Smoking during pregnancy rates trends in a high smoking prevalence state, 1990-2009.

OBJECTIVE: To assess the trends for smoking during pregnancy for whites and blacks in Missouri, a state with a high prevalence of smoking, for the period 1990-2009. METHODS: Retrospective cohort study of annual pregnancy smoking rates recorded on birth certificates. Trends were assessed by regression analyses for all births, births to whites and blacks, births to whites and blacks in aggregate, and by zip codes within the combined jurisdictions of Kansas City, St Louis City, and St Louis County. Zip code smoking during pregnancy rates matched with the respective zip code race-specific population compositions were analyzed by chi-square tests. RESULTS: Smoking during pregnancy rates trends for whites and blacks differed significantly during the 2 decades. Although rates for whites declined over time, they were relatively stable from 1999 through 2007. Rates for blacks exhibited a steep decline in the early 1990s, remaining stable after 1995. Within the combined jurisdictions, rates for blacks who smoked during pregnancy surpassed those of whites beginning in 2001. The lack of prenatal care for either race was the only maternal characteristic consistently associated with lack of reduction in smoking during pregnancy. There also were no declines among young birth mothers of either race who had 12 or fewer years of education. Rates of smoking during pregnancy for blacks and whites were highest in zip codes with a ≥50% black population. CONCLUSIONS: Rates for smoking during pregnancy for whites and blacks in Missouri overall have not changed appreciably from 2000 to 2009. Beneficial antismoking during pregnancy effects that could reverse this trend may be achievable via improved access to prenatal care, especially for young, uneducated women.

Demographic risk factors affecting emergency room visits caused by benzodiazepine poisoning in Kansas City, Missouri, from 2001 to 2007.

OBJECTIVE: The study objective was to identify demographic risk factors associated with emergency room visits caused by benzodiazepine poisoning. METHODS: A retrospective study was conducted utilizing Missouri Hospital Discharge Data for Kansas City, Missouri, USA, for 2001-2007. The data included patients' demographics such as racial group, age, sex, health insurance status and annual income. Emergency room visits due to benzodiazepine poisoning were identified by ICD-9 code 969.4. The frequencies of patient visits were calculated according to categories of each demographic variable. Chi-square tests were used to assess the difference of emergency room visits among categories of each demographic variable. A multiple logistic regression analysis was performed, where the outcome variable was emergency room visits due to benzodiazepine poisoning (yes/no), and the independent variables were the demographic variables. KEY FINDINGS: Of 1317566 emergency room visits over the 7-year period, 562 were due to benzodiazepine poisoning. Seventy-seven per cent of these visits were made by patients who were white, of whom 53% were 30-49years old, 56% were female, 74% had health insurance and 44% lived in zip codes with median family incomes of $40000-59999. Chi-square tests were significant for racial group, age and annual income (P<0.01). In the logistic regression white patients were 73% more likely than black patients to have emergency room visits caused by benzodiazepine poisoning (P<0.01), with an odds ratio (95% confidence interval) of 5.63 (4.33-7.30). Compared with those aged 0-19 years, the odds ratio for patients aged 30-39 to have such visits was 2.73 (2.09-3.57), and the odds ratio for patients aged 40-49 was 2.84 (2.17-3.71). CONCLUSIONS: White patients and patients aged 30-49years were at higher risk for emergency room visits due to benzodiazepine poisoning. Health interventions such as medication review by pharmacists may reduce the risk of benzodiazepine poisoning for these patients.

Risk factors for recurrent small-for-gestational-age birth.

