Background:

While high-quality skilled birth attendance in facilities can avert maternal and neonatal morbidity and mortality, about 60% of births in the Sierra Madre region occur at home. Compañeros En Salud (CES), Partners In Health’s affiliate in Mexico, works to strengthen health care delivery in 10 rural communities and a hospital-birth center (HBCAAC/Casa Materna) in Chiapas.

Methods:

Through retrospective analysis of the CES Maternal Health Census, the proportion of women who delivered in HBCAAC/Casa Materna were compared between August 2016-July 2017 and August 2017-July 2018 using a 2-sample test for equality of proportions. Surveys about CES resource utilization and barriers to facility-based delivery were conducted with women living in the 5 CES-affiliated communities closest to HBCAAC/Casa Materna but delivered between January 2017-July 2018 elsewhere.

Results:

In August 2016-July 2017, 33.7% (111/329) of women living in CES catchment areas delivered at HBCAAC/Casa Materna. Despite CES resources (gasoline vouchers, food vouchers, accommodation) to facilitate facility-based delivery, this rate minimally increased to 38.2% (128/335) from August 2017-July 2018 (p=0.26). Among survey respondents, 84.5% (49/58) reported awareness of aforementioned resources, but 69.0% (40/58) reported home births--main reasons for which included lack of desire or necessity of facility-based delivery, increased trust in traditional midwives, not enough time to get to HBCAAC/Casa Materna, and cost.

Conclusions:

Our findings suggest that understanding modifiable barriers is crucial to increasing access to high-quality childbirth care and will guide the maternal health team in modifying resources to better meet the needs of women in Chiapas.

Background: Most deaths due intentional firearm injuries (>90% firearm suicides and homicides) in developed countries occur in the US. States vary by firearm legislation restrictiveness. States with restrictive legislation have lower intentional firearm mortality (IFM) rates than those with least restrictive legislation. Concerns arise that mortality due to other means (e.g., overdoses, stabbing) rise as IFM falls, with “compensation”, and no net decline in mortality.

Methods: Data on state firearm legislation were obtained from the Giffords Law Center to Prevent Gun Violence website. Data on intentional firearm and non-firearm mortality in 15-19-year-olds were obtained from the CDC Underlying Cause of Death database from 1999-2017 IFM and intentional non-firearm mortality (Inon-FM) rates were compared by legislation restrictiveness.

Results: A total of 22,856 IF and 12,847 Inon-FM deaths occurred in US youth in study years. IFM rates ranged from 1.46 to 24.7 (median=10.5) per 100,000 youth and varied inversely with increasing legislation restrictiveness (Slope= -0.581; P=0.002). Inon-FM rates ranged from 3.9 to 19.8 (median=6.27) per 100,000; they and also varied inversely with increasing legislation restrictiveness, but the protective effect of restrictive legislation for non-firearm intentional mortality did not achieve statistical significance (Slope= -.113; P=0.337).

Conclusions: There is no evidence for migration to Inon-FM in youth in restrictive firearm legislation states. Lower levels of mortality due to non-firearm means suggests that these other means are less likely to result in death than IF injuries. Apparent protective effect of restrictive legislation on Inon-FM may reflect other factors in restrictive firearm legislation states.

Introduction: Maternal confidence is a strong predictor of Breastfeeding (BF) but is rarely assessed among African Americans (AA). In previous work, we showed a significant positive association between Breastfeeding Self-Efficacy (BFSE) assessed prenatally and breastfeeding intensity (% of feeds from BF versus Formula) at 6 wks postpartum (PP). Here we report the association between BFSE assessed at 6 wks PP with breastfeeding intensity at both 6 and 20 wks PP.

Methods: AA women were recruited in mid-late pregnancy from a prenatal clinic in Detroit, MI; then enrolled in a 2-arm randomized, controlled, feasibility trial of BF support and PP weight management. Data were collected at enrollment, 6 (n=28) and 20 (n=22) wks PP. Surveys included BFSE, social support, maternal diet, and infant feeding practices.

