Biomedical subjects

Dawn P Misra

Publications and source records attributed to Dawn P Misra.

11 recordsLinked to original sources

PubMed2006

Exposures to airborne particulate matter and adverse perinatal outcomes: a biologically plausible mechanistic framework for exploring potential effect modification by nutrition.

OBJECTIVES: The specific objectives are threefold: to describe the biologically plausible mechanistic pathways by which exposure to particulate matter (PM) may lead to the adverse perinatal outcomes of low birth weight (LBW), intrauterine growth retardation (IUGR), and preterm delivery (PTD); review the evidence showing that nutrition affects the biologic pathways; and explain the mechanisms by which nutrition may modify the impact of PM exposure on perinatal outcomes. METHODS: We propose an interdisciplinary conceptual framework that brings together maternal and infant nutrition, air pollution exposure assessment, and cardiopulmonary and perinatal epidemiology. Five possible albeit not exclusive biologic mechanisms have been put forth in the emerging environmental sciences literature and provide corollaries for the proposed framework. CONCLUSIONS: Protecting the environmental health of mothers and infants remains a top global priority. The existing literature indicates that the effects of PM on LBW, PTD, and IUGR may manifest through the cardiovascular mechanisms of oxidative stress, inflammation, coagulation, endothelial function, and hemodynamic responses. PM exposure studies relating mechanistic pathways to perinatal outcomes should consider the likelihood that biologic responses and adverse birth outcomes may be derived from both PM and non-PM sources (e.g., nutrition). In the concluding section, we present strategies for empirically testing the proposed model and developing future research efforts.

Air Pollutants↗

PubMed2005

Maternal smoking and birth weight: interaction with parity and mother's own in utero exposure to smoking.

BACKGROUND: Few studies have reported interactions between maternal smoking and other maternal characteristics and exposures. We examined maternal smoking in a cohort study for which data from 3 generations were available to examine maternal characteristics and exposures from a life-course perspective. METHODS: We had data from 3 generations: women enrolled in the U.S. Collaborative Perinatal Project (CPP) between 1959 and 1965 at the Baltimore site (G1); daughters (G2) of those G1 mothers who were followed to ages 27-33 years in the Pathways to Adulthood study; and children (G3) born to the G2 women who provided pregnancy and birth information during the Pathways study. These data allowed examination of exposures that occurred to the mother during her childhood and in utero. RESULTS: We found evidence of a 3-way interaction effect on birth weight for maternal smoking in pregnancy, maternal exposure to smoking in utero (grandmaternal smoking), and maternal parity. Maternal smoking reduced birth weight in 3 of the subgroups, with the size of the effect on birth weight moderated by parity and the mother's own in utero exposure to smoking. CONCLUSIONS: A mother's prenatal exposure to smoke may affect the birth weight of her offspring. This effect would be consistent with both the accumulation-of-risk and the fetal-programming hypotheses.

Adult↗

PubMed2004

The FIMR evaluation: objectives, concepts, frameworks, and methods.

FIMR is now a widespread strategy that has been adopted by more than 200 communities nationwide. Examining the impact of FIMR programs in a rigorous fashion presented a formidable challenge. A complex multiphase study design and innovative outcome measures were developed for the nationwide evaluation of FIMR. Data were collected from multiple respondents in nearly 200 communities across the United States. The results of this evaluation are an important contribution to the literature on the value of FIMR. However, while our study represents a substantial improvement over past research, limitations persist. Future work in this area will need to creatively address these limitations in order to better understand the effect of FIMR programs in communities.

Child Health Services↗

PubMed2004

The nationwide evaluation of fetal and infant mortality review (FIMR) programs: development and implementation of recommendations and conduct of essential maternal and child health services by FIMR programs.

OBJECTIVE: An evaluation of fetal and infant mortality review (FIMR) programs nationwide was conducted to characterize their unique role in improving the system of perinatal health care. The aim of this paper is to examine intermediate outcomes of the FIMR, in particular the development and implementation of recommendations produced by the FIMRs and the conduct of essential MCH services by the FIMRs. METHODS: We report on 74 FIMRs whose communities were selected for the nationwide evaluation and for whom we had data from the FIMR director or comparable respondent. We focus on the recommendations of the FIMRs and the essential maternal and child health (MCH) services conducted by the FIMRs as intermediate outcomes (or outputs) and then examine how selected characteristics of the FIMR may influence these. RESULTS: FIMRs developed recommendations on a broad range of topics but there were some areas for which nearly all programs had developed recommendations. The FIMRs relied primarily on strategies related to programs and practices, with few FIMRs reporting attention to policy-oriented approaches. Implementation of recommendations was high. Factors that influenced likelihood of implementing recommendations and conduct of essential MCH services included structure of the FIMR and training received by FIMR directors and staff. CONCLUSIONS: The focus of FIMR recommendations and the likelihood of implementation vary across FIMRs as does the conduct of essential MCH services. FIMR team structure and training of the director and staff are important areas to consider in efforts to maximize the impact of FIMR.

