Study looks at relationship between maternal depression, opioid use

Portrait of Kelli Ryckman, professor in the Department of Epidemiology at the University of Iowa College of Public Health.
Kelli Ryckman

A new study from researchers at the University of Iowa shows that mothers diagnosed with postpartum depression and having undergone a Cesarean section are five times more likely to fill at least two opioid prescriptions in the three months following labor than are mothers without those conditions.

Kelli Ryckman, associate professor of epidemiology at the University of Iowa College of Public Health, led the study, which was conducted by members of the Iowa Perinatal Health Research Collaborative.

“There’s been a lot of talk about the opioid crisis, but mothers who have delivered and get opioids for pain are underrepresented in the discussion about opioid misuse,” Ryckman says. “Yet they are at increased risk.”

Ryckman and her colleagues looked at the information available in a statewide insurance claims database managed by the University of Iowa Center for Public Health Statistics. All the records in the database are stripped of identifying information to protect the subjects’ privacy. From there, they carved out a cohort of 19,000 mothers who gave birth in Iowa between 2004 and 2015.

By matching a patient’s depression diagnosis with that patient’s pharmacy claims, the researchers looked at the relationship between maternal depression and the number of opioid prescription fills.

The findings — which will be presented during a February 2019 meeting of the Society of Maternal-Fetal Medicine — include:

  • Nearly 44 percent of the women in the cohort had at least one opioid prescription, and 12 percent had at least two prescription fills from the time of delivery until three months postpartum.
  • Women with a history of depression had about 1.6 greater odds of having an opioid fill and about a two times greater risk of having at least two opioid fills compared to women without a depression history.
  • Women who had a Cesarean section and had postpartum depression were five times more likely to fill at least two opioid prescriptions in the first three months after delivery.

“We suggest there is universal screening for perinatal depression that can identify women with probable depression who are at an increased risk for opioid misuse or opioid-related maternal mortality,” Ryckman says.

Climate change may increase congenital heart defects

Midwestern states could be most severely affected

Rising temperatures and extreme heat events associated with global climate change may have yet another important health impact: increased numbers of infants born with congenital heart defects (CHD). According to recent research conducted by a multi-disciplinary team that included University of Iowa investigators, heat waves in the United States over the next two decades may result in as many as 7,000 additional CHD cases between 2025 and 2035.

A portrait of Paul Romitti of the University of Iowa College of Public Health.
Paul Romitti

The study looked at climate change forecasts for eight representative states, including Iowa, and found that the greatest percentage increases in the number of congenital heart defects are predicted in the Midwest, followed by the Northeast and the South. Paul Romitti, professor of epidemiology in the UI College of Public Health, contributed to this research, which appeared in the Journal of the American Heart Association.

“Climate change may have a disproportionate impact on CHD in the Midwest,” said Romitti. “Our study predicts that this area of the country will potentially have the highest increase in maternal exposure to excessively hot days and heat event frequency and duration.”

Congenital heart defects are the most common birth defect in the United States, affecting some 40,000 newborns each year, according to the Centers for Disease Control and Prevention.

While previous research has found a link between maternal heat exposure and the risk for heart defects in offspring, the precise mechanisms remain unclear. Studies in animals suggest that heat may cause fetal cell death or interfere with several heat-sensitive proteins that play a critical role in fetal development, the researchers say.

The estimates in the current study are based on projections of the number of births between 2025 and 2035 in the United States and the anticipated rise in average maternal heat exposure across different regions as a result of global climate change. In their analysis, the researchers used climate change forecasts obtained from NASA and the Goddard Institute for Space Studies. They improved the spatial and temporal resolutions of the forecasts, simulated changes in daily maximum temperatures by geographic region, and then calculated the anticipated maternal heat exposure per region for spring and summer.

This study was supported by the National Institutes of Health and the Centers for Disease Control and Prevention, with partial support by the National Natural Science Foundation of China.

Iowa Perinatal Health Research Collaborative works to improve maternal and infant care

The provocative takeaway from a new study of maternal care is easy enough to summarize: Mothers diagnosed with postpartum depression and having undergone a Cesarean section are five times more likely to fill at least two opioid prescriptions in the three months following labor than are mothers without those conditions.

