Michele Kiely

Hypertension and its complications in African Americans (AA) remain an important public health challenge. Chronic hypertension (cHTN) in pregnant AA is an even more complex issue impacting both the mother and fetus. The risk of cHTN during pregnancy is 2-3Xs higher for AA contributing to significantly higher rates of preeclampsia (PE), preterm birth (PTB) and infant and maternal morbidity/mortality. In the District of Columbia, AA suffer from one of the highest maternal (22/100,000) and infant mortality rates (17/10,000) in the nation secondary to complications of cHTN including PE and PTB. Limited data exist to explain such health disparities associated with poor maternal and fetal outcomes. The Outcomes of Chronic Hypertension in Pregnancy is a prospective cohort study designed to identify health disparities that contribute to poor maternal and fetal outcomes. The study uses a multi-factorial approach to recruit 300 (50% AA and 50% C) pregnant women with cHTN to assess biological,...

Women with a history of gestational diabetes mellitus (GDM) are advised to control their weight after pregnancy. We aimed to examine how adiposity and weight change influence the long-term risk of developing type 2 diabetes after GDM. We included 1,695 women who had incident GDM between 1991 and 2001, as part of the Diabetes & Women's Health study, and followed them until the return of the 2009 questionnaire. Body weight and incident type 2 diabetic cases were reported biennially. We defined baseline as the questionnaire period when women reported an incident GDM pregnancy. We estimated HRs and 95% CIs using Cox proportional hazards models. We documented 259 incident cases of type 2 diabetes during up to 18 years of follow-up. The adjusted HRs of type 2 diabetes associated with each 1 kg/m(2) increase in BMI were 1.16 (95% CI 1.12, 1.19) for baseline BMI and 1.16 (95% CI 1.13, 1.20) for most recent BMI. Moreover, each 5 kg increment of weight gain after GDM development was assoc...

Women with a history of gestational diabetes mellitus (GDM) are at substantially increased risk of type 2 diabetes mellitus (T2DM). The identification of important modifiable factors could help prevent T2DM in this high-risk population. To examine the role of physical activity and television watching and other sedentary behaviors, and changes in these behaviors in the progression from GDM to T2DM. Prospective cohort study of 4554 women from the Nurses' Health Study II who had a history of GDM, as part of the ongoing Diabetes & Women's Health Study. These women were followed up from 1991 to 2007. Physical activity and television watching and other sedentary behaviors were assessed in 1991, 1997, 2001, and 2005. Incident T2DM identified through self-report and confirmed by supplemental questionnaires. We documented 635 incident T2DM cases during 59,287 person-years of follow-up. Each 5-metabolic equivalent hours per week (MET-h/wk) increment of total physical activity, which i...

We compared acceptability, adherence and efficacy of trans-dermal nicotine patches and cognitive behavioral therapy (Group 1) to cognitive behavioral therapy alone (Group 2) in minority pregnant smokers. This is a randomized controlled trial. 52 women were recruited during pregnancy with a mean gestational age 18.5 ± 5.0 weeks and followed through delivery. Randomization was by site and initial cotinine levels. Interventionists and interviewers were blinded to group assignment. Two different nicotine replacement therapy dosing regiments were administered according to the baseline salivary cotinine level. A process evaluation model summarized patient adherence. The main outcome measure was self-report of cessation since last visit, confirmed by exhaled carbon monoxide. Analyses of categorical and continuous measures were conducted as well as linear trend tests of salivary cotinine levels. Women lost to follow-up were considered treatment failures. Participants were on average 27.5 ± 5.4 years old, 81 % were single, 69 % unemployed and 96 % were Medicaid eligible. A process evaluation indicated patients in both groups were adherent to scheduled program procedures through Visit 4, but not for Visits 5 and 6. Confirmed quit rates were: at visit 3, 23 (Group 1) and 0 % (Group 2) (p = 0.02); at visits 4 and 5, no difference; at visit 6, 19 (Group 1) and 0 % (Group 2) (p = 0.05). Group 1 delivered infants with a mean gestational age of 39.4 weeks versus 38.4 weeks in Group 2 (p = 0.02). 73 % (52/71) of the eligible smokers agreed to participate and 65 % (17/26) of Group 1 completed the protocol (i.e. attended 6 visits). A comparison of Group 1 and 2 quit rates confirmed a non-significant difference.