Child Health Services↗

PubMed2004

Comparison of FIMR programs with other perinatal systems initiatives.

OBJECTIVES: While the goals of fetal and infant mortality review (FIMR) programs and other perinatal systems initiatives (PSI) are similar, our knowledge of the processes they use to meet their goals is limited. This article compares a nationwide sample of FIMR programs and PSIs with regard to their roles and involvement in performance of eight essential maternal and child health services (EMCHS) as part of a national evaluation of FIMR. METHODS: The evaluation was a cross-sectional observational study in which geographic units were sampled based on the presence or absence of a FIMR or other PSI using FIMRs as the sampling frame of reference. Telephone interviews were conducted with 74 FIMR and 62 PSI directors in the sampled communities. RESULTS: Both programs performed several of the essential MCH services. FIMRs were significantly more likely to be located in a local health department than were PSIs. The results of multiple logistic regression analyses indicate that the performance of the essential MCH services by the programs was increased when both a FIMR and a PSI were in the community. FIMR programs alone had reduced odds of performing several essential MCH services than did PSIs alone. The findings also indicate that performance of some essential MCH services was reduced for FIMR programs and PSIs located in a local health department. CONCLUSIONS: Comparisons between FIMR and other PSIs suggest that both programs are currently engaged in diverse efforts to attain their goal of improving the health and health care delivery system for pregnant women, infants, and their families. FIMR programs appear to be more circumscribed in their activities than PSIs, but the presence of both programs in a community appears to enhance the programs' performance of the essential MCH services.

Child Health Services↗

PubMed2004

The relation of FIMR programs and other perinatal systems initiatives with maternal and child health activities in the community.

OBJECTIVES: To evaluate the association of the presence of a fetal and infant mortality review (FIMR) program, other perinatal systems initiative (PSI), or both in a community with the performance of essential maternal and child health (MCH) services by local health departments (LHDs). METHODS: Data were obtained from telephone interviews with professionals from LHDs across the United States. Logistic regression was used to estimate the odds of a LHD conducting each essential MCH service in communities with and without FIMR programs or with and without PSIs, adjusted for geographic area. RESULTS: Of the 193 communities in the sample, 41 had only a FIMR program, 36 had only a PSI, 47 had both programs, and 69 had neither. The presence of a FIMR was related to greater performance of essential MCH services in LHDs in six areas: data assessment and analysis; client services and access; quality assurance and improvement; community partnerships and mobilization; policy development; and enhancement of capacity of the health care work force. Similar findings were noted for the same broad essential services for PSIs. The comparisons of LHDs in FIMR and non-FIMR communities, however, showed greater involvement of communities with a FIMR program in essential MCH services related to data collection and quality assurance than were found for comparisons of LHDs in communities with and without a PSI. The presence of a PSI was uniquely associated with conducting needs assessments for pregnant women and infants, participation in coalitions for infants, promoting access for uninsured women to private providers and involving local officials and agencies in health plans for both populations. When both programs were present, LHDs had a greater odds of engaging in essential MCH services related to assessment and monitoring of the health of the population, reporting on progress in meeting the health needs of pregnant women and infants, and presenting data to local political officials than when either program alone was in the community. CONCLUSIONS: Local health departments in communities with FIMR programs or PSIs appear to be more likely to conduct essential MCH services in the community. Some of these relations are unique to FIMR, particularly for data collection and quality assurance services, and some are unique to PSIs, for example those that involve interaction with other community agencies or groups. Performance of the essential MCH services also appears to be enhanced when both a FIMR program and a PSI are present in the community.

Chi-Square Distribution↗

PubMed2003

Integrated perinatal health framework. A multiple determinants model with a life span approach.

BACKGROUND: Despite great strides in improving prenatal care utilization among American women, key perinatal indicators have remained stagnant or worsened in the past decade, and the United States continues to rank near the bottom compared to other developed countries. A new approach is needed if we are to achieve improvements in perinatal health. METHODS: To propose a new framework that integrates a "life span" approach with a multiple determinants model. RESULTS: We recognize that (1) powerful influences on outcome occur long before pregnancy begins; (2) pregnancy outcome is shaped by social, psychological, behavioral, environmental, and biological forces; and (3) the demography of pregnancy has changed dramatically in the last few decades with more women delaying their first birth. Approaches that simultaneously consider the entire life span as well as multiple determinants may need to be adopted. We propose a framework that integrates these approaches and is supported by the research literature. The life span perspective focuses attention toward the preconceptional and interconceptional periods as targets for intervention in improving perinatal health. The multiple determinants model distinguishes among concepts of disease, health and functioning, and well-being for both women and their offspring. CONCLUSIONS: Our intent is to influence how policymakers, public health professionals, clinicians, and researchers approach perinatal health.

