Google AdWords and Facebook Ads for Recruitment of Pregnant Women into a Prospective Cohort Study With Long-Term Follow-Up Abstract Objectives Several types of epidemiologic studies suffer from decreasing participation rates, resulting in potential selection bias and delay or termination of studies. We aimed to determine the feasibility of online methods for recruitment of pregnant women into a prospective cohort study. Methods In addition to traditional recruitment through prenatal care providers, we advertized participation in the PRegnancy and Infant DEvelopment (PRIDE) Study, an ongoing prospective cohort study with long-term follow-up in The Netherlands enrolling women in early pregnancy, through Google AdWords (30 days) and Facebook Ads (31 and 27 days) campaigns between September 2016 and January 2017. We calculated costs per eligible participant and compared demographics, health-related characteristics, and follow-up rates between participants recruited through online methods and prenatal care providers. Results During the study period, we recruited six women through AdWords (€54.28 per participant), 59 through Facebook (€10.17 per participant), and 327 through prenatal care providers (no valid cost estimate available). Facebook participants seemed to be younger (29.0 vs. 30.7 years), to have a higher body mass-index and/or low/intermediate education (27.0 vs. 24.0 kg/m2 and 41 vs. 25%, respectively), and to start prenatal care in secondary care more often (12 vs. 5%) than participants recruited through prenatal care providers. Item non-response and loss to follow-up rates were higher among women recruited online than among those recruited through prenatal care providers. Conclusion Google AdWords did not contribute substantially, but Facebook Ads may complement traditional recruitment methods of pregnant women into prospective cohort studies, despite challenges that may threaten internal validity.

Outcomes of Implementing Routine Screening and Referrals for Perinatal Mood Disorders in an Integrated Multi-site Pediatric and Obstetric Setting Abstract Purpose We report on a successful quality improvement project designed to increase access to perinatal mental health services through universal screening for postpartum depression (PPD) and facilitating referrals for evaluation and treatment, at a multi-site, integrated system of pediatric and obstetric practices in Houston, Texas. Description Obstetric practices administered screenings twice during pregnancy and at 6 weeks postpartum. Pediatric practices screened women at the 2 week and 2, 4, and 6-month well-baby visit. Women with a score of 10 or higher on the Edinburgh Postnatal Depression Scale (EPDS) or women that reported thoughts of self-harm were offered a referral to a mental health provider. Data on screening and referrals were collected from the electronic medical record. Results A total of 102,906 screens for PPD were completed between May 2014 and July 2018. Of those, 6487 (6.3%) screened positive. The total number of women referred to treatment were 3893 (3.8%). Of referred women 2172 (55.8%) completed an appointment with a mental health provider within 60 days of referral. Rates of completed appointments varied by the level of integration of the mental health provider and referring physician: women referred by pediatrics in a Level 1 coordinated system completed 20.0% of referrals; obstetrics Level 4 co-located system, 76.6%; and obstetrics Level 5 integrated model, 82.7%. Conclusion This project demonstrated that with planning, systems review and trained staff, PPD screening can be integrated into obstetric and pediatric practices and high screening and referral rates can be achieved.

Fertility, Pregnancy, and Postpartum: A Survey of Practicing Georgia Obstetrician Gynecologists Abstract Purpose OBGYNs help patients plan families, conceive, and deliver children, however the personal reproductive history and goals, infertility experiences, and birth outcomes of OBGYNs are not well studied. We aim to characterize female OBGYN reproductive experiences with a particular focus on infertility, reproductive life planning (methods of pregnancy prevention, reasons why pregnancy is/was delayed), birth outcomes (mode of delivery, delivery timing), and the postpartum period (breastfeeding, maternity leave, postpartum depression). Description An anonymous email survey was distributed to female members of Georgia OBGYN Society and Emory University Department of Gynecology and Obstetrics. Descriptive statistics and bivariable analysis were performed using Microsoft Excel and OpenEpi. Assessment Of 352 surveys, 204 of 269 women who opened the survey agreed to participate (75.8% per opened email, 58.0% per sent email). Mean age of first childbirth was 30.7 (SD ± 4.2) years. Most pregnancies were intended (77%). Fertility treatments were used in 13% of pregnancies. Resident mothers compared to mothers who gave birth before or after residency were more likely to report postpartum depression [26% vs. 16%, OR 1.8 (95% CI 0.93–3.58)] and shorter maternity leave < 6 weeks [57% vs. 29%, OR 2.57 (CI 1.56–5.00)]; exclusive breastfeeding rates ≥ 6 months were similar [38% residents vs. 41% non-residents, OR 0.80 (CI 0.44–1.43)]. Among those not finished with childbearing, 68% worried about infertility, 29% were considering oocyte/embryo cryopreservation, and 5% had already cryopreserved oocytes. Conclusion Compared to the general population, the average age of first childbirth among Georgia OBGYNs was 4 years higher (30.7) with a greater proportion of pregnancies planned. Use of fertility services and obstetric course matched national rates, however postpartum depression was more prevalent among Georgia OBGYNs. Awareness of increased postpartum depression among residents may allow for improved counseling and treatment.

