Institute for Equity in Birth Outcomes Maternal Stress

Deborah Allen, ScDBoston Public Health Commission

A bit of context◦ Why the focus on stress

Modeling the impact of stress◦ Diderichsen model◦ A simplified model (GEfGW)

Putting the model to work◦ Programmatic options, downstream and up◦ Implementation tools

And beyond

<1500 grams

1500-2499 grams

2500+ grams

BOSTON 1.0% 5.4% 93.5%

Asian n<5 4.7% 94.9%

Black 1.8% 7.5% 90.7%

Latino 1.3% 5.7% 92.9%

White 0.6% 3.8% 95.6%

Data Source: Boston resident live births, Massachusetts Department of Public HealthData Analysis: Boston Public Health Commission Research and Evaluation Office

Race/Ethnicity

Timing of Birth

<28 Weeks 28-32 33-36

White 15 25 30

Latino 19 21 23

Black 56 47 35

Asian 7 4 6

Infant Deaths (per 1,000 live births)

2008 2009 2010

Boston 7.2 6.5 3.7

Asian n<5 8.2 n<5

Black 14.6 7.7 7.4

Latino 8.1 8.0 4.7

White 3.4 5.0 1.6

In US and internationally In relation to specific chronic conditions In relation to racial/social disparities in

health generally As an explanation for persistent disparities

in health outcomes As a guide to intervention

1) A focus on early exposure to risk• Or more broadly, risk at periods of high vulnerability

2) And on cumulative risk over the life span3) Renewed interest in social determinants of

health• This is not a new idea but it is rediscovered and

reframed periodically

4) A new emphasis on stress as the link between social experience and health

Evidence of the consequences of adverse birth outcomes◦ Proximal consequences◦ Distal consequences: the Barker Hypothesis

Some exposures are uniquely dangerous at specific critical periods◦ Folic acid deficit in first trimester◦ Alcohol dependency in adolescence

Concept of “critical periods” has been applied to impact of insults in utero◦ Cardiovascular disease◦ Non-insulin dependent diabetes◦ Hypertension

With acknowledgement of later modifying factors and/or later compounding factors◦ The case of asthma

Link to maternal prenatal stress Link to postpartum mother and child stress

Risk accumulates within lifetime of individual◦ Long term risk◦ Synergy across multiple risks

Evidence suggests risk accumulates across generations◦ “Grandmaternal” birth weight as predictor

of infant birth weight Adds a dynamic dimension to model

The causes most often listed for disparities in adverse outcomes across group of children◦ Components of the ACES

Substance abuse Family break-up Parental depression Child abuse and neglect Criminal involvement of family member

◦ Income◦ Employment◦ Education◦ Interaction with criminal justice system◦ Food: adequate, safe, healthy◦ Clean air and water◦ Housing and neighborhood safety◦ Social support◦ Access to health care◦ Transportation

Discrimination◦ Both as a cause of the elements listed above◦ And as a psychosocial experience, with its own

direct consequences for health

Doleac and Stein, 2010: discrimination in housing sales

Bertrand and Mullainathan, 2002: discrimination in employment◦ Even when applicant documented widely promoted “self

improvement” efforts Baker et all, 2006: unequal distribution of fast

food outlets and supermarkets and of healthy foods within those outlets in St. Louis

Poe-Yamagata and Jones, 2000: discrimination against youth of color at all stages in criminal justice process

According to the WHO, stress may reflect or be expressed in terms of

Anxiety Insecurity Low self-esteem Social isolation Lack of control over work and home life

The WHO perspective: It’s not just about money, it is also about the mind-body connection

Not necessarily defined by where the bottom and top of the ladder are

But affected by distance from bottom to top

NOTE: Survey question reads, “In your entire lifetime, have any close family members or close friends of yours been killed by violence, like being shot, stabbed, or beaten to death (do not include those include in war)?”DATA SOURCE: Boston Youth Survey, 2008; Harvard Youth Violence Prevention Center through a Cooperative agreement with the Center for Disease Control and PreventionDATA ANALYSIS: Harvard Youth Violence Prevention Center

