disorders, including postpartum depression and anxiety, compared to the United States national estimates. The aim of the research is to identify social, structural, and economic disparities of Black perinatal women and birthing people's experience to understand the impact of perinatal mental health on infants' mental health. Black mothers and birthing people may often face social and structural barriers that limit their opportunity to seek and engage with interventions and treatment that address the root causes of their perinatal mood disorder. To enhance understanding of racial disparities caused by social and structural determinants of health on Black mothers and birthing people's mental health and health care experiences that influence infant mental health, the study team conducted semi-structured interviews among self-identified cisgender Black women health professionals nationwide, who provide care to pregnant or postpartum Black women and birthing people. Our study attempted to identify themes, pathways, interventions, and strategies to promote equitable and anti-racist maternal and infant mental health care. Using a Rigorous and Accelerated Data Reduction (Radar) technique and a deductive qualitative analytic approach it was found that limited access to resources, lack of universal screening and mental health education, and the disjointed healthcare system serves as barriers, contribute to mental health issues, and put Black mothers and birthing people at a disadvantage in autonomous decision making. Our study concluded that instituting education on healthy and culturally appropriate ways to support infant development in parent education programs may support Black parents in establishing healthy attachment and bonds. Prioritizing strategies to improve maternal mental health and centering Black parents in developing these educational parenting programs may optimize parenting experiences.

Pathways To Equitable And Antiracist Maternal Mental Health Care: Insights From Black Women Stakeholders.

Structural racism causes significant inequities in the diagnosis of perinatal and maternal mental health disorders and access to perinatal and maternal mental health treatment. Black birthing populations are particularly burdened by disjointed systems of care for mental health. To identify strategies to address racism and inequities in maternal and infant mental health care, we interviewed ten Black women who support Black birthing people, including mental health practitioners, researchers, and activists, in February 2021. The five key pathways to address racism and inequities that we identified from the stakeholder interviews are educating and training practitioners; investing in the Black women mental health workforce; investing in Black women-led community-based organizations; valuing, honoring, and investing in community and traditional healing practices; and promoting integrated care and shared decision making. These pathways highlight critical resources needed to improve the quality of maternal mental health care for Black birthing populations.

Required examinations and tests before initiating contraception: Provider practices from a national cross-sectional survey.

OBJECTIVE(S): We estimated the prevalence of requiring specific examinations or tests before providing contraception in a nationwide survey of family planning providers. STUDY DESIGN: We conducted a cross-sectional survey of public-sector health centers and office-based physicians providing family planning services across the United States in 2019 (n = 1395). We estimated the weighted proportion of providers (or their health center or practice) who required blood pressure measurement, pelvic examination (bimanual examination and cervical inspection), Papanicolaou (Pap) smear, clinical breast examination (CBE), and chlamydia and gonorrhea (CT/GC) screening before initiating hormonal or intrauterine contraception (IUC) for healthy women. We performed multivariable regression to identify factors associated with pelvic examination practices aligned with clinical recommendations; these recommendations classify examinations and tests as recommended or unnecessary before initiation of specific contraceptive methods. RESULTS: The overall response rate was 51%. Most providers required blood pressure measurement before initiating each method. Unnecessary CBE, Pap smears, and CT/GC screening were required by 14% to 33% of providers across methods. Fifty-two to 62% of providers required recommended pelvic examination before IUC placement; however, 16% to 23% of providers required unnecessary pelvic examinations before non-intrauterine hormonal method initiation. Factors associated with recommendation-aligned pelvic examination practices included having a higher proportion of patients using public funding (Medicaid or other assistance) and more recently completing formal clinical training. CONCLUSIONS: Almost half (47%) of providers did not require necessary pelvic examination before placing IUC. Conversely, many providers required unnecessary examinations and tests before contraception initiation for patients. IMPLICATIONS: Most providers required the few recommended examinations and tests for safe contraceptive provision. Reduction of unnecessary examinations and tests may reduce barriers to contraceptive access. There are also opportunities to increase use of recommended examinations, as up to 48% of providers did not require recommended pelvic examination before IUC.

