Introdução: No Brasil, a elevada taxa de cesárea, o uso excessivo e rotineiro de intervenções no parto vaginal, as taxas elevadas de morbimortalidade materna e a inobservância de direitos básicos das mulheres são pontos críticos da assistência obstétrica. No plano internacional, as evidências de que a assistência pode causar danos promoveu o movimento pela segurança da paciente, com a criação de estratégia inovadora para a promoção do cuidado livre de danos (harm free care). Este compreende o dano a partir da perspectiva da paciente, medido por meio de termômetros de segurança. Objetivos: Verificar a frequência, e fatores associados, de danos causados pela assistência às puérperas e aos recém-nascidos do Sudeste brasileiro durante e após o parto, e a associação destes danos com sintomas de depressão pós-parto (DPP) entre 2011 e 2012. Método: A partir do Nascer no Brasil: Inquérito Nacional sobre Parto e Nascimento, verificou-se a frequência dos cinco danos previstos no Termômetro de Segurança da Maternidade (TSM), utilizado neste estudo como referência. Também se verificou a prevalência de DPP nas puérperas da Região Sudeste do Brasil (n=10.155), com até um ano de pós-parto, utilizando-se a Escala de Depressão Pós-parto de Edimburgo (EPDS). Resultados: Entre os danos, separação mãe-bebê, cesarianas e traumas perineais foram aqueles que apresentaram maior frequência (69,5 por cento , 52,6 por cento e 37,5 por cento , respectivamente). Relatos de desrespeito, abuso e maus-tratos foram observados em 44,6 por cento das mulheres. O cuidado livre de dano correspondeu a 2 por cento . Ter sofrido uma cesariana dobrou a chance de ter um dano (OR:2,21; IC95 por cento 1,20 - 4,07), e quadruplicou a chance de ter dois ou mais danos (OR:4,08; IC95 por cento 2,27 - 7,32). A prevalência de casos prováveis de DPP foi de 25,8 por cento . Entre os fatores de risco associados, identificaram-se fonte de pagamento pública (OR=1,80; IC95 por cento 1,44 - 2,23); ensino fundamental incompleto ou completo (OR:1,64; IC95 por cento 1,37 - 1,96); ser das classes C, D ou E (OR:1,24; IC95 por cento 1,02 - 1,50); fumar durante a gestação (OR:1,62; IC95 por cento 1,20 - 2,18); não desejar engravidar naquele momento (OR:1,52; IC95 por cento 1,22 - 1,90); ter tido uma ou duas (OR:1,55; IC95 por cento 1,24 - 1,94) e três ou mais gestações anteriores (OR:2,10; IC95 por cento 1,52 - 2,90); referir a experiência do parto como regular, ruim ou péssima (OR:1,47; IC95 por cento 1,12 - 1,93) e ter sofrido três danos no TSM (OR:1,35; IC95 por cento 1,12 - 1,62) e quatro ou mais danos (OR:2,81; IC95 por cento 1,90 - 4,16). Conclusão: A assistência ao parto, na Região Sudeste do Brasil, promove alta frequência de danos evitáveis, tratando-se de importante problema de saúde pública. O cuidado livre de dano é exceção no Brasil (2 por cento ). Fatores socioeconômicos estão associados à DPP, assim como fatores relacionados à assistência ao parto, especialmente quando ocorridos em hospital público. Fatores de risco que indicam vulnerabilidade individual ou que estão relacionados a paridade também se mostraram associados / Introduction: In Brazil, the high rates of cesarean section, the excessive and routine use of interventions in labor, the high rates of maternal morbidity and mortality, and the non-observance of basic human rights are critical points of obstetric care. At the international level, however, evidence that assistance can cause harm has given rise to a patient safety movement, which in turn has led to an innovative strategy being created to promote harm free care, based on the understanding of harm from the patients perspective and on \"safety thermometers\". Objectives: To verify the frequency and the associated factors of harm caused by care, to southeastern Brazilian postpartum women and their newborns during and after childbirth, and the association of these harms with symptoms of postpartum depression (PPD) between 2011 and 2012. Method: This study searched the Born in Brazil Survey database for the five harms under the Maternity Safety Thermometer (MST), which was used as a reference. The prevalence of PPD in postpartum women in the southeastern region of Brazil (n = 10,155) was also verified, up until one year postpartum, using