Exploring Human Resource Managers’ Decision-Making Process for Workplace Breastfeeding-Support Benefits Following the Passage of the Affordable Care Act Abstract Objectives To explore factors that shape decisions made regarding employee benefits and compare the decision-making process for workplace breastfeeding support to that of other benefits. Methods Sixteen semi-structured, in-depth interviews were conducted with Human Resource Managers (HRMs) who had previously participated in a breastfeeding-support survey. A priori codes were used, which were based on a theoretical model informed by organizational behavior theories, followed by grounded codes from emergent themes. Results The major themes that emerged from analysis of the interviews included: (1) HRMs’ primary concern was meeting the needs of their employees, regardless of type of benefit; (2) offering general benefits standard for the majority of employees (e.g. health insurance) was viewed as essential to recruitment and retention, whereas breastfeeding benefits were viewed as discretionary; (3) providing additional breastfeeding supports (versus only the supports mandated by the Affordable Care Act) was strongly influenced by HRMs’ perception of employee need. Conclusions for Practice Advocates for improved workplace breastfeeding-support benefits should focus on HRMs’ perception of employee need. To achieve this, advocates could encourage HRMs to perform objective breastfeeding-support needs assessments and highlight how breastfeeding support benefits all employees (e.g., reduced absenteeism and enhanced productivity of breastfeeding employee). Additionally, framing breastfeeding-support benefits in terms of their impact on recruitment and retention could be effective in improving adoption.

“Baby Wants Tacos”: Analysis of Health-Related Facebook Posts from Young Pregnant Women Abstract Objectives Pregnant young women gain more weight than recommended by the National Academy of Medicine, increasing the likelihood of adverse maternal and fetal outcomes. The purpose of this study is to use online social media to understand beliefs and practices surrounding weight gain, diet and exercise during pregnancy among young women. Methods Facebook posts were mined from young women ages 16 to 24 during pregnancy who were consented from two Midwest primary care clinics serving low-income communities. Natural language processing was used to identify posts related to weight gain, exercise and diet by keyword searching. Two investigators iteratively coded the mined posts and identified major themes around health behaviors. Outcome measures included the frequency of posts and major themes regarding health behaviors during pregnancy. Results Participants (n = 43) had a mean age of 21 (SD 2.3), and the largest subgroups identified as black (49%; 26% white, 16% Hispanic, 9% other) and having graduated from high school (49%; 24% completed some high school and 24% completed at least some post-secondary education). Among the 2899 pregnancy posts analyzed, 311 were related to weight. Major themes included eating behaviors and cravings (58% of identified posts), body image (24%), the influence of family, partners and friends (14%), and the desire to exercise (4%). Conclusions for practice Facebook posts revealed that young women often frame their thoughts and feelings regarding weight gain in pregnancy in the context of food cravings and body image and that friends and family are important influencers to these behaviors.

Effects of a Multi-site Expansion of Group Prenatal Care on Birth Outcomes Abstract Objectives Perinatal Quality Collaboratives across the United States are initiating projects to improve health and healthcare for women and infants. We compared an evidence-based group prenatal care model to usual individual prenatal care on birth outcomes in a multi-site expansion of group prenatal care supported by a state-wide multidisciplinary Perinatal Quality Collaborative. Methods We analyzed 15,330 pregnant women aged 14–48 across 13 healthcare practices in South Carolina (2013–2017) using a preferential-within cluster matching propensity score method and logistic regression. Outcomes were extracted from birth certificate data. We compared outcomes for (a) women at the intent-to-treat level and (b) for women participating in at least five group prenatal care visits to women with less than five group visits with at least five prenatal visits total. Results In the intent-to-treat analyses, women who received group prenatal care were significantly less likely to have preterm births (absolute risk difference − 3.2%, 95% CI − 5.3 to − 1.0%), low birth weight births (absolute risk difference − 3.7%, 95% CI − 5.5 to − 1.8%) and NICU admissions (absolute risk difference − 4.0%, 95% CI − 5.6 to − 2.3%). In the as-treated analyses, women had greater improvements compared to intent-to-treat analyses in preterm birth and low birth weight outcomes. Conclusions for Practice CenteringPregnancy group prenatal care is effective across a range of real-world clinical practices for decreasing the risk of preterm birth and low birth weight. This is a feasible approach for other Perinatal Quality Collaboratives to attempt in their ongoing efforts at improving maternal and infant health outcomes.

