Strategies to optimize birth outcomes are a top priority in the current health care delivery system, where the examination and elimination of health disparities in childbearing women remain an important public health objective. Several studies have examined the relationships between socioeconomic status (SES), occupational status, ethnicity, insurance status, health care utilization, and educational level on birth outcomes, all known to influence gestational age and newborn mortality. Lesser-known variables are the influence of provider practice and hospital characteristics on birth outcomes.The purpose of this study was to evaluate several dimensions of birth outcomes employing birth certificate records and information available from provider licensing surveys for a one year period to calculate how much variation was due to differences in; a) hospital organizational characteristics; b) provider characteristics; and c) patient socio-demographic characteristics.The Quality Health Outcomes Model by Mitchell et al. (1998) provided a valuable framework which allowed the analysis of the interplay between intervention, client, and system characteristics, and their impact on birth outcomes for Maricopa County in 2005.The study design was a retrospective descriptive study using secondary data analysis with a dataset (Arizona HealthQuery, housed at the Center for Health Information and Research at Arizona State University) that included birth certificate information and the physician licensing renewal surveys.Secondary data analysis of this large administrative dataset provided the advantage of having a large sample size (62,816) of demographically diverse cases, thus minimizing concerns related to sample size and generalizability. Multiple regression and non-linear estimation models were deployed to control for confounding and effect modifying variables that could influence the relationship of labor induction on birth outcomes, including prolonged labor, use of forceps or vacuum extractors, cesarean births, Apgar scores, and newborn intensive care unit (NICU) admission.

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Objective: To examine associations between in utero marijuana exposure and birth outcomes. Study design: In two separate cohorts (Appalachian, Rocky Mountain), data were collected from medical records. Marijuana exposure was positive based on urine drug screening at delivery, with nonexposed controls matched on multiple factors including other substance exposure. Result: Marijuana-exposed newborns (n = 531) had significantly worse birth outcomes than controls (n = 531), weighing 218 g less, 82%, 79%, and 43% more likely to be low birth weight, preterm, or admitted to the NICU, respectively, and significantly lower Apgar scores. Conclusion: Marijuana exposure in utero predicted newborn factors linked to longer-term health and development issues. Effects were not attributable to other comorbidities in this study due to rigorous matching and biochemical verification of marijuana and other drug use. Findings add to growing evidence linking marijuana exposure to adverse birth and longer-term outcomes. Women should be encouraged to avoid marijuana use during pregnancy.

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In order to ensure clean drinking water for all, it is crucial to understand potential upland stressors that compromise the quality of source waters treated by local community water systems (CWSs). Contamination associated with specific types of land cover can result in downstream water quality degradation, which may reduce the effectiveness of treatment by CWSs. Surface mining has been hypothesized as a source of drinking water degradation within the Central Appalachian region, which may result in adverse exposures and health disparities. The purpose of this study was to identify potential correlations between land cover and adverse birth outcomes (ABOs) through the application of watershed epidemiology, an emerging environmental health paradigm. Birth records for the Central Appalachian region were acquired from their respective state health departments from 2001 to 2015: each record contained the mother's street address, outcome variables, and covariates. Records were included in later analyses if they fell within an approximated CWS service area. Contributing land cover to each CWS was determined via previously delineated watersheds that relied on CWS intake points. A binomial generalized linear model was used to compare low birth weight (LBW), term low birth rate (tLBW), and preterm birth (PTB) incidence to CWS source watershed land cover, Safe Drinking Water Act (SDWA) violations, CWS size, and covariates related to the birth records. Source watershed mining and SDWA health based (HB) violations were significantly associated with greater risks for preterm birth (PTB) and low birth weight (LBW). Future work should be conducted to explore upstream flow impacts, address missing data in the birth records, and to more accurately represent CWS service areas to better characterize exposure. / Master of Science / Millions of individuals throughout the world are sickened by waterborne exposures every year. To ensure clean drinking water long-term, it is crucial to understand how human land cover might change the water quality of source watersheds, as this may impact the effectiveness of water treatment and increase adverse human health exposures. The goal of this effort is to understand whether land cover is linked to downstream adverse birth outcomes (ABOs) in Central Appalachia, a region of the United States previously associated with high disease incidence suspected to be partially linked to environmental exposure. Birth records were acquired for the years of 2001 to 2015 from four (VA, WV, TN, KY) respective state health departments. Each record contained the mother's address, outcome variables, and covariates (e.g., race, ethnicity). Births were located within approximate service areas for 140 surface water dependent community water systems (CWS) within the region. Data from each CWS, including weighted land cover proportions for their source watershed, were merged with the birth records according to approximate service areas. Statistical analysis suggested that higher source watershed levels of mining and urban development were associated with higher risks of preterm birth (PTB) and low birth weight (LBW). The number of health based (HB) violations associated with each CWS was also associated with both of these outcomes. Major limitations of this work include birth record data gaps and the lack of publicly available CWS service areas and/or water consumption rates, which does increase the risk of exposure misclassification.