the Edinburgh Postpartum Depression Scale (EPDS). Results: Among all harms, mother-baby separation, cesarean sections, and trauma to the perineum ranked highest in frequency (69.5 per cent , 52.6 per cent , and 37.5 per cent , respectively). Reports of disrespect, abuse and mistreatment (DAMT) were observed in 44.6 per cent . Harm-free care totaled less than 2 per cent . Having a cesarean section doubled the chance of a harm (OR: 2.21, 95 per cent CI 1.20 - 4.07), and quadrupled the chance of two or more harms (OR: 4.08; 95 per cent CI 2.27-7.32). The prevalence of probable cases of PPD was 25.8 per cent . Among the associated risk factors, this study found: public payment sources (OR = 1.80, 95 per cent CI 1.44-2.23); incomplete or incomplete elementary schooling (OR: 1.64; 95 per cent CI 1.37-1.96); lower income brackets (C, D, or E) (OR: 1.24, IC95 per cent 1.02 - 1.50); smoking during pregnancy (OR: 1.62; 95 per cent CI: 1.20 - 2.18); not wanting to become pregnant (OR: 1.52; 95 per cent CI 1.22-1.90); having one or two (OR: 1.55, 95 per cent CI 1.24-1.94) or three or more previous pregnancies (OR: 2.10; 95 per cent CI 1.52-2.90); considering the birth experience fair, bad or very bad (OR: 1.47, 95 per cent CI 1.12-1.93), having suffered three MST-listed harms (OR: 1.35, 95 per cent CI, 1.12-1, 62), and having suffered four or more harms (OR: 2.81; 95 per cent CI: 1.90 - 4.16). Conclusion: Childbirth care in the southeastern Brazil, the most developed region in the country, is marked by a high frequency of preventable damages, which translates as a significant public health problem. Harm free care is an exception in Brazil (2 per cent ). Socioeconomic factors are associated with PPD, as well as factors related to childbirth care, especially when birth takes place in a public hospital. Risk factors that indicate individual vulnerability or risk factor related to parity are also associated

The prevalence of childhood overweight and obesity is increasing at an alarming rate in the United States. Currently more than 1 in 3 children aged 2-19 are overweight or obese. This is of major concern because childhood overweight and obesity leads to chronic conditions such as type II diabetes and tracks into adulthood, where more severe adverse health outcomes arise. In this study I used the premise of the social ecological model (SEM) to analyze the common levels that a child is exposed to daily; the intrapersonal level, the interpersonal level, the school level, and the community level to better understand what risk factors are significantly associated with child weight status. Data came from the 2012 National Survey of Children's Health (NSCH) (n=41,361). Frequencies and confidence intervals were used to describe risk factors at each level. Bivariate analyses were conducted between each risk factor and the outcome variable. Using all risk factors that were significantly associated with overweight and obesity in the bivariate analyses, multinomial logistic regressions were performed for each SEM level. The 4 SEM levels were then analyzed together using stagewise multinomial logistic regression. A significance level cutoff of 0.05 was applied to all analyses. Thirty-three percent of participants were overweight or obese. Child sex, race, age, child physical activity participation, mother’s education and health, the child’s family structure, the child’s participation in extracurricular activities, frequency of family meals at home, safety and engagement in school, the number of amenities and the safety and support within their communities were found to be significantly associated with child weight status. The odds ratios of the covariates in the final stagewise model were similar to those in each individual model. Understanding both the risk factors associated with child overweight and obesity in each individual level and in the complete socio-ecological perspective is important when working toward more effective policy and program creation and the reduction of childhood obesity. Recognizing that all levels of a child's SEM influence his or her likelihood of being overweight or obese can lead to more effective strategies that tackle multiple SEM levels collectively instead of each level independently.