Using the Wilder Collaboration Factors Inventory to Strengthen Collaborations for Improving Maternal and Child Health.

INTRODUCTION: The Wilder Collaboration Factors Inventory is a free, publicly available questionnaire about the quality and context of community collaboration. The purpose of this article is to share lessons from using this questionnaire in a North Carolina maternal and child health initiative. METHODS: In 2015, the State's General Assembly funded five local health departments to implement evidence-based strategies for improving maternal and child health. Each health department formed a community action team for this purpose. Members of each community action team completed the Wilder Collaboration Factors Inventory (Inventory) in the first year of funding and again 1 and 2 years later. Technical assistance coaches also asked community action team conveners to complete a brief questionnaire annually, and used these as well as Inventory results to plan for improvements. RESULTS: During the first year, community action teams emerged as strong in seeing collaboration in their self-interest. A primary challenge noted by conveners was engaging consumers on the community action teams. Strategies to address this included using social media and compensating consumers for attending meetings. By the second year, teams' average scores in engaging multiple layers of participation increased, and eight additional factors became strengths, which generally continued in year three. The most consistent challenge was supporting community action teams administratively. DISCUSSION: The Wilder Collaboration Factors Inventory provided a feasible tool for identifying opportunities for improvement in several local, cross-sector partnerships, suggesting promise for other communities seeking to enhance their collective impact on maternal and child health.

A Systematic Review of Patient-, Provider-, and Health System-Level Predictors of Postpartum Health Care Use by People of Color and Low-Income and/or Uninsured Populations in the United States.

Introduction: People of color and low-income and uninsured populations in the United States have elevated risks of adverse maternal health outcomes alongside low levels of postpartum visit attendance. The postpartum period is a critical window for delivering health care services to reduce health inequities and their transgenerational effects. Evidence is needed to identify predictors of postpartum visit attendance in marginalized populations. Methods: We conducted a systematic review of the peer-reviewed literature to identify studies that quantified patient-, provider-, and health system-level predictors of postpartum health care use by people of color and low-income and uninsured populations. We extracted study design, sample, measures, and outcome data from studies meeting our eligibility criteria, and used a modified Cochrane Risk of Bias tool to evaluate risk of bias. Results: Out of 2,757 studies, 36 met our criteria for inclusion in this review. Patient-level factors consistently associated with postpartum care included higher socioeconomic status, rural residence, fewer children, older age, medical complications, and previous health care use. Perceived discrimination during intrapartum care and trouble understanding the health care provider were associated with lower postpartum visit use, while satisfaction with the provider and having a provider familiar with one's health history were associated with higher use. Health system predictors included public facilities, group prenatal care, and services such as patient navigators and appointment reminders. Discussion: Postpartum health service research in marginalized populations has predominantly focused on patient-level factors; however, the multilevel predictors identified in this review reflect underlying inequities and should be used to inform the design of structural changes.

Input Connectivity Reveals Additional Heterogeneity of Dopaminergic Reinforcement in Drosophila.

Different types of Drosophila dopaminergic neurons (DANs) reinforce memories of unique valence and provide state-dependent motivational control [1]. Prior studies suggest that the compartment architecture of the mushroom body (MB) is the relevant resolution for distinct DAN functions [2, 3]. Here we used a recent electron microscope volume of the fly brain [4] to reconstruct the fine anatomy of individual DANs within three MB compartments. We find the 20 DANs of the γ5 compartment, at least some of which provide reward teaching signals, can be clustered into 5 anatomical subtypes that innervate different regions within γ5. Reconstructing 821 upstream neurons reveals input selectivity, supporting the functional relevance of DAN sub-classification. Only one PAM-γ5 DAN subtype γ5(fb) receives direct recurrent feedback from γ5ß'2a mushroom body output neurons (MBONs) and behavioral experiments distinguish a role for these DANs in memory revaluation from those reinforcing sugar memory. Other DAN subtypes receive major, and potentially reinforcing, inputs from putative gustatory interneurons or lateral horn neurons, which can also relay indirect feedback from MBONs. We similarly reconstructed the single aversively reinforcing PPL1-γ1pedc DAN. The γ1pedc DAN inputs mostly differ from those of γ5 DANs and they cluster onto distinct dendritic branches, presumably separating its established roles in aversive reinforcement and appetitive motivation [5, 6]. Tracing also identified neurons that provide broad input to γ5, ß'2a, and γ1pedc DANs, suggesting that distributed DAN populations can be coordinately regulated. These connectomic and behavioral analyses therefore reveal further complexity of dopaminergic reinforcement circuits between and within MB compartments.