The factors associated with recurrent small-for-gestational-age birth (R-SGA) have not been previously studied in a multiracial population. This is a retrospective cohort study of 5932 black and white women who had consecutive singleton first and second births in a Midwestern metropolis, from 1995 through 2004, to measure the risk and determine the factors associated with R-SGA. The rates for second-born small-for-gestational-age birth and R-SGA were 10.3% and 4.0%, respectively. Compared with mothers of firstborns who were appropriate for gestational age, mothers of firstborns who were small for gestation age had a higher risk of second-born small-for-gestational-age infants (relative risk [RR] = 3.93; 95% confidence interval [95% CI] = 3.36 to 4.59). Among those with firstborns who were small for gestational age, the odds ratio (OR) and 95% CI of R-SGA were higher for lean body mass index + poor gain (2.83; 1.20 to 6.69), blacks (1.58; 1.09 to 2.29), and smokers (1.61; 1.05 to 2.47). R-SGA occurs in 4% of second births and is responsible for 40% of second-born small-for-gestational-age infants. R-SGA is potentially preventable because of its association with potentially modifiable factors such as smoking and weight gain in pregnancy.

Ponderal index of the newborn: effect of smoking on the index of the small-for-gestational-age infant.

The ponderal index (PI) is evaluated in the context of its distribution within a given population. Low PI (<10th percentile for gestational age) has been extensively studied but not much is known about the distribution and factors associated with a high (>90th percentile) PI among small-for-gestational-age (SGA) infants. This retrospective study of singleton live first births from 1990 to 2007 in a Midwestern city explores factors associated with a high PI, particularly among SGA infants. Independent variables included exposures (none, smoke, hypertension) and maternal and infant demographic characteristics. There were 45,453 births, 28 to 42 weeks' gestational age, 55% Whites and 51% male. Mean PI increased with gestational age and was highest among Hispanics and lower among SGA infants. High PI was present in 11% of appropriate-for-gestational-age and 4% of SGA infants. Among SGA infants, odds ratios (ORs) of high PI were higher for smoke exposure (1.21; 95% confidence interval 0.97, 1.87) and lower for males (0.66; 0.47, 0.93). In conclusion, the distribution of PI varies by exposures and of high PI by race/ethnicity/gender. SGA infants with high PI have relative surplus of mass, and ostensibly, adiposity, for their frame. There is a need to use PI in exploring and defining previously observed associations between SGA and adult-onset obesity/metabolic syndrome.

Excess Hispanic fetal-infant mortality in a midwestern community.

OBJECTIVE: We assessed excess fetal-infant mortality for Hispanic, non-Hispanic white, and non-Hispanic black populations in five contiguous counties of Missouri and Kansas. METHODS: We conducted a perinatal periods of risk (PPOR) assessment of fetal-infant mortality using electronic linked birth-death record files from 2001 through 2005. We generated an internal reference group in accordance with established PPOR protocol. We used Kitagawa analysis to determine whether excess deaths were due to birthweight distribution (a higher frequency of prematurity or growth retardation) or to higher mortality rates once born at that birthweight (birthweight-specific mortality). RESULTS: We found the excess fetal-infant death rates for Hispanic and non-Hispanic white populations to be similar and considerably lower than that for non-Hispanic black populations. Among Hispanic children, we judged 21.6% of fetal-infant mortality to be excess in relation to the reference population. Within the PPOR matrix, Hispanic excess mortality rates were distributed differently from those of non-Hispanic white and non-Hispanic black populations. Among Hispanic children, 93.6% of the excess mortality could be explained by low birthweight and birthweight-specific mortality, with the greatest contribution attributable to low birthweight. CONCLUSION: The excess fetal-infant mortality experience of Hispanic people in the five-county region was similar to that of the non-Hispanic white population, but was distributed differently in the PPOR model, which has significance regarding interventions targeting reductions in fetal-infant mortality.

Pre-pregnancy overweight status between successive pregnancies and pregnancy outcomes.