The Centers for Disease Control and Prevention (CDC) estimates that 1.5 million women are victims of intimate partner violence (IPV) each year, and 324,000 of these women are pregnant (2013). Research on the predictability of certain factors and their relationship to current and historical IPV is limited. In order to better understand IPV as it related to a sample of 1,016 Appalachian pregnant women selected for the Tennessee Interventions for Pregnant Smokers (TIPS), it was important to evaluate various influences that may predict the prevalence of IPV in this population when compared to the State of Tennessee and the U.S. (Aim 1). An evaluation of psychological, sociocultural, and socioeconomic variables as they relate to both current and historical IPV in pregnant women presenting for prenatal care was conducted (Aim 2), and the results from this evaluation were used to model significant IPV influences to determine pregnancy predictors in the study sample when historical and current IPV is present (Aim 3). Percent prevalence of self-reported IPV was higher in the TIPS sample for Carter, Greene, Hawkins, Johnson, Sullivan, Washington, and Unicoi counties, when compared to criminal reports for State of Tennessee IPV victimization rates, and the rate per 1,000 IPV victimization rate was also higher in the TIPS sample when compared to the criminal report for the U.S. Self-esteem, social, support, stress, substance abuse, and alcohol were positive as independent effects for predicting IPV via ordinal regression; however, when evaluated via multinomial logical regression with controls for age, race, income, education, marital status, whether or not a pregnancy was planned, and parity, this effect was no longer noted. Unplanned pregnancies and lower education were significant control variables in these evaluations. The lack of support for predictive ability of those selected psychological and sociocultural variables for IPV only underscores the importance of taking into consideration the uniqueness of various populations and across various regions such as Appalachia. The influences of unplanned pregnancy and lower education may be significant predictors if IPV in pregnant women in Appalachia and warrant further research.

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection in the U.S., where one HPV-related cancer is diagnosed every 20 minutes. The most common HPV-related cancer is cervical cancer, with an estimated incidence of 12,000 cases annually, a third of which lead to death. Cervical cancer disparately affects women of ethnic minority groups and geographically isolated regions, such as Appalachia. Tennessee ranks third highest in cervical cancer incidence in the country. Many cases of cervical cancer could be prevented through vaccination against HPV, however, vaccination rates for females in Tennessee are among the lowest in the country. This mixed-methods study included an in-depth exploration of the factors that influence HPV vaccine acceptance in Appalachian Tennessee. Healthcare providers, mothers of adolescent girls, and college-aged women were recruited to participate in the study. From October 2016 to January 2017, interviews were conducted with healthcare providers (n=12), focus groups were conducted with mothers (n=13), and a survey was administered to college women (n=479). Interview and focus group sessions were recorded, transcribed and analyzed using a thematic framework. Survey responses were analyzed using descriptive tests, comparison of means, and regression analyses. The predominant barriers to vaccine acceptance identified in the study were: cost and novelty of the vaccine, vaccine safety, lack of school-entry requirement, and the implication of vaccine acceptance on adolescents’ sexual activity. Most negative perceptions towards the vaccine appeared to be propagated by the sociocultural influence on sex and reproductive health communication within the community. Perceived benefits for cancer prevention and receipt of strong and personal provider recommendations facilitated vaccine acceptance. Additionally, college students who reported vaccine acceptance reported discussing sexual health topics with their mothers more often than those who had not been vaccinated. The findings from this study provide foundational insights about the facilitators and barriers of HPV vaccine acceptance in Appalachian Tennessee. Identifying and understanding these factors is crucial to improving HPV vaccination rates and essential to maximizing the primary benefit of the vaccine in addressing the existing cervical cancer disparity in the region.

