title: An integrated randomized intervention to reduce behavioral and psychosocial risks: pregnancy and neonatal outcomes.
abstract: While biomedical risks contribute to poor pregnancy and neonatal outcomes in African American (AA) populations, behavioral and psychosocial risks (BPSR) may also play a part. Among low income AA women with psychosocial risks, this report addresses the impacts on pregnancy and neonatal outcomes of an integrated education and counseling intervention to reduce BPSR, as well as the contributions of other psychosocial and biomedical risks. Subjects were low income AA women ≥18 years living in the Washington, DC, metropolitan area and seeking prenatal care. Subjects (n = 1,044) were screened for active smoking, environmental tobacco smoke exposure (ETSE), depression, or intimate partner violence (IPV) and then randomized to intervention (IG) or usual care (UCG) groups. Data were collected prenatally, at delivery, and postpartum by maternal report and medical record abstraction. Multiple imputation methodology was used to estimate missing variables. Rates of pregnancy outcomes (miscarriage, live birth, perinatal death), preterm labor, Caesarean section, sexually transmitted infection (STI) during pregnancy, preterm birth (<37 weeks), low birth weight (<2,500 g), very low birth weight (<1,500 g), small for gestational age, neonatal intensive care unit (NICU) admission, and >2 days of hospitalization were compared between IG and UCG. Logistic regression models were created to predict outcomes based on biomedical risk factors and the four psychosocial risks (smoking, ETSE, depression, and IPV) targeted by the intervention. Rates of adverse pregnancy and neonatal outcomes were high and did not differ significantly between IG and UCG. In adjusted analysis, STI during the current pregnancy was associated with IPV (OR = 1.41, 95% CI 1.04-1.91). Outcomes such as preterm labor, caesarian section in pregnancy and preterm birth, low birth weight, small for gestational age, NICU admissions and >2 day hospitalization of the infants were associated with biomedical risk factors including preexisting hypertension and diabetes, previous preterm birth (PTB), and late initiation of prenatal care, but they were not significantly associated with active smoking, ETSE, depression, or IPV. Neither the intervention to reduce BPSR nor the psychosocial factors significantly contributed to the pregnancy and neonatal outcomes. This study confirms that biomedical factors significantly contribute to adverse outcomes in low income AA women. Biomedical factors outweighed psychosocial factors in contributing to adverse pregnancy and neonatal outcomes in this high-risk population. Early identification and management of hypertension, diabetes and previous PTB in low income AA women may reduce health disparities in birth outcomes.                         Level of evidence I.
authors.affiliation: Division of Neonatology, Georgetown University Hospital, 3800 Reservoir RD NW, Main 3400, Washington, DC 20007, USA. sivasubk@georgetown.edu
authors.forename: Siva
authors.initials: S
authors.lastname: Subramanian
authors.forename: Kathy S
authors.initials: KS
authors.lastname: Katz
authors.forename: Margaret
authors.initials: M
authors.lastname: Rodan
authors.forename: Marie G
authors.initials: MG
authors.lastname: Gantz
authors.forename: Nabil M
authors.initials: NM
authors.lastname: El-Khorazaty
authors.forename: Allan
authors.initials: A
authors.lastname: Johnson
authors.forename: Jill
authors.initials: J
authors.lastname: Joseph
mesh_terms: D001741:Black or African American / Q000523:psychology* / Q000706:statistics & numerical data; D001521:Behavior Therapy / Q000379:methods*; D003376:Counseling / Q000379:methods*; D003863:Depression / Q000208:ethnology / Q000517:prevention & control; D004219:District of Columbia / Q000453:epidemiology; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D007231:Infant, Newborn; D016015:Logistic Models; D008297:Male; D011247:Pregnancy; D011248:Pregnancy Complications / Q000208:ethnology* / Q000517:prevention & control*; D011256:Pregnancy Outcome / Q000208:ethnology*; D047928:Premature Birth / Q000208:ethnology* / Q000517:prevention & control; D011295:Prenatal Care / Q000379:methods*; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012907:Smoking / Q000208:ethnology; D000074606:Smoking Prevention; D012959:Socioeconomic Factors; D013179:Spouse Abuse / Q000208:ethnology / Q000517:prevention & control; D016896:Treatment Outcome