OBJECTIVE: The two objectives of this study were to (1) examine factors associated with changes in pre-pregnancy overweight to pre-pregnancy normal/underweight or obese Body Mass Index (BMI) in the subsequent pregnancy, and (2) assess select pregnancy and newborn outcomes associated with changes in pre-pregnancy BMI. METHODS: Birth certificates from 1995-2004 for residents of Kansas City, Missouri, were used to identify overweight nulliparous women who had a singleton birth and subsequently a second singleton birth. Maternal factors associated with changes in BMI between pregnancies were determined. Hypertension in pregnancy, preterm birth, emergency cesarean section, small-for-gestational age, and large-for-gestational age outcomes were examined. RESULTS: At second pregnancy, 55% of the women remained overweight, 33% were obese, and 12% had normal/underweight BMIs. The upward shift in BMI was associated with being unmarried and having a birth interval of 18 or more months, while the downward shift was associated with gestational weight gain. Of the five outcomes variables, only emergency cesarean section was significantly associated with an upward shift in BMI. CONCLUSIONS: Clinical interventions for pre-pregnancy overweight women should focus on appropriate weight gain during pregnancy and motivators for loss of pregnancy-related weight during the postpartum period.

Secular trends in excess fetal and infant mortality using perinatal periods of risk analysis.

Perinatal periods of risk (PPOR) provide an alternative analytical approach to studying infant mortality. Results can be used to focus community activities to improve infant and maternal health. This article demonstrates the use of PPOR to monitor trends in excess fetal and infant mortality related to disparities associated with race and ethnicity in Kansas City, MO (KC). Based on a comparison of PPOR analyses for 1996-2000 and 2001-2005, there was a 30% reduction in excess fetal and infant mortality in Kansas City and reductions for both non-Hispanic blacks (17%) and non-Hispanic whites (66.7%). However, the disparity ratio for excess mortality rates between non-Hispanic blacks and non-Hispanic whites nearly doubled. Prematurity, the most frequent cause of infant mortality in Kansas City during 2001-2005 accounted for 42.5% of the infant deaths. Being a teenage mother; having less than a high-school education; being unmarried; having an unintended pregnancy; being obese preconceptually; being diabetic; using substances such as tobacco or drugs during pregnancy; receiving late, inadequate or intermediate amounts of prenatal care; having a multifetal pregnancy; having a primary elective cesarean section; delivering a preterm infant or having a male infant; and being enrolled in Medicaid all increased the risk of infant death.

Fetal mortality: timing of racial disparities.

Whether or not racial disparities exist in fetal mortality rate (FMR) statistics depends upon the methodology used to calculate the rates. While there appears to be consensus that there is a black-white disparity in late gestation (> or = 28 weeks), the issue is unclear for early gestation (20-27 weeks). To clarify this issue, we assessed disparities in FMR for singleton fetal deaths and live births between non-Hispanic blacks and non-Hispanic whites in three counties of Missouri using gestational age- and weight-specific analyses. These analyses demonstrated statistically significant disparities for non-Hispanic whites when fetal deaths occurred < 28 weeks gestation and also at weights < 1,000 g. Statistically significant disparities for non-Hispanic blacks were not evident until gestation was > or = 32 weeks or weights were > or = 2,500 g. The results of these analyses were consistent with each other and suggest that the non-Hispanic black disparity in FMR is a late gestational issue. The lack of disparity for non-Hispanic blacks and the disparity for non-Hispanic whites during earlier gestation or with low weights were associated with the disparate rates for very preterm live birth.

Changes in smoking behavior between first and second pregnancies.

OBJECTIVE: To assess changes in maternal smoking behavior at the second pregnancy. METHODS: First and second birth certificates were matched for 5241 white and black mothers in Kansas City, Mo, who had singleton births between 1994 and 2003. RESULTS: The pregnancy-smoking quit rate was 24.9%, and the pregnancy-smoking initiation rate was 4.8%. CONCLUSION: Twenty-five percent of women who smoked and 5% of women who did not smoke during their first pregnancy changed their behavior during their second pregnancy. These findings reflect a minimal net shift in pregnancy-smoking between pregnancies and support the importance of persistent antismoking socialization that is independent of a pregnant woman's previous pregnancy-smoking status.

Perinatal periods of risk analysis of infant mortality in Jackson County, Missouri.