Objective To evaluate the efficacy of an integrated multiple risk intervention delivered mainly during pregnancy, in reducing such risks (smoking, environmental tobacco smoke exposure, depression and intimate partner violence) postpartum. Design Data from this randomized ...

ABSTRACT Objectives This study sought to examine relationships between depressive symptoms and prenatal household (HH-) ETSE among urban minority women. Methods We analyzed private, audio computer-assisted self interview (A-CASI) data from a clinic-based sample of 467 non-smoking minority pregnant women in Washington, D.C. Depressive symptoms were assessed via the Beck Depression Inventory Fast-Screen (BDI-FS). HH-ETSE, defined as ETSE in the home at least 1 day in the past 7 days, was assessed via self-report. Bivariate analyses between women with or without HH-ETSE compared depressive symptoms, age, ethnicity, education, employment, and trimester of pregnancy. Measures associated with HH-ETSE in bivariate analysis at p<0.20 were included in adjusted logistic regression models. Individual sources of ETSE as possible indicators of women's social smoking network were also contrasted. Results Women reporting moderate-to-severe depressive symptoms showed significantly higher adjusted odds of prenatal HH-ETSE (AOR 2.5, 95% CI [1.2, 5.2]). Individual sources of ETSE were higher among those reporting HH-ETSE than those who did not: living with a smoker (74.5% vs. 17.3%), smoking partner (59.6% vs. 35.0%), and/or visitors smoking in your home (52.2% vs. 6.9%) (p<.05 for each). Conclusions Health care providers should be aware of possible correlations between depression and ETSE during pregnancy. Interventions designed to encourage behavior change to reduce exposure should include screening and counseling for depression, and build confidence and skills so that women are better able to address the social environment. Close attention should be given to women who report smoking in their immediate social networks.

The rate of Caesarian sections is continuing to rise in the US despite efforts to limit it. C-sections confer additional risks for both the mother and her infant. It is important to understand factors predicting C-sections in an already high risk population. We followed 1,044 African American women during pregnancy if they were >17 years, spoke English, were <28 weeks pregnant and screened positive for smoking, environmental tobacco smoke exposure, depression or intimate partner violence. Mode of delivery was known for 837 live births, 29% of which were C-sections. In bivariate analysis, women with preconception or gestational diabetes were more likely to have a C-section (p<0.001 and p=0.092). Women with a multiple pregnancy and women who were primiparous were more likely to have a C-section (p=0.003 and p=0.033, respectively). Women with less than a high school diploma or some college were more likely to have a C-section compared to those with a high school degree (p=0.07...

Ecological factors may play an important role in modifying the effect of personal characteristics in mothers who initiate breastfeeding (BF) . The relative importance of these factors is unclear. In this study, 684 pregnant African Americans were followed through postpartum (PP). Mothers were >18 years, <28 weeks gestation and had one or more risk factors: smoking, environmental tobacco smoke, depression or intimate partner violence. Sociodemographic and psychobehavioral data were collected at baseline (BL), during follow-up in the second and third trimesters (FU) and at PP. Logistic models showed significantly increased odds of initiating BF in women who had some college education, were first time mothers, had a partner at BL and were not receiving Medicaid. Mothers depressed at BL who either recovered or remained depressed were more likely to initiate BF than mothers who were not depressed at BL but became depressed later in pregnancy. Some college versus Medicaid recipient ...