Family Planning Services↗

PubMed2002

Infant mortality among singletons and twins in the United States during 2 decades: effects of maternal age.

OBJECTIVE: Whereas it is well-established that maternal age has a U-shaped relationship with infant mortality among singletons, effects on the risk of mortality among multiple births remains unexplored. If there is a relationship, then assessment of maternal age may identify pregnancies and births that should be targeted by both clinical and public health interventions. The objective of this study was to characterize the relationship between maternal age and infant mortality in singleton and twin births in the United States. METHODS: A retrospective cohort study was conducted of all live births (singleton: n = 22 546 718; twin: n = 535 544) in the United States in 1985-1986, 1990-1991, and 1995-1996. Risks and relative risks for infant deaths by maternal age before and after adjustments for birth cohort, gravidity, birth weight, and gestational age were measured. RESULTS: Maternal age had a U-shaped association with mortality among singletons, with highest rates seen at extremes of age. Among twins, however, there was a steep and inverse relationship between age and mortality, with those born to young mothers experiencing the highest mortality rates. Seven percent of twin births resulted in an infant death for women who were younger than 20 years, 2.7% for those 30 to 34 years, and 2.0% for women 40 to 49 years. Even after adjustments for gravidity, birth weight, and gestational age, these trends persisted. Additional examination by timing of death indicated that this relationship was primarily a function of postneonatal rather than neonatal mortality. CONCLUSIONS: The highest mortality among twins occurred to women who delivered in their teens and early 20s. The implications of these findings, both from a clinical and a public health perspective, deserve attention.

Adolescent↗

PubMedDate not supplied

Acceptability of a self-sampling technique to collect vaginal smears for gram stain diagnosis of bacterial vaginosis.

To diagnose asymptomatic bacterial vaginosis (BV), self-sampled vaginal smears were collected during a study of risk factors for preterm birth in African American women. More than 90% of those women who were willing to participate in the interview portion of the study were also willing to provide a self-sampled vaginal smear. The smears are an acceptable and efficient way of detecting BV in an urban minority population.

Adult↗

PubMedDate not supplied

Achieving safe motherhood: applying a life course and multiple determinants perinatal health framework in public health.

Safe motherhood has begun to be identified as a priority for the health of American women. We argue that safe motherhood can be achieved through application of a life course and multiple determinants framework. This framework, with its focus on the preconception period, poses a dilemma in that it links together periods of life and domains of activities that have traditionally not been linked with maternal health. The interests of women and children have often been juxtaposed in the making of policy. Further, the domains of women's health, maternal and child health, and family planning have often clashed over policy priorities and funds. This framework shows that the research literature now links them inextricably to better health outcomes, albeit indirectly; there are no intervention studies that have demonstrated the empirical efficacy of this approach. Thus, although this framework creates a strong rationale for the linkages described, it also demands attention to a set of implementation strategies that will overcome existing barriers. Through a focus on one maternal factor, obesity, we discuss how a range of strategies grounded in the framework can be undertaken to address maternal morbidity and mortality. We then examine selected strategies at each level of the multiple determinants life course framework and emphasize how public policies and public and private sector professional practice can be reexamined to improve outcomes for women in all time periods and aspects of reproductive potential, which in turn might enhance outcomes for their offspring, both at birth and beyond. Our intent is to influence how policy makers, public health professionals, clinicians, and researchers approach safe motherhood.

Female↗

PubMedDate not supplied

Variation and predictors of vaginal douching behavior.

INTRODUCTION: Vaginal douching is a widespread practice among American women. Little research has been done examining variation in the practice or identifying risk factors. METHODS: We collected data on douching, as well as hypothesized predictors of vaginal douching, as part of a cohort study on preterm birth. African-American women residing in Baltimore City, Maryland, were enrolled if they received prenatal care or delivered at The Johns Hopkins Medical Institution. Interview data were collected on 872 women between March 2001 and July 2004, with a response rate of 68%. Logistic regression analysis was selected to identify factors associated with douching in the 6 months prior to pregnancy. RESULTS: Almost two thirds of women reported ever douching and more than two thirds of those women reported douching in the 6 months prior to pregnancy. Variation was seen in the practice of douching with regard to frequency as well as technique. After adjusting for several confounders, prenatal enrollment (odds ratio [OR], 1.80; 95% confidence interval [CI], 1.29, 2.53), more unmet needs for time for "non-essentials" (OR, 1.83; 95% CI, 1.27, 2.63), smoking in the year prior to the birth (OR, 1.78; 95% CI, 1.22, 2.60), and age >19 years (OR, 2.60; 95% CI, 1.36, 4.97) were significant predictors of douching in the 6 months prior to pregnancy. DISCUSSION: We identified considerable heterogeneity in the practice of vaginal douching in a cohort of low income African-American women. CONCLUSIONS: Future studies should incorporate measures of the predictors of douching and detailed exposure information to determine the independent contribution of vaginal douching to health outcomes.

Adolescent↗