Leveraging an Academic-Practice Partnership to Improve Maternal and Child Health Outcomes in North Carolina.

BACKGROUND In 2016, the North Carolina Division of Public Health (DPH) launched the Improving Community Outcomes for Maternal and Child Health (ICO4MCH) program to provide 5 local health departments (LHDs) with financial resources and technical assistance to address 3 aims: improve birth outcomes, reduce infant mortality, and improve health for children from birth to 5 years.METHOD: State legislation established an academic-practice partnership between NCDPH and the University of North Carolina at Chapel Hill (UNC) to provide program evaluation and implementation coaching to LHDs. ICO4MCH used a collective impact framework, principles of implementation science, and a health equity approach to implement evidence-based strategies to address the program's aims.RESULTS: A shared measurement system was developed by an evaluation stakeholders group led by the NCDPH and UNC in which LHDs reported data on a quarterly basis and the evaluators returned reports to drive improvements. Structured assessments and technical assistance provided by implementation coaches helped grantees address barriers to implementation including cultivating and sustaining a diverse community action team, addressing staff turnover, and using data to drive improvements.LIMITATIONS: It was challenging for grantees to balance community needs and build partnerships in the first year while integrating data from multiple assessments into action plans to meet the performance measures. It was necessary to streamline assessments and reduce indicators to make data more actionable.CONCLUSION: An academic-practice partnership was integral to successful implementation of the ICO4MCH program and may serve as a model for moving evidence-based maternal child health programs to practice in LHDs.

Changes in US health care provider attitudes related to contraceptive safety before and after the release of National Guidance.

OBJECTIVE: The US Medical Eligibility Criteria for Contraceptive Use (USMEC) is the first national guidance containing evidence-based recommendations for contraception. We describe provider attitudes about contraceptive safety before and after the 2010 USMEC release. STUDY DESIGN: We conducted two cross-sectional mailed surveys using different nationwide samples of office-based physicians and Title X clinic providers before (2009-2010) and after (2013-2014) the USMEC release. We compared the proportion of providers reporting select contraceptive methods as safe for women with specific characteristics or medical conditions before and after the USMEC release and conducted multivariable logistic regression to adjust for provider characteristics. RESULTS: For the following select characteristics for which the USMEC classifies specific contraceptive methods as safe (Category 1 or 2), a significantly (p<.05) higher proportion of providers reported the method safe after versus before the USMEC release: intrauterine devices (IUDs) for adolescents (79.8% versus 60.2%), IUDs for women with HIV (72.4% versus 50.6%), depot medroxyprogesterone acetate (DMPA) for women with obesity (89.5% versus 76.1%), and DMPA for women with history of bariatric surgery (87.6% versus 73.9%). These differences remained significant after adjustment for provider characteristics. CONCLUSIONS: While we observed many positive changes in health care provider attitudes related to contraception safety after the USMEC release, gaps remain. Continuing education and evidence-based training for providers, and ensuring office and health center protocols address medical eligibility for contraception for the full range of characteristics included in the USMEC might bridge remaining gaps and increase delivery of high-quality contraception care. IMPLICATIONS: Gaps between evidence and provider attitudes remain that can inform future efforts to improve contraceptive service delivery.

Health Care Provider Attitudes about the Safety of "Quick Start" Initiation of Long-Acting Reversible Contraception for Adolescents.

