1. Associations Between Psychosocial Factors and Intrauterine Growth Retardation Sharon Durousseau MD, MPH California Department of Health Services Maternal Child Health Branch

2. Intrauterine Growth Retardation Intrauterine growth retardation (IUGR) –Babies born too small for gestational age Over 10,000 full-term infants with IUGR born in California annually Increased risk for death and disability Long-term effects

3. Incidence Rate of IUGR, CA 1992-1999

4. Incidence of IUGR by Race/Ethnicity, CA 1999

5. Psychosocial Factors and IUGR? Risk factors include – Smoking – Poor nutrition – Prior pregnancy history Stress and social factors might affect fetal growth

6. Study objectives Can we identify women at risk by the psychosocial profile? Can social support programs affect IUGR rates?

7. Maternal Infant Health Assessment Annual population-based survey Includes mothers with singleton live births Surveys maternal behaviors and conditions before, during, and after pregnancy

8. All live births in California Feb. to May 1999 165,898 Sampling Design

9. All live births in California Feb. to May 1999 165,898 Sampling Design Excluded: -Mothers aged <15 yrs -Infants adopted -Mothers deceased -Incomplete contact information

10. All live births in California Feb. to May 1999 Eligible Population 165,898 156,514 Sampling Design Excluded: -Mothers aged <15 yrs -Infants adopted -Mothers deceased -Incomplete contact information

11. All live births in California Feb. to May 1999 Stratified by race/ethnicity, region and education Eligible Population 165,898 156,514 4,967 Sampling Design Excluded: -Mothers aged <15 yrs -Infants adopted -Mothers deceased -Incomplete contact information Random sample strata

12. All live births in California Feb. to May 1999 Stratified by race/ethnicity, region and education 70.1% response Eligible Population 165,898 156,514 4,967 3,483 Sampling Design Excluded: -Mothers aged <15 yrs -Infants adopted -Mothers deceased -Incomplete contact information Random sample strata

13. IUGR Case Definition A case defined as a mother of a term infant ( >37 weeks gestational age) weighing < 2500 grams at birth All other term infants were non-cases

14. Cases and Non-cases 3,127 mothers of term infants 3,483

15. Cases and Non-cases 716 preterm excluded 3,127 mothers of term infants 3,483

16. 73 cases 3,054 non-cases Cases and Non-cases 716 preterm excluded 3,127 mothers of term infants 3,483

17. Psychosocial Factors Wanting to become pregnant Initial happiness about becoming pregnant Maternal sense of control score

18. Statistical Methods Univariate Analysis with SPSS/SUDAAN Logistic regression controlling for Race/ethnicity Maternal age Prior low birthweight Smoking status EducationMarital status Poverty Data weighted to reflect state population Tested for interaction

19. IUGR Risk Factors Crude OR 95% CI 19 years(ref) African-American3.1(1.6, 6.2) Native American3.7(0.5, 29.2) Asian/Pacific Islander 2.9 (1.3, 6.3) Hispanic1.4(0.7, 2.6) White/Other(ref)

20. IUGR Risk Factors Crude OR95% CI < 12 Years education1.7(1.01, 2.9) Unmarried1.7(1.05, 2.9) Medicaid1.8(1.04, 2.9) Income < federal poverty level2.4(1.4, 4.1)

21. IUGR Risk Factors Crude OR95% CI Prior Low Birth Weight Infant12.7 (5.6,28.8) Underweight prior to pregnancy2.4(1.3, 4.2) Smoked during pregnancy1.7(0.9, 3.3) Alcohol use during pregnancy0.8(0.4, 1.6) No first trimester Prenatal Care 0.9 (0.4, 1.9)

22. Univariate Analysis: Wanting to Become Pregnant

23. Univariate Analysis: Happiness About Becoming Pregnant

24. Univariate Analysis: Maternal Sense of Control Scores

25. Multivariate Analysis OR 95% CI Did not want/Unsure2.2 (0.8, 6.7) Very unhappy1.5(0.2, 9.5) Low control score1.3(0.2, 9.2)

26. Strengths and Weaknesses Strengths –Population based sample –Diverse population Weaknesses –Retrospective, possible recall bias –Limited detail –Possible low power

27. Conclusions Psychosocial factors associated with IUGR include –Not wanting/being unsure about becoming pregnant –Being unhappy about becoming pregnant After adjusting for other variables, these factors are not statistically significant.

28. Implications Assessing maternal feelings toward pregnancy not sufficient to identify women at risk for having infant with IUGR Consider other risk factors More focused or prospective study might be needed to explore relationship further

29. Acknowledgements Gilberto Chavez Don Taylor Kristen Marchi Paula Braveman Rhonda Sarnoff Andrea Winquist

30. Pregnancy Wantedness “ Thinking back to just before you got pregnant, how did you feel about getting pregnant? ” I wanted to get pregnant then. I wanted to get pregnant later. I did not want to get pregnant then or in the future. I wasn’t sure what I wanted.

31. Initial Happiness About Becoming Pregnant How did you feel when you found out you really were pregnant ? –Very happy –Somewhat happy –Somewhat unhappy –Very unhappy

32. Maternal Sense of Control Aggregate score from series of seven questions “ How much do you agree with each of the following statements ? ” –Sample questions: “ I have little control over the things that happen to me.” “ What happens to me in the future mostly depends on me.”

33. Power Calculations Sample sizes needs to detect 50% difference for each variable (  = 0.05 and  =.20 ) –wantedness 1,088 –happiness 4,702 –control score 7,738 Power calculation done in EPI 6.0.