Prematurity is a recognized measurable outcome for high risk pregnancy and a predictor of infant death. The gestation of <37 weeks although agreed upon as the international standard is currently not associated with increased risk for neonatal mortality in industrialized countries. Recent literature suggests being very premature (VPM), defined as <34 weeks gestation, to be more predictive of morbidity and mortality. In this randomized clinical trial 1,044 African American residents of the District of Columbia participated in an integrated behavioral intervention targeting active smoking, environmental tobacco smoke exposure, depression and intimate partner violence (IPV) in pregnancy. The intervention consisted of counseling/behavioral modification sessions for risks reported at baseline. The differences in rates of prematurity among singleton births in intervention (IG) and usual care groups (UCG) were compared. The prematurity rate (11.9%) in IG was not significantly differen...

The use of substances during pregnancy continues to represent a significant challenge to health providers caring for high risk populations. More information is needed on the comparison of risk exposure to tobacco, alcohol and illicit drugs. Such information would be useful to health providers and can be used to educate pregnant women receiving care. We followed 1,044 African American women during pregnancy if they were >18 years, spoke English, <28 weeks pregnant and screened positively for smoking, environmental tobacco smoke, depression or intimate partner violence. Of mothers with known pregnancy outcomes (n=909), 18.3% smoked during pregnancy, 21.9% admitted to consuming alcohol during pregnancy and 12.2% admitted to illicit drug use during pregnancy. Compared to US African American rates for 2003, the women in this study who smoked tobacco had strikingly high rates of neonatal death (1.8% vs. 0.9%), of perinatal death (3.6% vs. 1.2%) and low birth weight (17.9% vs. 13.4%)...

The relationship between diabetes, eclampsia, Body Mass Index (BMI), hypertension and behavioral risks (smoking, environmental tobacco smoke, depression, intimate partner violence (IPV)), and adverse pregnancy outcomes (low birthweight (LBW), preterm births (PTB) and large-for-gestational-age (LGA)) in high risk AAs in Washington, DC was investigated. 1044 pregnant AAs were enrolled and interviewed at baseline, 2nd, and 3rd trimester. Birthweight and gestational age were abstracted from medical records. Classification and Regression Trees (CART) was used. Women were more likely to have LBW (<2,500 grams) babies if diagnosed with: eclampsia (OR=3.13,p=0.002), preconception diabetes & no gestational hypertension (OR=3.14,p=0.018), and smoking, preconception diabetes & no gestational hypertension (OR=1.76,p=0.037). Women were more likely to have PTB (<37 weeks gestation) if diagnosed with: eclampsia and no preconception diabetes (OR=2.47,p=0.031), preconception diabetes (OR=3.93,...

African American (AA) mothers have an increased likelihood of their pregnancy ending in a perinatal death. Causal factors are not fully understood. This study examines associations between demographic, biological and behavioral risk factors in pregnancy and perinatal mortality (20 weeks gestation up to 4 weeks postnatal deaths) in a population of AA mothers. An RCT testing the efficacy of a behavioral intervention to reduce risk was conducted in Washington DC. AA pregnant women were screened for eligibility and risk: women 18+ years old, exposed to smoking, environmental tobacco smoke, depression and intimate partner violence during pregnancy were recruited. Baseline and follow up data were collected by telephone interview during pregnancy and postpartum. Outcomes were collected by medical record review. Bivariate analysis was conducted using demographic, medical risk and behavioral risk data. Variables retained in a reduced model were those at p-value <0.15. In 887 pregnancies, ...

This paper evaluates the acceptability, communication mode and use of audio computer-assisted self-interview (A-CASI) among minority pregnant women receiving prenatal care in six Washington, DC sites. A total of 2,913 women were screened for demographic eligibility (18+ years old, <29 weeks gestation, Black/African-American or Hispanic) and risk (smoking, environmental tobacco smoke exposure, depression, intimate partner violence). Questions were displayed on touch screen laptop monitors and heard through earphones. The mean length of time to complete the screener was almost 6 minutes.A-CASI experience, which included difficulty in using the computer, acceptability (enjoyment), and preferred communication mode, was compared across sites, the eligibility and risk groups and a subset of 878 enrolled women for whom educational attainment and receipt of WIC (a proxy for income) were available. Respondents thought A-CASI was not difficult to use and liked using the computer. Black/Afr...