Integrating Community Health Worker Roles to Improve Facility Delivery Utilization in Tanzania: Evidence from an Interrupted Time Series Analysis Abstract Objectives Despite renewed interest in expansion of multi-tasked community health workers (CHWs) there is limited research on HIV and maternal health integration at the community-level. This study assessed the impact of integrating CHW roles for HIV and maternal health promotion on facility delivery utilization in rural Tanzania. Methods A 36-month time series data set (2014–2016) of reported facility deliveries from 68 health facilities in two districts of Tanzania was constructed. Interrupted time series analyses evaluated population-averaged longitudinal trends in facility delivery at intervention and comparison facilities. Analyses were stratified by district, controlling for secular trends, seasonality, and type of facility. Results There was no significant change from baseline in the average number of facility deliveries observed at intervention health centers/dispensaries relative to comparison sites. However, there was a significant 16% increase (p < 0.001) in average monthly deliveries in hospitals, from an average of 202–234 in Iringa Rural and from 167 to 194 in Kilolo. While total facility deliveries were relatively stable over time at the district-level, during intervention the relative change in the proportion of hospital deliveries out of total facility deliveries increased by 17.2% in Iringa Rural (p < 0.001) and 14.7% in Kilolo (p < 0.001). Conclusions for Practice Results suggest community-delivered outreach by dual role CHWs was successful at mobilizing pregnant women to deliver at facilities and may be effective at reaching previously under-served pregnant women. More research is necessary to understand the effect of dual role CHWs on patterns of service utilization, including decisions to use referral level facilities for obstetric care.

Behind the Scenes: Publishing in the Maternal and Child Health Journal Abstract The Editors of the Maternal and Child Health Journal offer an inside look at publishing in the journal, including advice for potential authors and reviewers.

An Integrative Review: Understanding Parental Use of Social Media to Influence Infant and Child Health Abstract Objectives Parents of young children have unique informational needs and it has been demonstrated that information-seeking behaviors influence health outcomes. Due to social media’s popularity, understanding parents’ use of social media may assist in disseminating accurate parenting information and in developing targeted interventions. Thus, we aimed to identify and describe the existing literature of parental use of social media for parenting in the U.S. Methods After searching nine databases with two separate Boolean phrases, identified articles were reviewed. Inclusion and exclusion criteria were applied, resulting in 12 articles published between January 2004 and May 2018 that related to parental use of social media for parenting or infant health in the U.S. Data from relevant articles were then extracted and analyzed. Results Facebook was the most frequent social media format. Parental utilization of social media varied by race/ethnicity and region. Studies primarily focused on women and a range of article topics were identified, the most common being infant feeding practices. Finally, two themes emerged: (1) parental support via social media and (2) effectiveness of using social media for health communication targeting parents. Conclusions for Practice Social media provided support for parents and was effective for communicating health information; thus, public health organizations should include social media in their efforts to promote infant and child health. More research is needed to further identify demographic differences in social media use among parents.

Breastfeeding Support Offered at Delivery is Associated with Higher Prevalence of Exclusive Breastfeeding at 6 Weeks Postpartum Among HIV Exposed Infants: A Cross-Sectional Analysis Abstract Objective HIV-exposed uninfected infants are almost twice as likely to die compared to infants born to HIV-uninfected women. HIV-exposed uninfected children whose mothers are on ART and who are breastfed have the lowest risk of dying by 24 months of age. Interventions to improve breastfeeding among HIV-infected mothers are needed. We aimed to assess the association between support/counseling provided by healthcare workers following delivery and the rate of exclusive breastfeeding (EBF) at 6-week postpartum. Methods This is a secondary analysis of data collected as part of a trial to evaluate the effect of conditional cash transfers on retention in and uptake of PMTCT services. Between April 2013 and August 2014, newly diagnosed HIV-infected women, ≤ 32 weeks pregnant, registering for antenatal care (ANC), in 89 clinics in Kinshasa, Democratic Republic of Congo, were recruited and followed through 6 weeks postpartum. At 6-week, participants were asked if they had given anything other than breastmilk to their infant in the 24 h preceding the interview (No = EBF) and whether a nurse or a doctor talked to them about breastfeeding after they gave birth (YES = received breastfeeding support/counseling). Logistic regression was used to estimate the odds ratios (OR) and 95% confidence intervals (CI) measuring the strength of the association between EBF and receiving breastfeeding support/counseling by a healthcare provider following delivery. Results Of 433 women enrolled, 328 attended a 6-week postpartum visit including 320 (97%) with complete information on EBF. Of those 320, 202 (63%) reported giving nothing other than breastmilk to their infant in the previous 24 h; 252 (79%) reported that a healthcare provider came to talk to them about breastfeeding following delivery. Mothers who reported receiveing breastfeeding support/counseling from a healthcare provider were more likely to exclusively breastfeed compared to those who did not (69% vs. 38%, OR 3.74; 95% CI 2.14–6.54). Adjustment for baseline sociodemographic characteristics did not change the association substantially, (adjusted OR 3.72; 95% CI 2.06–6.71). Conclusion for Practice Receipt of breastfeeding support/counseling from a healthcare provider after delivery among HIV-infected mothers in care at 6-weeks postpartum in Kinshasa almost quadrupled the odds of EBF.