US and international studies link ambient violence to preterm birth, low birth weight and infant death

Lauderdale, looking at Arabic-named women in CA six months after 9/11, found 2-fold increase in LBW compared with prior year

Increasing evidence that asthma rates (incidence and exacerbation) link to community violence

Our strategies must◦ Reduce early adverse exposures◦ Disrupt accumulation of risk over time◦ Address social determinants◦ Eliminate or reduce impact of stressors

Figure

Source: The Lancet 2002; 359:259 (DOI:10.1016/S0140-6736(02)07418-4)

Terms and Conditions

Healthy Start in Housing Medical-Legal Partnership CORI reform Financial literacy Improved access to benefit programs

◦ One-stop shopping, etc.

Centering and other group models Project LAUNCH Problem Solving Education Father/partner engagement Access to stress reduction programs

Centering Universal newborn home visiting Enhanced case management Defending Childhood Initiative/Trauma

informed care

Breastfeeding Improved pregnancy care

◦ Progesterone access Improved access to LARCs Primary care/ob linkage to mental health

Primary Outcome: Maternal Functioning

General health The 12-Item Short Form Health Survey (SF-12) is a widely used, reliable and valid measure of physical and mental health.19, 20 21 The mental health component includes domains of vitality, social functioning, role functioning, and general mental health.

Depressive symptoms

Center for Epidemiological Studies Depression Scale (CES-D) is a 20 item self-report depressive symptom scale which has been used a diverse populations.22 23 24 Its validity as a measure of depression has been confirmed in adolescents,25 adults 15, 26, and clinically depressed individuals 27.

Social Functioning

Social Adjustment Scale Self-Report (SAS-SR) 28 examines social and role functioning in six areas: work; social activities; relationships with family; role as spouse, parent; family member. The SAS has high internal consistency (Cronbach α, r=0.74) and test-retest reliability (r=0.80).

Primary Outcome: Maternal Stress

General Stress Perceived Stress Scale (PSS) – Stress domains include unpredictability, lack of control, burden overload, and stressful circumstances. Reliability studies show Cronbach’s α of 0.78 -0.86 29-31.

Parenting Stress

Parenting Stress – Short Form (PSI) – The PSI assesses a wide range of parenting behaviors, including attachment to child, social isolation, competence, relationship with partner, and parental health 32, 33. Cronbach’s α for the parent domain is 0.93 and the test-retest coefficient is 0.96 34.

Primary Outcome: Maternal Health Behaviors Associated with Healthy Birth Outcomes**

Substance Use Pregnancy Risk Assessment Monitoring System (PRAMS) was designed to collect state population-based data on maternal attitudes and experiences before, during, and after pregnancy. We will use phase 6 questions from the core and standard questionnaires that focus on alcohol and tobacco use 35.

Birth Spacing Pregnancy Risk Assessment Monitoring System (PRAMS) We will use phase 6 questions that focus on pregnancy intention, contraceptive use, and length of time between pregnancies 35 .

Health risk/ promotion behaviors

Self-report – daily vitamin supplement, sexual risk practices, exercise

Follow-up for pregnancy risks

Chart review – examples: OGTT for women with gestational diabetes; follow-up for BP monitoring for women with hypertension; engagement in mental health services

Secondary Outcome: Parenting Practices and Family Cohesiveness

Family Routines

The Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) was designed to provide policy makers and researchers with detailed information about children's early life experiences. We will use questions from 9 month, 2 year, and preschool interviews that focus on family routines 36

Secondary Outcome Child Health Services Utilization** Child health service utilization

Proportion of well child visits scheduled and attended – child’s medical record Emergency room visit – self report Immunization delays – child’s medical record

Potential Mediating Variables Problem Solving Skills

Social Problem Solving Inventory -Revised (SPSI-R) is 25 item instrument that measures problem orientation and problem-solving skills. It was validated with a diverse community sample. Subscale internal consistency scores range from .76-.92; test-retest reliability ranges from 0.72-0.88 37, 38.