STUDY OBJECTIVE: To identify characteristics associated with provider attitudes on the safety of "Quick Start" initiation of long-acting reversible contraception (LARC) for adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional survey of providers in public-sector health centers and office-based physicians (n = 2056) during 2013-2014. RESULTS: Overall, the prevalence of considering "Quick Start" initiation of LARC for adolescents as safe was 70.9% for implants and 64.5% for intrauterine devices (IUDs). Among public-sector providers, those not trained in implant or IUD insertion had lower odds of perceiving the practice safe (adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.25-0.41 for implants; aOR 0.42; 95% CI, 0.32-0.55 for IUDs), whereas those practicing at health centers that did not receive Title X funding had lower odds of perceiving the practice safe for IUDs (aOR, 0.77; 95% CI, 0.61-0.98). Among office-based physicians, lack of training in LARC insertion was associated with lower odds of perceiving "Quick Start" initiation to be safe for IUDs (aOR, 0.31; 95% CI, 0.12-0.77). Those specializing in adolescent medicine had higher odds of reporting "Quick Start" initiation of LARC as safe (implants: aOR, 2.21; 95% CI, 1.23-3.98; IUDs: aOR, 3.37; 95% CI, 1.39-8.21) compared with obstetrician-gynecologists. CONCLUSION: Approximately two-thirds of providers considered "Quick Start" initiation of LARC for adolescents safe; however, there were differences according to provider characteristics (eg, Title X funding, training in LARC insertion, specialty). Targeted LARC insertion training and dissemination of evidence-based family planning guidance and implementation into facility and practice-level policies might increase access to "Quick Start" initiation of LARC for adolescents.

Health Care Provider Attitudes and Practices Related to 'Quick Start' Provision of Combined Hormonal Contraception and Depot Medroxyprogesterone Acetate to Adolescents.

PURPOSE: Adolescents may encounter many barriers to initiating contraception. 'Quick Start' is a recommended approach for initiating contraception on the same day as a provider visit. We examined factors associated with health care provider attitudes and practices related to 'Quick Start' provision of combined hormonal contraception (CHC) and depot medroxyprogesterone acetate (DMPA) to adolescents. METHODS: We analyzed weighted survey data from providers in publicly funded health centers and from office-based physicians (n = 2,056). Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of the associations between provider characteristics and frequent (very often or often vs. not often or never) 'Quick Start' provision of CHC and DMPA to adolescents in the past year. RESULTS: The prevalence of considering 'Quick Start' as safe was high for CHC (public-sector providers [87.5%]; office-based physicians [80.2%]) and DMPA (public-sector providers [80.9%]; office-based physicians [78.8%]). However, the prevalence of frequent 'Quick Start' provision was lower, particularly among office-based physicians (CHC: public-sector providers [74.2%]; office-based physicians [45.2%]; DMPA: public-sector providers [71.4%]; office-based physicians [46.9%]). Providers who considered 'Quick Start' unsafe or were uncertain about its safety had lower odds of frequent 'Quick Start' provision compared with those who considered it safe (public-sector providers: CHC aOR = 0.09 95% CI 0.06-0.13, DMPA aOR = 0.07 95% CI 0.05-0.10; office-based physicians: CHC aOR = 0.06 95% CI 0.02-0.22, DMPA aOR = 0.07 95% CI 0.02-0.20). CONCLUSIONS: While most providers reported that 'Quick Start' initiation of CHC and DMPA among adolescents is safe, fewer providers reported frequent 'Quick Start' provision in this population, particularly among office-based physicians.

State-Identified Implementation Strategies to Increase Uptake of Immediate Postpartum Long-Acting Reversible Contraception Policies.