But for this particular study by the Iowa Perinatal Health Research Collaborative, the final conclusion isn’t the end point of the research; it’s just the beginning.

The collaborative — funded by the Iowa Institute of Public Health Research and Policy — was created to improve the health outcomes of children born prematurely or at low birth weight. It brings together groups of researchers, clinicians, and patient advocates to improve access to existing statewide databases and to identify volunteers for studies in outcomes research, quality improvement initiatives, and interventions.

Improving Care for Mothers and Infants

During its first two years, the group’s community engagement efforts have resulted in more than 250 women signing up to be available for various research endeavors.

“These individuals have agreed to be contacted for future studies, so this gives us a good data bank for investigators in the collaborative who may want to dive deeper with additional studies,” says Kelli Ryckman, the leader of the collaborative and an associate professor of epidemiology at the University of Iowa College of Public Health.

(story continues below video)

 

The collaborative has heard from more than 130 Iowa researchers — from obstetrics, gynecology, neonatology, pediatric neurodevelopment, epidemiology, biostatistics, and other fields — who want to work cooperatively to find ways to improve the care of mothers and preterm infants in the weeks, months, and years following birth.

Future research topics will be determined by input from a 10-member community advisory board, but the group’s inaugural study is focused on an emerging issue in maternal care: How opioid-related deaths account for between 11 and 20 percent of pregnancy-associated deaths in the U.S.

New Moms and Opioid Misuse

“There’s been a lot of talk about the opioid crisis, but mothers who have delivered and get opioids for pain are underrepresented in the discussion about opioid misuse,” Ryckman says. “Yet they are at increased risk.”

Ryckman and her colleagues looked at the information available in a statewide insurance claims database managed by the UI Center for Public Health Statistics. All the records in the database are stripped of identifying information to protect the subjects’ privacy. From there, they carved out a cohort of 19,000 mothers who gave birth in Iowa between 2004 and 2015.

By matching a patient’s depression diagnosis with that patient’s pharmacy claims, the researchers looked at the relationship between maternal depression and the number of opioid prescription fills.

The findings — which will be presented during a February 2019 meeting of the Society of Maternal-Fetal Medicine — include:

  • Nearly 44 percent of the women in the cohort had at least one opioid prescription, and 12 percent had at least two prescription fills from the time of delivery until three months postpartum.
  • Women with a history of depression had about 1.6 greater odds of having an opioid fill and about a two times greater risk of having at least two opioid fills compared to women without a depression history.
  • Women who had a Cesarean section and had postpartum depression were five times more likely to fill at least two opioid prescriptions in the first three months after delivery.

“We suggest there is universal screening for perinatal depression that can identify women with probable depression who are at an increased risk for opioid misuse or opioid-related maternal mortality,” Ryckman says.

Sharing Information

Portrait of Kelli Ryckman, professor in the Department of Epidemiology at the University of Iowa College of Public Health.
Kelli Ryckman

Ryckman notes she probably could have conducted a similar study without the collaborative in place, but such a study would have required the creation of a narrow data set designed to answer a specific question.

This study, instead, serves as the first of what Ryckman hopes will be many collaborations that make use of the large amount of information already available in the various databases.

It’s now the job of the collaborative’s community advisory board to help the researchers and clinicians brainstorm ways to ensure the information gets to the mothers whose medical and parenting decisions could be most affected by it.

The goal is not only to get the research findings into the peer-reviewed journals read by OB-GYNs and other providers; it’s also to make use of the websites and blogs that parents of preterm and low-birth-weight children turn to for advice and support.

That’s the type of information that Sara Connell, an advisory board member, wishes had been in place eight years ago when, while she was pregnant with her son Jacob, an ultrasound discovered very little amniotic fluid and almost no cord blood flow. The high-risk obstetrics team at UI Hospitals & Clinics diagnosed her with HELLP syndrome, a very severe form of preeclampsia that is life-threatening for both mother and child.