Women who develop gestational diabetes mellitus or impaired glucose tolerance during pregnancy are at substantially increased risk for type 2 diabetes and comorbidities after pregnancy. Little is known about the role of genetic factors and their interactions with environmental factors in determining the transition from gestational diabetes mellitus to overt type 2 diabetes mellitus. These critical data gaps served as the impetus for this Diabetes & Women's Health study with the overall goal of investigating genetic factors and their interactions with risk factors amenable to clinical or public health interventions in relation to the transition of gestational diabetes mellitus to type 2 diabetes mellitus. To achieve the goal efficiently, we are applying a hybrid design enrolling and collecting data longitudinally from approximately 4000 women with a medical history of gestational diabetes mellitus in two existing prospective cohorts, the Nurses' Health Study II and the Danish...

Several studies have demonstrated that acute otitis media (AOM) in children can be managed without antibiotics. Because children with AOM have traditionally been treated with antibiotics in the United States, there are concerns that parents may not be comfortable with their children being treated with pain control alone. Recently, Cates in England showed that antibiotic usage for AOM could be decreased by prescribing a safety-net antibiotic prescription (SNAP) to be filled if symptoms do not resolve with observation after 48 hours. It is not clear whether a SNAP will be acceptable to parents in other settings such as the United States. The objective of our study was to determine whether parents in the United States find a SNAP for AOM acceptable and whether antibiotic usage could be decreased by its use. A pediatric practice-based research network in a midwestern community of 1.8 million was the setting for this study. The Cincinnati Pediatric Research Group (CPRG) includes practices in Ohio, Kentucky, and Indiana. Children who were between 1 and 12 years of age and presented to the offices of the CPRG with uncomplicated AOM were eligible for the study. Children were excluded when they had temperature >101.5 degrees F, had an ear infection in the past 3 months, showed signs of another bacterial infection, or were toxic appearing. Families were given acetaminophen, ibuprofen, or topical otic anesthetic drops for pain control. They were also given a prescription for an antibiotic and instructed not to fill it unless symptoms either increased or did not resolve after 48 hours. The data were entered directly by investigators via an Internet site. A total of 194 children were enrolled in 11 offices over 12 months; 175 (90%) completed the follow-up interview. The average child's age was 5.0 years. Only 55 (31%) of the 175 who were contacted for follow-up had filled their antibiotic prescription. Compared with their previous experience, parents were overwhelmingly willing to treat AOM with pain medication alone (chi(2) = 111). Seventy-eight percent (95% confidence interval: 71%-84%) of parents reported that the pain medication was effective. Sixty-three percent (95% confidence interval: 55%-70%) of parents reported that they would be willing to treat future AOM episodes without antibiotics and with pain medication alone. A subset of parents find a safety-net prescription and pain control acceptable in the treatment of AOM, and antibiotic usage can be lowered with this strategy.

Pediatricians can decrease antibiotic use by treating acute otitis media (AOM) with a safety-net antibiotic prescription (SNAP). This study assessed whether the practitioners of the Practice-Based Research Network who participated in the study continued to use the SNAP and report a 60-day follow-up of the study patients. Charts were reviewed of study patients for 60 days following study enrollment. A survey on antibiotic use for AOM was mailed to the 17 study practitioners (SP) and 30 randomly selected community pediatricians (CP). Eight of the SP used the SNAP more than 20 times over the year following the study vs 1 of the CP. Sixty-two percent of patients never received antibiotics. The recurrence/relapse rate was greater in children younger than 2 years old compared to those older, 34% vs 10%. Practitioners who participate in a Practice-Based Research Network study are more likely to use a study intervention than others.