BACKGROUND: In 2014, the Association of State and Territorial Health Officials (ASTHO) convened a multistate Immediate Postpartum Long-Acting Reversible Contraception (LARC) Learning Community to facilitate cross-state collaboration in implementation of policies. The Learning Community model was based on systems change, through multistate peer-to-peer learning and strategy-sharing activities. This study uses interview data from 13 participating state teams to identify state-implemented strategies within defined domains that support policy implementation. MATERIALS AND METHODS: Semistructured interviews were conducted by the ASTHO team with state team members participating in the Learning Community. Interviews were transcribed and implementation strategies were coded. Using qualitative analysis, the state-reported domains with the most strategies were identified. RESULTS: The five leading domains included the following: stakeholder partnerships; provider training; outreach; payment streams/reimbursement; and data, monitoring and evaluation. Stakeholder partnership was identified as a cross-cutting domain. Every state team used strategies for stakeholder partnerships and provider training, 12 reported planning or engaging in outreach efforts, 11 addressed provider and facility reimbursement, and 10 implemented data evaluation strategies. All states leveraged partnerships to support information sharing, identify provider champions, and pilot immediate postpartum LARC programs in select delivery facilities. CONCLUSIONS: Implementing immediate postpartum LARC policies in states involves leveraging partnerships to develop and implement strategies. Identifying champions, piloting programs, and collecting facility-level evaluation data are scalable activities that may strengthen state efforts to improve access to immediate postpartum LARC, a public health service for preventing short interbirth intervals and unintended pregnancy among postpartum women.

Addressing Intimate Partner Violence to Improve Women's Preconception Health.

Exposure to violence can harm women's overall health and well-being. Data suggest that one in three women in the United States experience some form of violence by an intimate partner in their lifetime. In this commentary, we describe the implications of intimate partner violence (IPV) on women's health, specifically for women of reproductive age. We use a life-course perspective to describe the compounded impact of IPV on preconception health. Preconception health generally refers to the overall health and well-being of women (and men) before pregnancy. This report also discusses primary prevention of IPV and healthcare recommendations, and highlights surveillance systems that capture IPV indicators among women of reproductive age. Ongoing collection of state-level surveillance data may inform the implementation of intervention programs tailored to reproductive age women at risk for IPV.

Lower Regional Pediatric In-hospital Mortality Albeit Racial/ethnic Disparities.

PURPOSE: Variability in pediatric morbidity and mortality tends to be influenced by several factors including though not limited to social determinants of health, namely health inequity as an exposure function of health disparities. We aimed to assess the cumulative incidence of pediatric mortality, racial/ethnic disparities, and the predisposing factors for the disparities. METHOD: The current study retrospectively examined the Nemours/Alfred I. duPont Hospital for Children medical records of 16,121 patients diagnosed with any pediatric condition during 2009 and 2010. RESULTS: In-hospital pediatric mortality cumulative incidence was relatively low (80 deaths, 0.49%) when compared with similar settings in the U.S. (national average range, 0.8e1.1%) during the same period. Compared with whites/Caucasians, mortality was higher among blacks/African Americans, prevalence odds ratio (POR), 1.06, 95% CI, 0.77e1.45, and higher for some other race, POR, 1.48, 95% CI, 1.06e2.10. After controlling for potential confounders (severity of illness, insurance status, and length of stay), racial differences in pediatric mortality did not persist between whites and some other race, adjusted POR, 1.08, 99% CI, 0.75e1.57. CONCLUSIONS: In-hospital pediatric mortality cumulative incidence was relatively low in our region, and racial disparities exist but did not persist after controlling for confounders. These findings are suggestive of the importance of social determinants of health namely quality care, adequate medical insurance, and early detection, diagnosis in pediatric morbidity and epigenomic alterations, as well as the need to go beyond the "close medical model" to improve pediatric morbidity and survival by addressing health inequity as a function of health disparities.

Maternal Sociodemographic Characteristics, Experiences and Health Behaviors Associated with Postpartum Care Utilization: Evidence from Maryland PRAMS Dataset, 2012-2013.