Results: There were no differences in BF duration at 6 or 20 wks PP by study arm. Data presented are from women with complete data on targeted variables. Age ranged from 18-43 yr, 53% were WIC enrollees, and 63% had ≥ some college. BF rates among participants were 67% at 6 and 47% at 20 wks PP. BFSE, measured at 6 wks PP, was associated with BF intensity at both 6 and 20 wks PP in fully adjusted models (6 wks= prenatal BFSE, study arm, WIC enrollment, and age [β =.188, p=.0001]; 20 wks= prenatal BFSE, study arm, WIC enrollment, and age [β =.162, p=.006]).

Conclusion: Assessment of BFSE provides direction for individualized confidence-building interventions to help improve the disproportionately low rates of BF rates in AA.

Background: Prepregnancy diabetes is associated with neonatal mortality of low birthweight newborns, however, little is known about the association of prepregnancy diabetes and mortality among babies with average birthweight (≥7lbs). We examined Average Birth-Weight Infant Mortality (ABIM), by pregnancy Body Mass Index for women diagnosed with diabetes prior to pregnancy.

Methods: Data from CDC's NVSS-Linked Birth-Infant Death dataset, 3,638,143 newborns in 2011 were analyzed. The outcome was ABIM, defined as annual deaths per 1,000 live births with birthweight of ≥7pounds. The independent variable was self-reported diabetes (of any type) prior to pregnancy. Covariates were maternal co-morbidities, hospital and infant characteristics. Underlying causes of death (ICD codes 10th Revision) was included. Chi-square tests, stratified models and adjusted logistic regression analysis were conducted using STATA/SE v.15.1. P-values < 0.05 were considered statistically significant.

Results: 7,419 average birthweight newborns died before their first birthday. ABIM was prevalent among diabetic mothers (0.3%), women who smoked (0.5%), infants born ≥37 weeks (0.4%) and African Americans (0.3%), with 65% of deaths occurring during post-neonatal period. The leading causes were congenital malformations (25.35%) and SIDS (20.0%). The odds of ABIM were 2 times higher for obese diabetic mothers (95%CI:1.6-2.8) compared to non-diabetic obese mothers. Among infants born ≥37 weeks, the odds of ABIM were 2 times higher for all BMI categories compared to infants born <37 weeks.

Conclusions: Obese-diabetic mothers, smokers and full-term infants were at increased risk of ABIM, and particularly congenital malformations and SIDS. Interventions should focus on reducing maternal obesity, smoking and promoting safe sleep.

Background: Intentional firearm mortality (IFM), is a major cause of intentional mortality (homicide and suicide) in US youth. Restrictive firearm legislation has been linked to lower risk of IFM, but recently, increasing access to mental health and specialized trauma care have been proposed.

Methods: To compare the potential impacts of these strategies, state IFM rates from the CDC Underlying Cause of Death Mortality Statistics (1999-2016) for 0-19-year-olds were compared by states’ firearm legislation restrictiveness, proportion of depressed adolescents that were untreated, and number of verified specialized pediatric trauma centers (PTCs) per 100,000 youth (US persons aged <20 years).

Results: From 1999-2016, 48,400 deaths in US youth were attributed to firearm injuries; 93% were due to IFM. State IFM rates ranged from .45-7.58 per 100,000 youth (Hawaii, Alaska, respectively). Most states [28 (56%)] had extremely permissive legislation. IFM varied inversely with increasing legislation restrictiveness (Slope= -0.160, P= 0.003) and prevalence of PTC (Slope=-6.65, P=.70), but rose with increasing proportion of untreated adolescent depression (Slope=0.042, P=0.05). In logistic regression, extremely permissive state firearm legislation (adjusted odds ratio [aOR]=4.86; P= 0.049), >66% of depressed adolescents untreated (aOR=4.53; P=0.042), and <.006 PTC per 100,000 youth (aOR=5.24; P=0.027) were independently associated with IFM rates >75^th percentile. When stratified by legislation restrictiveness, untreated depression and PTC protective effects were confined to states with permissive legislation.

Conclusions: Improved pediatric trauma and mental health care access can contribute to IFM reduction, especially in states with extremely permissive firearm legislation. However, restrictive firearm legislation is associated with lowest IFM.