Coping Orientation

Brief Coping Orientation to Problems (Brief COPE) is a 28 item scale that measures 14 different adaptive and problematic coping reactions. Subscale Cronbach alpha scores range from .50-.9039.

Behavioral Activation

Behavioral Activation for Depression Scale (BADS) is a 25 item scale measuring avoidance behaviors and engagement in pleasant activities that affect depressive symptoms. Internal consistency and test-retest reliability were acceptable (α=.87, r=.74, respectively).40

Mastery Pearlin Mastery Scale, a widely used measure of perception of control consisting of 7 items. Internal consistency scores range from 0 .76-0.77 41, 42.

Hope The Adult Hope Scale is a 12 item scale that measures agency and cognitive appraisals. Cronbach's alphas ranged from .74 to .84. The test-retest correlations were .76-.82 over a 10 week interval 43.

Potential confounding and effect modifying variables Participant characteristics Self-report of age, race, ethnicity, nativity, family composition, health history

Housing history We use housing history questions from the U.S. Department of Housing and Urban Development study of the impact of housing on 3,000 homeless families across 12 communities.44 The questions assess present housing, history of homelessness, and housing barriers.

Trauma history and symptoms

Stressful Life Events Questionnaire is standardized trauma history screening measure with good test-retest reliability (kappa=0.73) and adequate convergent validity (kappa=0.64). 45 Modified PTSD Symptom Scale (MPSS) is a psychometrically valid 17-item scale that assesses trauma experience and posttraumatic stress symptoms. DSM-IV criteria can be applied to create a proxy variable for PTSD diagnostic status. 46

Social Support Medical Outcomes Survey Social Support (MOS-SS) comprises 4 functional support scales (emotional/informational, tangible, affectionate, and positive interaction) and an overall social support index. Subscales are reliable (α’s > 0.91).17

What tools are being used to screen women before and after pregnancy? What is being used in Boston? Available tools other than Edinburgh?

◦ CES-D, BEC What best practices are provided to women at risk of depression to prevent poor birth outcomes

◦ PSE, Centering, father involvement, Wrap around in early childhood mental health, trauma informed care How do you reach the very hard-to-reach mothers?

◦ Newborn home visiting, Healthy Start in Housing, Partnership with Health Care for the Homeless Does BPHC have an evidenced based curriculum that is being used?

◦ PSE, Centering, Fatherhood Is BPHC holding any group sessions for maternal stress and how are they dealing (if at all) with the father

involvement piece? ◦ Centering, Women’s Circles, Healthy Start in Housing

Group-based and population/community-based strategies to reduce maternal stress? ◦ Centering. wide promotion and support for trauma informed care, summer enrichment

Are there strategies, such as social marketing, being used to increase social capital in order to mitigate the impact of stress?

◦ Social marketing around early childhood mental health, ECMH Parent Council, Healthy Start Consumer Work Group, Violence Prevention and Intervention, Centering

Who provides the services, professional/ paraprofessional, nurse, mental health counselor? ◦ All of the above

Are there interventions that can address cumulative stress vs. pregnancy stress? ◦ Progesterone promotion, HSiH, Early Childhood Mental Health, LARC Loan Pilot Project◦ Weak on preconceptional care

How to measure depression as related to birth outcomes? ◦ Screening in pediatrics, newborn home visiting

Have you collected data on the sources of stress, including ACEs, or symptoms only? ◦ Healthy Start in Housing, Women’s Health Questionnaire, Early Childhood Mental Health

Life course is teaching us humility◦ It teaches us to identify the stress in women’s

lives and to respect their struggles◦ And acknowledges that there are major social

forces at work: health education is not enough; individual resilience has its limits

But it also opens the door◦ To community organizing approaches◦ To new partnerships with the women they serve

And to a renewed commitment to equality

W.E.B. Dubois, The Souls of Black Folk