Objectives Postpartum visits are increasingly recognized as a window of opportunity for health care providers to counsel new mothers and promote healthy behaviors, including increasing contraceptive use and screening for postpartum depression. In Maryland, there is a lack of research on postpartum visit (PPV) attendance and the specific risk factors associated with not receiving postpartum care. In this study, we estimated the proportion of mothers in Maryland who attended a PPV and assessed maternal sociodemographic characteristics and health behaviors associated with PPV non-attendance. Methods Data were analyzed from the 2012 and 2013 Maryland Pregnancy Risk Assessment Monitoring System (n = 2204). Bivariate and multivariable logistic regression were performed to examine the association between covariates and PPV non-attendance. Results Overall, 89.6% of women reported PPV attendance. Bivariate analyses between maternal sociodemographic and health behavior characteristics and PPV non-attendance indicated that being unmarried (OR 3.03, 95% CI 2.12-4.31), experiencing infant loss (OR 7.17, 95% CI 2.57-19.97), working during pregnancy (OR 0.44, 95% CI 0.31-0.63) and not receiving dental care (OR 2.03, 95% CI 1.43-2.88) as significant risk factors for PPV non-attendance. After controlling for known and theoretical confounders, experiencing an infant loss (aOR 5.18, 95% CI 1.54-17.4), not receiving dental care (aOR 1.54, 95% CI 1.06-2.26) and working during pregnancy (aOR 0.61, 95% CI 0.41-0.93) emerged as strong predictors of PPV non-attendance. Conclusions for Practice Mothers who recently experienced an infant death were at greatest risk for not attending a PPV, suggesting the need to establish comprehensive support networks, including grief counseling and additional service reminders for mothers who experienced an infant death.

Disparities in Preconception Health Indicators - Behavioral Risk Factor Surveillance System, 2013-2015, and Pregnancy Risk Assessment Monitoring System, 2013-2014.

PROBLEM/CONDITION: Preconception health is a broad term that encompasses the overall health of nonpregnant women during their reproductive years (defined here as aged 18-44 years). Improvement of both birth outcomes and the woman's health occurs when preconception health is optimized. Improving preconception health before and between pregnancies is critical for reducing maternal and infant mortality and pregnancy-related complications. The National Preconception Health and Health Care Initiative's Surveillance and Research work group suggests ten prioritized indicators that states can use to monitor programs or activities for improving the preconception health status of women of reproductive age. This report includes overall and stratified estimates for nine of these preconception health indicators. REPORTING PERIOD: 2013-2015. DESCRIPTION OF SYSTEMS: Survey data from two surveillance systems are included in this report. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based, landline and cellular telephone survey of noninstitutionalized adults in the United States aged ≥18 years that is conducted by state and territorial health departments. BRFSS is the main source of self-reported data for states on health risk behaviors, chronic health conditions, and preventive health services primarily related to chronic disease in the United States. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing U.S. state- and population-based surveillance system administered collaboratively by CDC and state health departments. PRAMS is designed to monitor selected maternal behaviors, conditions, and experiences that occur before, during, and shortly after pregnancy that are self-reported by women who recently delivered a live-born infant. This report summarizes BRFSS and PRAMS data on nine of 10 prioritized preconception health indicators (i.e., depression, diabetes, hypertension, current cigarette smoking, normal weight, recommended physical activity, recent unwanted pregnancy, prepregnancy multivitamin use, and postpartum use of a most or moderately effective contraceptive method) for which the most recent data are available. BRFSS data from all 50 states and the District of Columbia were used for six preconception health indicators: depression, diabetes (excluded if occurring only during pregnancy or if limited to borderline/prediabetes conditions), hypertension (excluded if occurring only during pregnancy or if limited to borderline/prehypertension conditions), current cigarette smoking, normal weight, and recommended physical activity. PRAMS data from 30 states, the District of Columbia, and New York City were used for three preconception health indicators: recent unwanted pregnancy, prepregnancy multivitamin use, and postpartum use of a most or moderately effective contraceptive method by women or their husbands or partners (i.e., male or female sterilization, hormonal implant, intrauterine device, injectable contraceptive, oral contraceptive, hormonal patch, or vaginal ring). Heavy alcohol use during the 3 months before pregnancy also was included in the prioritized set of 10 indicators, but PRAMS data for each reporting area are not available until 2016 for that indicator. Therefore, estimates for heavy alcohol use are not included in this report. All BRFSS preconception health estimates are based on 2014-2015 data except two (hypertension and recommended physical activity are based on 2013 and 2015 data). All PRAMS preconception health estimates rely on 2013-2014 data. Prevalence estimates of indicators are reported for women aged 18-44 years overall, by age group, race-ethnicity, health insurance status, and reporting area. Chi-square tests were conducted to assess differences in indicators by age group, race/ethnicity, and insurance status. RESULTS: During 2013-2015, prevalence estimates of indicators representing risk factors were generally highest and prevalence estimates of health-promoting indicators were generally lowest among older women (35-44 years), non-Hispanic black women, uninsured women, and those residing in southern states. For example, prevalence of ever having been told by a health care provider that they had a depressive disorder was highest among women aged 35-44 years (23.1%) and lowest among women aged 18-24 years (19.2%). Prevalence of postpartum use of a most or moderately effective method of contraception was lowest among women aged 35-44 years (50.6%) and highest among younger women aged 18-24 years (64.9%). Self-reported prepregnancy multivitamin use and getting recommended levels of physical activity were lowest among non-Hispanic black women (21.6% and 42.8%, respectively) and highest among non-Hispanic white women (37.8% and 53.8%, respectively). Recent unwanted pregnancy was lowest among non-Hispanic white women and highest among non-Hispanic black women (5.0% and 11.6%, respectively). All but three indicators (diabetes, hypertension, and use of a most or moderately effective contraceptive method) varied by insurance status; for instance, prevalence of current cigarette smoking was higher among uninsured women (21.0%) compared with insured women (16.1%), and prevalence of normal weight was lower among women who were uninsured (38.6%), compared with women who were insured (46.1%). By reporting area, the range of women reporting ever having been told by a health care provider that they had diabetes was 5.0% (Alabama) to 1.9% (Utah), and women reporting ever having been told by a health care provider that they had hypertension ranged from 19.2% (Mississippi) to 7.0% (Minnesota). INTERPRETATION: Preconception health risk factors and health-promoting indicators varied by age group, race/ethnicity, insurance status, and reporting area. These disparities highlight subpopulations that might benefit most from interventions that improve preconception health. PUBLIC HEALTH ACTION: Eliminating disparities in preconception health can potentially reduce disparities in two of the leading causes of death in early and middle adulthood (i.e., heart disease and diabetes). Public health officials can use this information to provide a baseline against which to evaluate state efforts to improve preconception health.