The perinatal periods of risk (PPOR) methodology provides an easy-to-use analytical approach to infant mortality that helps focus community initiatives for improving maternal and infant health. Because few analyses have been published, many public health practitioners may be unfamiliar with PPOR. This article demonstrates the application of PPOR analysis using infant mortality in Jackson County, Missouri. While the PPOR consists of two phases, this analysis was restricted to the initial phase of the overall process. The second phase builds on the initial findings and prioritizes the contributing factors of fetal/infant mortality so that targeted interventions can be developed. For Jackson County, the PPOR analysis found that racial and geographic disparities existed and, for very low-birth-weight infants, different interventions strategies may be needed on the basis of race. In addition, a mother who experienced a fetal or infant death was more likely to have had a medical risk factor, to have smoked cigarettes, to have started prenatal care after the first trimester or received no prenatal care, and to have been nulliparous.

Cumulative and residual risks of small for gestational age neonates after changing pregnancy-smoking behaviors.

This retrospective cohort study examines the relationship between changing pregnancy-smoking behaviors, from the first to the second pregnancy, on second-pregnancy rates of small for gestational age (SGA) neonates. Electronic birth records provided data on 5107 pregnant women who had two singleton births in Kansas City, MO, from 1994 to 2003. Pregnancy-smoking behavior was classified by smoking status (nonsmoker [NS] or smoker [SMK]) during the first (previous)/second (current) pregnancy: NS/NS, NS/SMK, SMK/SMK, and SMK/NS. The overall second-pregnancy SGA rate was 6.7% and varied with pregnancy-smoking behavior: 5.9%, NS/NS; 6.6%, SMK/NS; 12.5%, NS/SMK; and 12%, SMK/SMK; P < 0.001 Current pregnancy-smoking was associated with increased odds ratio (OR) of SGA; SMK/SMK (OR, 2.80; 95% confidence interval [CI], 2.00 to 3.93) versus NS/SMK (OR, 1.83; 95% CI, 1.19 to 2.82) versus SMK/NS (OR, 1.31; 95% CI, 0.65 to 2.65) versus NS/NS (OR, 1.00; 95% CI, reference). Being black (OR, 3.73; 95% CI, 2.91 to 4.79) and having medical risk factors (OR, 1.31; 95% CI, 1.09 to 1.74) also were significantly associated with a SGA neonate in second pregnancy. In conclusion, risk of delivering a SGA neonate in a current pregnancy is related to current rather than previous pregnancy-smoking. Therefore, antismoking socialization during pregnancy should focus on preventing and stopping current pregnancy-smoking, irrespective of past behavior.

The effect of health compromising behaviors on preterm births.

OBJECTIVES: The objective of our study was to determine whether there were combined effects of smoking, alcohol, and illicit drug use during pregnancy on the frequency of preterm births, and if so, the magnitude of the association after adjusting for confounding factors. METHODS: We conducted a retrospective cohort study of singleton live births in Kansas City, Missouri from 1990-2002. We defined health compromising behaviors as the use of cigarettes, alcohol, and illicit drugs. The effect of these behaviors on preterm births was considered for each substance individually, and in combination. The rates of preterm births for these groups were calculated. Using logistic regression, adjusted odds ratios were used to estimate the relative risk of preterm births among these groups. RESULTS: Over 13% of infants born to women who smoked were preterm, compared to 9.6% for non-smokers. Of infants born to women who reported alcohol use, 17.3% were preterm compared to 10.1% for non-drinkers. Smoking and alcohol use in combination was associated with 18.0% preterm births, while alcohol and drug use in combination was associated with 20.8% preterm births. The use of all three substances was associated with 31.4% preterm births. CONCLUSION: Women who engaged in health compromising behaviors during pregnancy showed an increased proportion of preterm births compared to those who did not. There is significant interaction between these behaviors leading to higher rates of preterm births than predicted by their additive effects. To decrease preterm births, we must deal with the effects of smoking, drinking, and drug use simultaneously.

Failure to embrace the barrier/condom use message.