At the time, Connell was somewhat familiar with the risks of preeclampsia, but she had no idea of what the HELLP acronym stood for — hemolysis, elevated liver enzymes, low platelet count — let alone what a huge impact the diagnosis would have on her pregnancy and her later life.

When Jacob was born via Cesarean section at 25 weeks, he weighed 1 pound and 5.5 ounces. With underdeveloped lungs and a hole in his heart, he spent the next 126 days in the Neonatal Intensive Care Unit (NICU) at the UI Stead Family Children’s Hospital and, after being discharged, remained on oxygen until just before his second birthday. The years since have included physical therapy, occupational therapy, and ophthalmology visits as well as high-risk follow up and a host of other issues.

“Prematurity doesn’t end when a child comes home from the hospital,” Connell says.

Making Connections

 Since Jacob’s birth, Connell has started the 1,400-member NICU Families of Eastern Iowa Facebook Group and has co-founded the Butterfly Brigade, a mom-to-mom outreach organization of the UI Hospitals and Clinics for women placed on bedrest for the remainder of a pregnancy.

“We like to connect with moms before they even deliver to show them support and to provide them with some informational resources,” she says. “Whenever I go in and talk to these moms — or when I’m engaged in a dialogue in our Facebook group — I’m just letting them know that what they’re feeling is okay. That it’s normal. That this is hard, and we ‘get it.’”

Nichole Nidey, a PhD student in epidemiology and a graduate researcher for the collaborative, says hearing the personal perspectives from parents like Connell is especially beneficial for the many master’s degree and undergraduate students who volunteer with the collaborative.

“Just listening to their stories made me think about how to do research in a different ways,” Nidey says.

Study examines how water access and sanitation affect birth outcomes

A new study by researchers in the University of Iowa College of Public Health examines the complex relationships between water and sanitation access and social conditions on birth outcomes among women in India.

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child illnesses and death. In low-income countries, the challenges women face to meet their basic water, sanitation, and hygiene (WASH) needs may be a major contributor to adverse health outcomes.

Kelly Baker, assistant professor of occupational and environmental health, and Will Story, assistant professor of community and behavioral health, co-authored the study.

Read more…

Additional Media Coverage

Water access and sanitation shape birth outcomes and earning potential (Mongabay)

Poor sanitation, harassment reasons for birth problems in India (The Hindu)

Water access and sanitation shape birth outcomes and earning potential (Investment Guru India)

Study looks at impact of water, sanitation, and social conditions on birth outcomes in India

photo of a woman collecting water in plastic potsA new study by researchers in the University of Iowa College of Public Health examines the complex relationships between water and sanitation access and social conditions on birth outcomes among women in India.

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child illnesses and death. In low-income countries, the challenges women face to meet their basic water, sanitation, and hygiene (WASH) needs may be a major contributor to adverse health outcomes.

“Many homes in low-income countries have no private drinking water source. Women and girls are tasked with fetching water from outside the home, which can be physically stressful,” says Kelly Baker, assistant professor of occupational and environmental health, who co-authored the study. “In addition, homes often lack private toilet facilities, meaning women must use shared or public latrines or manage their sanitation needs in open spaces.”

A portrait of Kelly Baker, professor in the Department of Occupational and Environmental Health at the University of Iowa College of Public Health.
Kelly Baker

The lack of water and sanitation in the home forces women to navigate challenging, and sometimes personally threatening, social and environmental public conditions to collect water and to find a safe, private place to defecate, bathe, or manage menstruation, leading to psychosocial stress.

“Determining whether WASH-related stress—both physical and psychosocial—affects birth outcomes for women in low- and middle-income countries is critical for understanding whether the global prevalence of preterm birth and low infant birth weight could be reduced by improving the social and environmental conditions in which pregnant women seek clean water and proper sanitation,” says study co-author William Story, assistant professor of community and behavioral health.

For the study, which was published online Oct. 8, 2018, in PLOS ONE, the researchers used data from the India Human Development Survey . The survey asked women about their drinking water source, walking time to that source, time spent fetching water, sanitation (toilet) access, harassment of women and girls, local crime, whether community problems are solved collectively or individually, the amount of conflict within the community, as well as education, household wealth, and other characteristics.

portrait of William Story
William Story

The researchers examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012. Of these women, 14.9 percent experienced premature birth and 15.5 percent delivered a low birth weight baby.