For birthing parents, the quality of care falls flat in the United States relative to other developed countries as rates of pregnancy-related deaths (PRD) continue to rise. California has in recent years made extraordinary progress in decreasing birthing parent mortality across the board. Yet, health disparities remain between race/ethnicities as Black birthing parents die at three to four times the rate of white birthing parents. In comparison to white Americans marginalized ethnic/racial groups in the United States have less access to quality care, experience and receive lower quality of health care and have less access to quality care, with few exceptions. Intersecting factors such as education, socioeconomic status and acculturation are investigated. Implicit bias, or racism is often overlooked within the medical professions that has real implications on the above-mentioned sociological factors and in turn birthing mortality rates. Institutional and grassroot methods to bring attention to these factors should be referenced for a more intentional approach to solving this social problem historically engrained in our medical institutions.

Establishing healthy eating behaviors is vital in the early years to help combat the development of obesity and other chronic diseases. Mothers play an invaluable role in shaping their children's eating habits through controlling what and when children eat as well as the overall food environment, which is why a better understanding of what influences mothers’ decisions about these behaviors is important. The purpose of the dissertation was to gain a better understanding of what impacts maternal feeding decisions regarding toddler nutrition behaviors. This was a two-phased mixed methods study. The aim of the initial study was to explore, using a Theory of Planned Behavior (TPB) framework, the influences on mothers’ toddler feeding decisions. These included attitude, subjective norms, and perceived behavioral control. These constructs were derived from discussions about what sources of nutrition information mothers use and trust. The aim of the subsequent study was to use the TPB to assess factors affecting a mother’s behavioral intention to provide their toddler with a healthy diet and to see if the addition of the parental role construction variable strengthened the TPB’s ability to significantly predict the mother’s behavioral intention. The first study used a qualitative approach to gather data from three focus groups that consisted of mothers of toddlers (N = 15). Qualitative thematic analysis was used to define prominent themes. Four major themes emerged from the data analysis: (1) attitudes (subthemes: positive towards maternal role of feeding and negative towards the maternal role of feeding); (2) subjective norms positively accepted (subthemes: social media, pediatricians, and registered dietitians); (3) subjective norms negatively accepted (subthemes: pediatricians and registered dietitians); (4) perceived behavioral control (subthemes: acceptance, scarcity of time and outside influences). An online survey was created using data gathered from the focus groups and a previously validated survey that fit the theoretical basis of the study. The survey utilized the TPB to assess the connections between the constructs and the mothers’ behavioral intentions surrounding toddler feeding. The final sample consisted of 148 mothers. The mean age was 32.83 (SD = 6.16) years. The majority of participants were married (87.2%), had earned a college degree or higher (79.7%), held part-time or fulltime employment, (60.8%), and were White (90.3%). The TPB model predicted 53% of the variance in mother’s behavioral intention surrounding the behavior of providing meals that include a wide variety of the five food groups in appropriate amounts. The addition of the parental role construction variable added 6% more predictive power to the model. The most salient predictors included attitude, perceived behavioral control, and parental role construction. Mothers positively and negatively receive information from a variety of sources, they have many strong emotions associated with feeding that are deeply rooted in their roles as mothers, and their feeding decisions were strongly influenced by the TPB constructs. Health promotion efforts should aim to increase the mother’s sense of behavioral control and parental responsibility rather than focusing on the benefits of healthy eating. Programs should provide tangible ways to help mothers overcome perceived barriers and, in turn, increase mothers’ beliefs in their ability to provide toddlers with a balanced diet.

