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SAIDA SHARAPOVA The role of stress in racial disparities of preterm and low birth weight births in Georgia (Under the direction of Richard Rothenberg, MD, MPH) Preterm birth (PTB) and low birth weight (LBW) are the leading causes of infant deaths in Georgia. Georgia PRAMS data (2004-2008) were analyzed for non-Hispanic White and non-Hispanic Black women with singleton births, using SAS 9.2 survey procedures. Thirteen stressful life events experienced in a year before delivery, socio-demographic, medical and behavioral risks were used as predictors of PTB and LBW. Significant racial disparity in birth outcomes and risks was found. In Whites stressful events were associated with adverse birth outcomes in bivariate logistic regression, but weakened when controlling for other factors (income, education, maternal age, maternal health, alcohol and tobacco use, infant’s gender and birth defects). In Blacks, association between stressful events and adverse birth outcomes adjusted for other risks was stronger. Socio-economic factors and mother’s health status were more significant in predicting birth outcome. Women’s health and SES improvement might increase favorable pregnancy outcomes and reduce racial disparities.

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Background: Health policies that seek to improve pregnancy outcomes focus on increasing the availability and access to prenatal care (PNC) services based on studies that support an association between insufficient PNC and adverse birth outcomes. These studies employ PNC utilization indices that measure the adequacy of PNC use, but these indices fail to account for the content or specific components of PNC. Objectives: The purpose of this study was to utilize PRAMS and birth certificate data to evaluate the content and quality of PNC in Virginia, and its impact on preterm birth and maternal postpartum health behaviors. Methods: Data was from the 2007 Virginia Pregnancy Risk Assessment Monitoring System (PRAMS). This population-based data is representative of all Virginia women who have had a live birth recently and included 1,236 female participants. Results: Inadequate PNC was associated with nearly a three-fold increase in risk of low birth weight (OR = 2.8, 95% CI = 1.5, 5.2), but not preterm birth. Women with adequate plus PNC were more likely to deliver infants who were preterm (OR = 10.2, 95% CI = 4.3, 24.4) and low birth weight (OR = 6.3, 95% CI = 4.2, 9.4). After adjusting for method of payment, income, and reported problems during pregnancy, women with lower income and no private insurance were more likely to have inadequate PNC (OR = 1.4, 95% CI = 0.5, 4.1) and (OR = 8.8, 95% CI = 1.3, 59.8), respectively. Provider discussions were not different based on adequacy of PNC. In addition, among women who received adequate PNC, those whose providers discussed postpartum birth control use were 4.5 times more likely to use birth control after delivery compared to women who did not receive education (95% CI=1.7, 11.8). Conclusion: The lack of strong associations between adequacy of PNC and birth outcomes indicate that there are other factors (intergenerational, stress, cultural) that may play a more prominent role in predicting maternal and infant health.

Statement of Purpose The purpose of this study is to examine the impact of preconception health on adverse pregnancy outcomes through the theoretical lens of reciprocal determinism. Thus, this study aims to develop a preconception health conceptual framework that accounts for the interactive relationships among behavior, the environment, and the person. Rationale for the Study Women may not recognize a pregnancy until the first or second missed menstrual cycle, a full four to eight weeks or more after conception. Once a woman realizes the possibility of a pregnancy, it takes further time to confirm the pregnancy with a home pregnancy kit or a visit to the health care provider. In that time period, the woman may have unknowingly exposed her embryo to nutritional deficiencies, over-the-counter drugs, tobacco, alcohol, or other toxins. Because nearly half of all pregnancies are unintended, yielding about three million unintended pregnancies in the U.S. annually, there is a need to shift care to an earlier period in a woman's life cycle with greater potential to prevent birth defects and other adverse pregnancy outcomes, also known as preconception care. The preconception health movement began with the rationale that many adverse pregnancy outcomes are determined prior to prenatal care initiation. Thus, in addition to prenatal care, the need for preconception health arose. The empirical literature makes a strong case for the benefit of individual preconception health components and their effects on adverse pregnancy outcomes. However, the actual effectiveness of collective preconception health in reducing adverse pregnancy outcomes has not yet been demonstrated. In an effort to evaluate the impact of preconception health on maternal morbidity, infant morbidity, and infant mortality, this study examined the reciprocal relationships between environmental, personal, and preconception behavioral factors and their associations with adverse pregnancy outcomes. Methods A secondary data analysis was conducted using the Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2005-2008 to test a preconception framework. Project 1 examined all variables in the preconception framework among the following states: Maine, New Jersey, Ohio, and Utah. Project 2 examined all variables except of two among all PRAMS-participating states. All of the variables in the proposed framework were derived from questions in the PRAMS survey or from PRAMS-linked birth certificate data. The research questions posed in this study were resolved through the path analyses of reduced and full iterations of the preconception framework in Projects 1 and 2. Results In Project 1, list-wise deletion of missing data resulted in a decrease from the original 27,933 participants to 12,239 participants. In Project 2, this action resulted in a decrease from the original 200,008 participants to 128,551 participants. The analysis of the reduced frameworks for both projects revealed extremely low R-squared values (1.1% or less). Subsequent analyses examining the full framework in Projects 1 and 2, as well as an additional post hoc analysis with supplementary PRAMS variables, resulted in R-squared values of 13.1%, 11.4%, and 30.5%, respectively. Implications This study examined the impact of preconception health behaviors on adverse pregnancy outcomes through the theoretical lens of reciprocal determinism. Preconception health behaviors alone accounted for a negligible portion of the variance associated with adverse pregnancy outcomes. As hypothesized, preconception health behaviors work in concert with environmental factors, personal influences, prenatal and natal factors. Significant predictors supported in the literature included lower socioeconomic status, pregnancy intention, pregnancy history, older maternal age, black maternal race, Hispanic ethnicity, overweight maternal BMI, tobacco use prior to pregnancy, maternal complications, hospitalization during pregnancy, later prenatal care initiation, fewer prenatal care visits, plurality, and cesarean section. Even so, there is a large portion of the variance in adverse pregnancy outcomes that is not accounted for, and further examination is required.

