Theses and Dissertations from UMD
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Item EXAMINING THE ASSOCIATION BETWEEN INTERPREGNANCY INTERVAL AND MATERNAL HEALTH IN THE POSTPARTUM PERIOD(2023) Barber, Gabriela A; Thoma, Marie E; Family Studies; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Interpregnancy interval (IPI) is defined as the period of time between a previous birth and a subsequent conception, usually measured in months. While recommendations issued by the World Health Organization and the American College of Obstetricians and Gynecologists provide guidance for ideal birth spacing, many births occur after non-optimal IPIs – either too short (<18 months) or too long (60+ months). These recommendations were motivated by the body of research on a host of adverse infant and maternal health outcomes associated with non-optimal IPIs. To date, the literature has focused heavily on the association between IPI and adverse infant health outcomes, with limited attention in comparison being given to IPI and maternal health. Within the research on IPI and maternal health, there is a narrow focus on physical health outcomes related to pregnancy/delivery complications, with few studies looking at health outcomes in the postpartum and beyond. In order to fill this gap, this research investigated the association between IPI and several postpartum maternal health outcomes/indicators, including 1) postpartum depression (PPD), 2) attendance at a postpartum checkup, and 3) postpartum contraceptive use (any and type). One of the perennial difficulties in studying IPI is parsing out whether IPI has an independent association with a health outcome or behavior or is exerting its effects through pregnancy intention, therefore, for each aim, pregnancy intention was tested as a moderator. For each aim, unique cut-offs for IPI were determined after examination of the association between more detailed IPI categories and the outcome of interest. Categories were collapsed into broader IPI classifications when the associations were similar in order to maximize precision of the estimates and in order to allow us to characterize the most clinically relevant exposure for specific health outcomes. In fully adjusted models, individuals who had IPIs less than 18 months were significantly more likely to experience elevated PPD symptoms (aOR: 1.19, 95% CI: 1.02 – 1.39, p=0.024) when compared to individuals with long IPIs, and individuals who had IPIs less than 12 months were significantly less likely to attend their postpartum checkup (aOR: 0.78, 95% CI: 0.66 – 0.93, p=0.006) when compared to those with long IPIs. Pregnancy intention was not found to significantly moderate either of these associations. For the third aim, pregnancy intention was found to moderate the association between IPI and any use of postpartum contraception. Stratified analyses show that it is among unintended pregnancies that there is an association between short IPI and increased use of any contraception in the postpartum. Among unintended pregnancies, those with IPIs less than 6 months (aOR: 2.31, 95% CI: 1.37 – 3.90, p=0.002) and those with IPIs of 6-11 months (aOR: 2.15, 95% CI: 1.48 – 3.10, p=0.001) were more likely to be using any contraception in the postpartum than those with long IPIs, and the magnitude of this association exceeded that of other IPI intervals and pregnancy intention categories. Among those who were using contraception in the postpartum, individuals with IPIs less than 6 months were more likely to be using highly-effective methods (aOR: 1.59, 95% CI: 1.22 – 2.10, p=0.001) than least-effective methods of contraception. Pregnancy intention did not significantly moderate the association between IPI and type of contraception. Future research should continue to explore the association between IPI and a broader range of maternal health outcomes and work to identify the mechanisms through which IPI may be impacting these outcomes. Recent changes in reproductive policies in the U.S. may also soon change the proportion of individuals who experience short IPIs, therefore making it even more important to understand how this shift may impact a broad range of maternal health behaviors and outcomes. This research highlights how an increase in births occurring after a short IPI would likely increase rates of PPD and increase demand for certain family planning services.Item The Self Reported Health of US Women in the First Postpartum Year: NHANES 2007-2018(2021) Fahey, Jenifer Osorno; Shenassa, Edmond; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background: Most existing information about the health of US postpartum mothers comes from studies of morbidity and mortality. As a result, relatively little is known about the general well-being of postpartum mothers. Self-rated health (SRH), a single-item, 