The objective of this study was to examine the consistency of barrier/condom use among men who have sex with men in the Kansas City metropolitan area. The authors sought to determine if barrier/condom usage patterns were associated with the type of sex act and whether it was insertive or receptive, HIV testing frequency, and number of sexual partners. Data were extracted from a 2003 community health assessment of the gay, lesbian, bisexual, and transgendered community in the metropolitan area. The health assessment instrument was anonymous, self-administered, and distributed at events in that community. Responses from 623 men indicated that consistent use of a barrier/condom was low regardless of the sex act. There was no relationship between barrier/condom usage patterns and HIV testing frequency for any sex act or the number of sex partners, with the exception of anal intercourse. The authors concluded that a different approach is needed to translate the barrier/condom use message into a behavioral response.

Emergency department visits and hospitalizations resulting from dog bites, Kansas City, MO, 1998-2002.

Dog bites are the second most costly public health problem in the United States with half of all Americans being bitten in their lifetime. Approximately 17 to 18 percent of dog bite injuries receive medical attention. Between 1998 and 2002, Kansas City, Missouri, residents made 3,467 emergency department visits for dog bite trauma and 96 individuals were hospitalized. We report the principal diagnoses for those visits and admissions. Median hospital charges for emergency department services and hospitalizations were $300 per visit and $4,698 per admission. We discuss deficiencies in the reporting of animal bites as well as recommended community efforts in reducing the burden of dog bite trauma.

Are fewer women smoking during pregnancy?

OBJECTIVE: To determine whether pregnancy-smoking rates have changed in last decade. METHODS: Retrospective cohort study of 67,395 pregnancies in Kansas City over 2 epochs, 1993-1997 and 1998-2002, using computer files of birth certificates. RESULTS: Overall pregnancy-smoking rates decreased from 18.1% (95% CI=17.7-18.5%) to 14.2% (13.8-14.5%). Among smokers, there was a distribution shift toward light smoking; light [39% (38.9-40.3%) vs 49% (47.6-50.4%)], moderate [36.8% (34.8%-38.8%) vs 34.4% (32.1-36.7%)], and heavy [23.1% (21.9-26.3%) vs 16.6% (14-19.1%)]. CONCLUSIONS: The results suggest decreasing heavier smoking. However, the trend toward light smoking suggests decreasing self-reporting. These findings highlight the dilemma in using self-reports for public health policy and emphasize the importance of antismoking socialization for all pregnancies.

When bioterrorism strikes: communication issues for the local health department.

Public health preparedness is a multifaceted planning process that becomes grounded in a response plan and in effective communications, internal and external. This article describes an incident when the presence of anthrax spores was detected in a postal facility within Kansas City, Missouri, and discusses the communications issues faced by the Kansas City Health Department (KCHD). This incident provided the KCHD the first opportunity to operationalize its Incident Management System-based response plan. However, accompanying its implementation were unforeseen issues related to both internal and external communications. These issues and the lessons learned are discussed.

Perinatal periods of risk: analysis of fetal-infant mortality rates in Kansas City, Missouri.

OBJECTIVES: The Perinatal Periods of Risk (PPOR) technique was used to analyze resident fetal and infant death data from Kansas City, Missouri, for the period 1998-2002. Results offer important information that can be used to develop community-based prevention strategies related to racial/ethnic disparities in infant mortality rates (IMR). METHODS: The PPOR approach for fetal and infant mortality can be mapped by birthweight at delivery and time of death into four strategic prevention areas: 1) Maternal Health/Prematurity (MHP), 2) Maternal Care (MC), 3) Newborn Care (NC), and 4) Infant Health (IH). For this analysis, all fetal and infant death certificates from the metropolitan Kansas City area were linked to their birth certificates and those associated with residents of Kansas City, Missouri, proper were used to create the dataset used in this analysis. Due to the small number of fetal and infant deaths among other ethnic groups, the analysis was restricted to a comparison of the disparity of IMR between Blacks, Whites, and a national non-Hispanic white reference group. The Kitagawa formula was used to determine contribution to excess deaths from birthweight-specific mortality and birthweight distribution rates. Logistic regression techniques were used to identify risk factors for death among Black fetuses and infants with very low birthweights and also deaths due to sudden infant death syndrome (SIDS). RESULTS: The PPOR analysis showed that of the excess deaths among black infants, when compared to a national reference group, 47% was attributable to MHP and another 29% was attributable to IH. Differences in MC and NC only accounted for 27 and 8% of the total excess deaths. During the study period, rates of sudden infant death syndrome (SIDS) were found to be significantly higher among Blacks as compared to Whites (2.12 vs. 0.81 per 1,000). An analysis of maternal characteristics for SIDS deaths among blacks using a step-wise logistic regression model, found that maternal age less than 20 years old, previous births, inadequate prenatal care, and being a Medicaid recipient were significant-adjusted odds ratios of 23.7 (95% Cl 10.48, 53.67), 8.4 (95% Cl 3.64, 19.21), 2.9 (95% Cl 1.38, 6.05) and 2.5 (95% Cl 1.04, 5.84), respectively. CONCLUSIONS: PPOR is an easy to use approach that helps focus community initiatives for improving maternal and infant health. In Kansas City, Missouri, efforts to further lower IMR in blacks can be achieved through the reduction of risk factors affecting maternal health and through maternal education to improve infant health.