Despite increased access to prenatal care, birth outcomes continue to be a major source of disparity among women in the United States. The focus on lifestyle choices and negative behaviors prior to a pregnancy to reduce adverse birth outcomes has become a well-documented strategy. The purpose of this study was to determine if preparing for a pregnancy in advance improves birth outcomes for African American women of childbearing age between the ages of 12 and 45 years in the State of Rhode Island (RI). The theoretical foundation for this study was based on Prochaska's model of change, which is also known as the readiness to change model. This study was conducted using secondary data from the Rhode Island Department of Health PRAMS data set. The research questions determined if African American women received preconception care education at the same rate as White women, if African American women had a higher rate of infant mortality than other races, and if African American women had a higher rate of unintended pregnancies than White women in the state of Rhode Island. Independent t tests and chi square tests were used to answer the research questions. The results indicated a difference between the infant mortality rates for African American women compared to other races as well as a difference between African American women compared to White women with regard to unintentional pregnancies in Rhode Island. However, there was no difference in African American women compared to White women receiving preconception education in the state of Rhode Island. The implications for positive social change include micro- and macro-level changes in support of how planning for a pregnancy in advance can reduce poor birth outcomes.

Despite increased access to prenatal care, birth outcomes continue to be a major source of disparity among women in the United States. The focus on lifestyle choices and negative behaviors prior to a pregnancy to reduce adverse birth outcomes has become a well-documented strategy. The purpose of this study was to determine if preparing for a pregnancy in advance improves birth outcomes for African American women of childbearing age between the ages of 12 and 45 years in the State of Rhode Island (RI). The theoretical foundation for this study was based on Prochaska's model of change, which is also known as the readiness to change model. This study was conducted using secondary data from the Rhode Island Department of Health PRAMS data set. The research questions determined if African American women received preconception care education at the same rate as White women, if African American women had a higher rate of infant mortality than other races, and if African American women had a higher rate of unintended pregnancies than White women in the state of Rhode Island. Independent t tests and chi square tests were used to answer the research questions. The results indicated a difference between the infant mortality rates for African American women compared to other races as well as a difference between African American women compared to White women with regard to unintentional pregnancies in Rhode Island. However, there was no difference in African American women compared to White women receiving preconception education in the state of Rhode Island. The implications for positive social change include micro- and macro-level changes in support of how planning for a pregnancy in advance can reduce poor birth outcomes.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine.

The objectives of the present study in rural Nepali pregnant women living in the terai were: 1) to identify the risk factors of severe anemia and investigate whether risk factors for anemia without iron deficiency, iron deficiency without anemia and iron deficiency anemia (IDA) were different; 2) to examine the effect of vitamin A supplementation, alone or combined with iron, on hemoglobin (Hb) and soluble transferrin receptor (sTfR); and 3) to identify the risk factors of low birth weight (LBW) and preterm delivery, focusing on maternal Hb concentrations. The prevalence of severe anemia (Hb < 8.0 g/dl) in this population (n = 3531) was 4.2% and that of iron deficiency was 31%. Logistic regression analyses indicated that risk factors of severe anemia included hookworm infestation, impaired dark adaptation, lack of iron supplement intake, a diet low in heme iron and malnutrition manifested by thinness and short stature. These same factors differed among non-iron-deficient anemic, iron deficient non-anemic, and iron-deficient anemic pregnant women. We found a significant positive correlation between Hb and retinol concentrations (Pearson r = 0.212, P < 0.0001) and one fourth of our anemic subjects were also vitamin A deficient. There was no evidence that vitamin A alone significantly increased Hb and decreased the prevalence of anemia (n = 498). However, vitamin A, when given together with iron, had an added beneficial effect on Hb but not sTfR. In addition, women with initially compromised iron status benefited more from iron and vitamin A supplementation. The prevalence of LBW and preterm delivery was 22% and 20%, respectively (n = 915). There was an increased risk of LBW associated with short stature, thinness and impaired dark adaptation. The association between Hb measured during the second trimester and risk of LBW had a U-shaped distribution, with risk increasing significantly with Hb < 8.0 g/dl. Based on our findings, we recommend that Hb is evaluated during the second trimester as an indicator of increased LBW risk. While vitamin A supplementation to all pregnant women is recommended, routine supplementation of iron and deworming during pregnancy are essential.

Although physical abuse during pregnancy has been linked to poor birth outcomes, the role of psychological abuse is less well understood. Associations between birth outcomes and types of psychological abuse during pregnancy (being threatened, screamed at, or insulted) were examined in 489 women with no history of physical abuse. Being threatened was significantly associated with adverse birth outcomes, with women reporting any instance during pregnancy twice as likely to deliver a low birth weight baby. These results remained after controlling for background factors. Finally, most of the variance between threats and birth weight was accounted for by mediating health behaviors (specifically prenatal care utilization and pregnancy weight gain), suggesting pathways for the negative effects of being threatened by an intimate partner during pregnancy.