Meeting Summary: State and Local Implementation Strategies for Increasing Access to Contraception During Zika Preparedness and Response - United States, September 2016.

Zika virus infection during pregnancy is a cause of microcephaly and other serious brain abnormalities (1). To support state and territory response to the threat of Zika, CDC's Interim Zika Response Plan outlined activities for vector control; clinical management of exposed pregnant women and infants; targeted communication about Zika virus transmission among women and men of reproductive age; and primary prevention of Zika-related adverse pregnancy and birth outcomes by prevention of unintended pregnancies through increased access to contraception.* The most highly effective,† reversible contraception includes intrauterine devices and implants, known as long-acting reversible contraception (LARC). On September 28, 2016, the Association of Maternal and Child Health Programs (AMCHP) and CDC facilitated a meeting in Atlanta, Georgia, of representatives from 15 states to identify state-led efforts to implement seven CDC-published strategies aimed at increasing access to contraception in the context of Zika virus (2). Qualitative data were collected from participating jurisdictions. The number of states reporting implementation of each strategy ranged from four to 11. Participants identified numerous challenges, particularly for strategies implemented less frequently. Examples of barriers were discussed and presented with corresponding approaches to address each barrier. Addressing these barriers could facilitate increased access to contraception, which might decrease the number of unintended pregnancies affected by Zika virus.

Implication of Socio-Demographics on Cognitive-Related Symptoms in Sports Concussion Among Children.