The Richard Cory phenomenon: suicide and wealth in Kansas City, Missouri.

This case-control study investigates the relationship between suicide and wealth in Kansas City, Missouri. House and personal property appraisal data on all victims of suicide from 1998 and 2002 and victims from a control population of deaths reported to the Jackson County Medical Examiner during the same time interval were obtained from the Jackson County Government website. The controls were matched to suicide cases by race, gender, year of death, and age at death (+/- 1 year). Data from the 426 members of each group of suicides and controls indicate that suicide victims were: 1) 77% more likely than controls to have lived in houses rather than in apartments or trailers, 2) more likely than controls to have lived in more expensive houses (mean values dollar 70,143 versus dolllar 61,513 respectively, p = 0.04) and 3) more likely to have killed themselves because of factors other than financial strain (8.0% of suicides showed financial strain).

Term-gestation low birth weight and health-compromising behaviors during pregnancy.

OBJECTIVE: To estimate the association between term-gestation low birth weight (term-LBW) rates and increasing numbers of health-compromising behaviors during pregnancy. METHODS: Retrospective cohort study of 78,397 term live births in Kansas City, Missouri, 1990-2002. Information on maternal and newborn characteristics was obtained form birth certificate records. Health-compromising behavior, specifically, smoking, alcohol, and drug use, was classified by the numbers and combinations of behaviors engaged in during pregnancy. Covariates included race, age, interconception interval, education, Medicaid status, medical risk factors, adequacy of prenatal care, and marital status. RESULTS: The cohort was 61% white, 16% less than 20 years of age, 45% on Medicaid, 24% with medical risk factor, and 45% single pregnant women. Overall term-LBW rate was 3.3%, and it increased with numbers of health-compromising behaviors: 2.6% (none), 5.5% (1), 10.8% (2), and 18.5% (3), P < .001. Unadjusted odds ratio (OR) for term-LBW increased with increasing numbers of behaviors (OR 1.0 [none]; 2.3, 95% confidence interval 2.0-2.4 [smoking]; 0.9, 0.6-1.4 [alcohol]; 2.1, 1.5-3.0 [drugs]; 4.6, 3.6-5.8 [smoking + alcohol]; 4.4, 3.6-5.4 [smoking + drugs]; 4.2, 1.5-11.9 [drugs + alcohol]; 8.4, 6.2-11.5 [smoking + alcohol + drugs]). However, on adjusting for covariates, smoking, alone (OR 2.3, 2.0-2.5) or in combinations with other behaviors (OR 4.4, 3.4-5.7 [smoking + alcohol]; 2.0, 1.6-2.6 [smoking + drugs]; and 3.3, 2.2-4.7 [smoking + alcohol + drugs]) remained the major risk factor for term-LBW. CONCLUSION: Smoking alone or in combination with alcohol and/or drug use is associated with term-LBW among women who engage in health-compromising behaviors. The effect is especially pronounced when smoking is combined with alcohol consumption.