Obesity is a significant health concern for women of childbearing age. More than 40% of women have a Body Mass Index (BMI) in the overweight or obese ranges at the time they conceive, posing significant health risks for both mother and child. Excessive weight gain during pregnancy is common and associated with numerous deleterious complications. The Institute of Medicine published gestational weight gain (GWG) guidelines based on prepregnancy BMI. However, more than 50% of women gain in excess of these recommendations. Further, many women report receiving minimal guidance from their healthcare providers regarding weight gain, nutrition, and physical activity during pregnancy. There is a clear need to enhance patient-provider communication to develop relevant and targeted interventions to reduce excessive GWG. The current study used a mixed-methods approach to assess perspectives of both pregnant and postpartum women, and obstetric healthcare providers (HCPs’). Interviews with pregnant and postpartum women with overweight or obesity prior to pregnancy indicated deference to providers regarding GWG. However, many women indicated suboptimal receipt of GWG information, disagreement with the GWG guidelines, and disapproval of the restrictive weight ranges for women in higher BMI categories. Additionally, parity emerged as a salient topic for women, especially as related to weight retention between pregnancies. HCPs’ survey data suggest systemic barriers to patient-provider communication (e.g. time, training) could serve as targets for future interventions. In sum, maternal overweight and obesity, excessive GWG, and patient-provider interaction are crucial topics to address to improve maternal and fetal outcomes, and decrease healthcare costs.

The health benefits of breastfeeding exceed well beyond the first few years of an infant's life. Breast milk is often referred to as liquid gold because of its extensive protective properties that promote child growth and development. Unfortunately, African American women have the lowest breastfeeding rates compared to any other racial group. Given that African American children are disproportionately affected by the current obesity epidemic in the United States, there may be a link between a mother's preference to breastfeed her infant and her influence over her child's eating behaviors and physical activity levels. Guided by social cognitive theory, the purpose of this quantitative longitudinal study was to explore the association between exclusive breastfeeding and maternal control over childhood nutrition and physical activity among African American women and children enrolled in the Women Infants and Children Nutritional Supplementation Program (WIC). Secondary data were used from the Infant Feeding Practices II Survey and its Year 6 Follow Up. Crosstabulations were performed to assess the relationship between exclusive breastfeeding and maternal control over child health behaviors after 6 years. The null hypotheses were not rejected, as there was no relationship between exclusive breastfeeding and maternal control over physical activity or child eating behaviors. Findings revealed moderate to high levels of maternal control among WIC participants who breastfed for 3 months. This study may lead to positive social change by increasing the number of children who benefit from breast milk and improving childhood nutrition and physical activity, which will ultimately reduce child obesity disparities and promote maternal and child health altogether.

Preterm birth (PTB) is defined as birth before 37 weeks gestational age. PTB is a common outcome and one that may be increasing in prevalence with serious individual and public health implications both immediately and long term. While PTB is a pregnancy specific outcome it is more appropriately viewed as the culmination of risk factors present both before pregnancy and possibly in past generations. This thesis attempts to review the implications, risk factors and current prevention strategies directed at PTB while placing it in an intergenerational and life cycle context. Three novel investigations are presented and their consequences are discussed. These investigations cover the lifespan and relate to identifying PTB and treating its immediate health outcomes. The first examines mitochondrial genetics and it's relation to PTB. There is a strong a priori hypothesis that mitochondrial genetics, being maternally inherited, may contribute to an individual's risk for PTB. However, in two genome wide association studies, no evidence is found for any mitochondrial polymorphisms being related to PTB. The second investigation reports an attempt to identify women at risk for PTB within a given pregnancy. Using routinely collected maternal information and serum screening data a potentially useful screening method is derived. While the algorithm does not have ideal performance characteristics it compares favorably to other population wide screening techniques and could be improved through future validation and data collection. The third and final investigation attempts to address quality of care for infants born preterm. In a network of neonatal intensive care units, wide variations in mortality outcomes are observed. Intensity of medical intervention appears to be an important predictor of mortality for the lowest gestational age infants. However, this intensity of intervention does not fully explain the observed differences in mortality outcomes. Finally, these study are discussed in context with one another and a new framework for considering PTB is presented that may help to guide future investigation into predicting, preventing and caring for those at risk for or experiencing a PTB.