BACKGROUND: Sports-related concussion remains a public health challenge due to its morbidity and mortality. One of the consequences of concussion is cognitive impairment (CI) and cognitive-related symptoms (CRS) which determine, to some extent, physical and behavioral functioning of children who sustain concussion. Despite the high prevalence of CI and CRS associated with concussion, the risk factors are not fully understood. We aimed to characterize CRS and to examine its relationship with race, ethnicity, age, insurance, and sex in a pediatric population. METHODS: A retrospective cohort (case-only) design was used to assess CRS prevalence and its relationship with race and sex using a pediatric hospital's electronic medical records. A consecutive sample was used with 1429 cases between 2007 and 2014. Study characteristics were examined using chi-square and log binomial regression for hypothesis-specific testing. RESULTS: Of the 1429 cases, 872 (61.0 %) were boys and 557 (39.0 %) were girls. The racial distribution indicated 1146 (80.2 %) Whites, 170 (11.9 %) Blacks/African Americans, and 113 (7.9 %) others. The prevalence of CRS was 78.0 %. Whereas boys had sustained more concussions, girls were more likely to present with CRS; prevalence risk ratio = 1.07, 95 % CI 1.01-1.13, p = 0.02. The crude analysis indicated no racial disparities in CRS prevalence, but the multivariable analysis did, comparing White to Black/African American children; adjusted prevalence risk ratio (aPRR) = 1.77, 99 % CI 1.02-3.08, p = 0.008. CONCLUSIONS: Racial disparities exist in CRS among children with sports-related concussion, and Black/African American children are more likely, relative to Whites, to suffer CRS. Due to uncertainty in causal inference, we caution the interpretation and application of these data in risk-adapted concussion prevention.

Sleep disturbances and quality of life in Sub-Saharan African migraineurs.

BACKGROUND: Although in the past decade occidental countries have increasingly recognized the personal and societal burden of migraine, it remains poorly understood in Africa. No study has evaluated the impact of sleep disturbances and the quality of life (QOL) in sub-Saharan Africans with migraine. METHODS: This was a cross-sectional study evaluating adults, ≥ 18 years of age, attending outpatient clinics in Ethiopia. Standardized questionnaires were utilized to collect demographic, headache, sleep, lifestyle, and QOL characteristics in all participants. Migraine classification was based on International Classification of Headache Disorders (ICHD)-II criteria. The Pittsburgh Sleep Quality Index (PSQI) and the World Health Organization Quality of Life (WHOQOL-BREF) questionnaires were utilized to assess sleep quality and QOL characteristics, respectively. Multivariable logistic regression models were fit to estimate adjusted odds ratio (OR) and 95% confidence intervals (95% CI). RESULTS: Of 1,060 participants, 145 (14%) met ICHD-II criteria for migraine. Approximately three-fifth of the study participants (60.5%) were found to have poor sleep quality. After adjustments, migraineurs had over a two-fold increased odds (OR = 2.24, 95% CI 1.49-3.38) of overall poor sleep quality (PSQI global score >5) as compared with non-migraineurs. Compared with non-migraineurs, migraineurs were also more likely to experience short sleep duration (≤7 hours) (OR = 2.07, 95% CI 1.43-3.00), long sleep latency (≥30 min) (OR = 1.97, 95% CI 1.36-2.85), daytime dysfunction due to sleepiness (OR = 1.51, 95% CI 1.12-2.02), and poor sleep efficiency (<85%) (OR = 1.93, 95% CI 1.31-2.88). Similar to occidental countries, Ethiopian migraineurs reported a reduced QOL as compared to non-migraineurs. Specifically Ethiopian migraineurs were more likely to experience poor physical (OR = 1.56, 95% CI 1.08-2.25) and psychological health (OR = 1.75, 95% CI 1.20-2.56), as well as poor social relationships (OR = 1.56, 95% CI 1.08-2.25), and living environments (OR = 1.41, 95% CI 0.97-2.05) as compared to those without migraine. CONCLUSION: Similar to occidental countries, migraine is highly prevalent among Ethiopians and is associated with poor sleep quality and a lower QOL. These findings support the need for physicians and policy makers to take action to improve the quality of headache care and access to treatment in Ethiopia.