5-level ordinal measure has been widely used as an indicator of general health status in epidemiologic and population health research. There are no US population studies of maternal SRH in the postpartum period. Methods: An analytic sample of 6,266 women ages 20-44 was created from the 2007-2018 waves of the National Health and Nutrition Surveys. The 5-level SRH measure was dichotomized into “good” and “poor” levels and multivariate logistic regression analysis was used to characterize the relationship between postpartum status and SRH and to test whether parity, cigarette smoking, pregnancy, depression, sleep duration, tiredness/fatigue, obesity, history of c-section and breastfeeding status independently predict poor SRH in the sub-population of postpartum women (n=508). Results: There is a significant relationship between postpartum status and SRH that is moderated by pregnancy status. For women who are not pregnant, postpartum status is associated with lower odds of poor SRH (OR 0.52, 95% CI, 0.34-0.79) while for women who are pregnant, postpartum status is associated with increased odds of poor SRH (OR 2.34, 95% CI 0.81-6.78), an association that did not reach statistical significance at a p=0.05 level. Having a high school education (OR 0.35, 95% CI, 0.13-0.95) breastfeeding (OR 0.22, 95% CI 0.10-0.52) were associated with lower odds of poor SRH, while being Hispanic (OR 3.51, 95% CI 1.20-10.27), tired (OR 2.40, 95% CI 1.08-5.57) or obese (OR 2.72, 95% CI, 1.35-5.56) were associated with higher odds of maternal report of poor health. Discussion: Postpartum status is associated with better SRH. This is not the case; however, for women who are pregnant again in the first postpartum year suggesting that a short interpregnancy interval (IPI) is a threat to postpartum maternal well-being. Breastfeeding, on the other hand, is associated with a strong protective effect on maternal postpartum SRH. These results suggest a need for postpartum contraceptive and breastfeeding promotion efforts that focus on immediate impacts on maternal health. Maternal postpartum obesity and maternal tiredness also emerge as priority areas for maternal postpartum health promotion initiatives. Additional research on the postpartum experience of Hispanic mothers is warranted.Item Labor, Delivery, and Neonatal Outcomes Associated with Placental Abruption(2015) Downes, Katheryne; Shenassa, Edmond; Family Studies; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Placental abruption, the premature detachment of the placenta, before birth and after 20 weeks gestation, occurs in 0.6% -1% of all pregnancies in the United States. Little is known about the duration of labor or the risk of neonatal morbidities attributed to abruption. This study examined labor duration, delivery mode, and neonatal outcomes associated with placental abruption among singleton pregnancies in the Consortium on Safe Labor study (n=223,252), a retrospective, observational study of deliveries from 2002-2008 in 19 U.S. hospitals. Models were fit using generalized estimating equations controlling for maternal age, race, pre-pregnancy BMI, insurance, history of cesarean, marital status, and study site (cervical dilation, birthweight, and gestational age were also included for labor and delivery analyses). Labor duration was modeled for each of the three stages and calculated separately by parity (nulliparous or multiparous) and labor type (induced or spontaneous). Abruption was associated with elevated risk of cesarean delivery among both nulliparous (RR=1.67, 99% CI: 1.54, 1.80) and multiparous women (RR=1.49, 99% CI: 1.38, 1.59). Abruption was not associated with differences in stage 1 or stage 2 labor in any group, but was associated with a shorter duration of stage 3 labor among multiparous women with spontaneous labor ((exp) β = 0.9, 99% CI: 0.8, 0.9) that was not clinically meaningful (1 minute). Abruption was associated with elevated risk of neonatal interventions including newborn resuscitation (RR=1.54, 99% CI: 1.48, 1.61) and longer Neonatal Intensive Care Unit Length of Stay (NICU LOS) (IRR=1.98, 99% CI: 1.83, 2.14), as well as morbidities and mortality including respiratory distress syndrome (RR= 7.40, 99% CI: 6.77, 8.04), apnea (RR=6.63, 99% CI: 5.86, 7.40), asphyxia (RR=8.96, 99% CI: 6.06, 11.85) and perinatal death (RR=7.29, 99% CI: 5.87, 8.70). With the exception of NICU LOS among term and non-low birthweight neonates, all associations remained significant regardless of the timing of abruption, gestational age, birthweight, or delivery mode. Contrary to prior studies, abruption was not associated with shorter duration of labor. Abruption was associated with increased morbidity among surviving neonates, which adds to the burgeoning literature highlighting the importance of placental functioning on health during infancy.