<p>Background: Globally, neonatal mortality (i.e. deaths occurring during the first month of life) accounts for 44% of the 11 million infants that die every year (Lawn, Cousens &amp / Zupan, 2005). Early&nbsp / detection of illness and referral of mothers and infants during the peri-natal period to higher levels of care can lead to substantial reductions in maternal and child mortality in developing&nbsp / countries. Establishing effective referral systems from the community to health facilities can be achieved through greater utilization of community health workers and improved health seeking&nbsp / behaviour. Study design: The Good Start Saving Newborn Lives study being conducted in Umlazi, KwaZulu-Natal, is a community randomized trial to assess the effect of an integrated home&nbsp / visit package delivered to mothers during pregnancy and post delivery on uptake of PMTCT interventions and appropriate newborn care practices. The home visit package is delivered by community health workers in fifteen intervention clusters. Control clusters receive routine health facility antenatal and postpartum care. For any identified danger signs during a home visit,&nbsp / community health workers write a referral and if necessary refer infants to a local clinic or hospital. The aim of this study was to assess the effectiveness of this referral system by describing&nbsp / community health worker referral completion rates as well as health-care seeking practices and perceptions of mothers. A cross- sectional survey was undertaken using a structured&nbsp / questionnaire with all mothers who had been referred to a clinic or hospital by a community health worker since the start of the Good Start Saving Newborn Lives Trial. Data collection: Informed consent was obtained from willing participants. Interviews were conducted by a trained research assistant in the mothers&rsquo / home or at the study&nbsp / offices. Road to Health Cards were reviewed to confirm referral completion. Data was collected by means of a cell phone (mobile researcher software) and the database was later transferred to Epi-info and STATA IC 11 for analysis.&nbsp / Descriptive analysis was&nbsp / conducted so as to establish associations between explanatory factors and referral completion and to describe referral processes experienced by caregivers. Significant&nbsp / associations between categorical variables were assessed using chi square tests and continuous variables using analysis of variance. Results: A total of 2423 women were&nbsp / enrolled in the SNL study and 148 had received a referral for a sick infant by a CHW by June 2010. The majority (95%) of infants were referred only once during the time of enrolment, the&nbsp / highest number of which occurred within&nbsp / the first 4 weeks of life (62%) with 22% of these being between birth and 2 weeks of age. Almost all mothers (95%) completed the referral by taking&nbsp / their child to a health facility. Difficulty in breathing and rash accounted for the highest number of referrals (26% and 19% respectively). None of the six mothers who did not complete referral recognised any danger signs in their infants. In only 16% of cases did a health worker give written feedback on the outcome of the referral to the referring CHW.&nbsp / Conclusion: This study found&nbsp / high compliance with referrals for sick infants by community health workers in Umlazi. This supports the current primary health care re-engineering process being undertaken by the South&nbsp / African National Department of Health (SANDOH) which will involve the establishment of family health worker teams&nbsp / including community health workers. A key function of these workers will&nbsp / be to conduct antenatal and postnatal visits to women in their homes and to identify and refer ill children. Failure of mothers to identify danger signs in the infant was associated with&nbsp / non-completion of referral. This highlights the need for thorough counseling of mothers during the antenatal and early postnatal period on neonatal danger signs which can be reinforced by&nbsp / community health workers. Most of the referrals in this study were&nbsp / neonates which strengthens the need for home visit packages delivered by community health workers during the antenatal&nbsp / and post-natal period as currently planned by the South African National Department of Health.Recommendations: This study supports the current plans of the Department of Health for greater involvement of CHWs in Primary Health Care. Attention should be given to improving communication between health facilities and CHWs to ensure continuity of care and greater&nbsp / realization of a team approach to PHC.</p>