Maternal depression during pregnancy can have a negative impact on the developing child. Numerous studies have focused on postpartum depression and the influences on infant outcomes; however, there are limited data on pregnancy-related depression. The problem addressed in this study was the inadequacy and insufficiency of depression screening during the pregnancy period and access to quality-related health services for women. The purpose of this quantitative retrospective study was to test social cognitive theory on low birth weight and prenatal care adherence to pregnancy-related depression in women residing in Colorado. This research measured an association between pregnancy-related depression and both low birth weight prevalence and prenatal care adherence. Secondary analysis of archived data included data from Colorado vital statistics and the 2016 Colorado Pregnancy Risk Assessment Monitoring System. Data were analyzed using Chi-square analysis and multiple logistic regression. The findings showed that pregnancy-related depression was statistically significant of very low birth weight. I reported a summary of findings on p. 68. Biopsychosocial variables were significant to pregnancy-related depression. Pregnancy-related depression was significant in prenatal and postpartum depression. The implications of these findings for social change include the potential to support improved depression screening strategies during pregnancy that may contribute to transformation within the community by promoting more efficient and accessible healthcare for women.

The purpose of this dissertation was to examine patterns of antenatal stressful life events (SLEs) experienced by women in the United States (U.S.) and their association with postpartum depression (PPD). It further explored the role of women's state-level socio-economic status (SES) on PPD; the racial/ethnic dispartites in SLE-PPD relationship; and the role of provider communication on perinatal depression. Data from 2009–11 Pregnancy Risk Assessment Monitoring System (PRAMS) and SES indicators published by the Institute of Women’s Policy Research (IWPR) were used. Latent class analysis (LCA) was performed to identify unobserved class membership based on antenatal SLEs. Multilevel generalized linear mixed models examined whether state-level SES moderated the antenatal SLE-PPD relationship. Of 116,595 respondents to the PRAMS 2009-11, the sample size for our analyses ranged from 78% to 99%. The majority (64%) of participants were in low-stress class. The illness/death related-stress class (13%) had a high prevalence of severe illness (77%) and death (63%) of a family member or someone very close to them, while those in the multiple-stress (22%) class endorsed most other SLEs. Eleven percent had PPD; women who experienced all types of stressors, had the highest odds (adjusted odds ratio [aOR]: 5.43; 95% confidence interval [CI]: 5.36, 5.51) of PPD. The odds of PPD decreased with increasing state-level social/economic autonomy index (aOR: 0.75; 95% CI: 0.64, 0.88), with significant cross-level interaction between stressors and state-level SES. Among non-Hispanic blacks and non-Hispanic whites, husband/partner not wanting the pregnancy (aOR: 1.47; 95% CI: 1.14, 1.90) and drug/drinking problems of someone close (aOR: 1.37; 95% CI: 1.21, 1.55) were respectively associated with PPD. Provider communication was protective. That 1 out of every 5 and 1 out of every 8 women were in the high- and emotional-stress classes suggests that SLEs are common among pregnant women. Our results suggest that screening for antenatal SLEs might help identify women at risk for PPD. The finding that the odds of PPD decrease with increasing social/economic autonomy, could have policy implications and motivate efforts to improve these indices. This study also indicates the benefits of antenatal health care provider communication on perinatal depression.