The study found that increased time daily spent fetching household water increased women’s risk of delivering a low birth weight baby. Open defecation and using a shared latrine within a woman’s building or compound were also associated with higher odds of low birth weight and preterm birth, respectively, compared to having a private household toilet.

Harassment of women and girls in the community also was associated with both low birth weight and preterm birth. The data also showed a possible association of local crime with low birth weight.

“This study contributes to the limited evidence related to environmental causes of PTB and LBW by demonstrating that lack of household WASH infrastructure and social factors, like crime and harassment of women and girls, are risk factors for adverse birth outcomes in women in low- and middle-income countries,” the researchers write. “Additionally, the findings suggest that gender norms that sanction harassment of women and girls and place the burden of household water fetching on women are key determinants of vulnerability to PTB and LBW among Indian women.”

Interventions that reduce domestic responsibilities related to water and sanitation and that change social norms related to gender-based harassment may reduce rates of PTB and LBW in India, the authors note.

Additional contributors to the study include Evan Walser-Kuntz and Bridget Zimmerman from the UI Department of Biostatistics. The paper is available online at https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0205345.

The study was funded by a pilot grant from the University of Iowa College of Public Health. Funding for the original IHDS study was provided to the University of Maryland and the National Council of Applied Economic Research, New Delhi, by the National Institutes of Health.

Risk of preterm birth reliably predicted by blood tests

A new study published in the Journal of Perinatology, suggests that blood tests can be used to predict the risk of preterm births among pregnant women with and without preeclampsia.

Portrait of Kelli Ryckman, professor in the Department of Epidemiology at the University of Iowa College of Public Health.The researchers found that screening for specific biomarkers along with understanding certain demographic information about the patient could identify the risk of most of the women in the study during their second trimester of pregnancy.

Senior author Kelli Ryckman, associate professor of epidemiology at the University of Iowa College of Public Health, says that knowing which women are in the high risk group would allow providers to suggest additional monitoring and even offer an opportunity for intervention.

“For example, our test identified about 95 percent of women who had a preterm birth with preeclampsia before 32 weeks,” Ryckman says. “These women could be offered low-dose aspirin as a way to help lower their risk for preeclampsia.”

The test, developed and studied in 400 women during their second trimester, screened for 25 biomarkers or substances in the blood that were signs of inflammation and immune system activation, as well as certain protein levels, indicative of a possible preterm birth risk.

While the results of the study are encouraging, Ryckman notes that the test is still in very early stages of development, and more research is needed to determine its accuracy and safety.

Additional authors of the study are Laura L. Jelliffe-Pawlowski, Larry Rand, and Mary E. Norton, University of California San Francisco School of Medicine; Bruce Bedell and Jeffrey C. Murray, University of Iowa Carver College of Medicine; Rebecca J. Baer and Scott P. Oltman, University of California San Diego; and Gary M. Shaw and David K. Stevenson, Stanford University School of Medicine.

Funding for the study was provided by the Bill & Melinda Gates Foundation, NIH/NHLBI, the March of Dimes Prematurity Center at Stanford University School of Medicine, the Stanford Child Health Research Institute at Stanford University School of Medicine, the Stanford Clinical and Translational Science Award CTSA to Spectrum, the March of Dimes Prematurity Center—Ohio Collaborative, March of Dimes, and the California Preterm Birth Initiative at the University of California San Francisco Benioff Children’s Hospital.

Related Media Coverage

CNN
https://www.cnn.com/2018/06/07/health/blood-test-preterm-birth-risk-study/index.html

EurekAlert
https://www.eurekalert.org/pub_releases/2018-05/uoc–rop052118.php

HealthLine
https://www.healthline.com/health-news/new-test-better-predicts-risk-of-premature-birth#1

Daily Mail
http://www.dailymail.co.uk/health/article-5766977/New-test-spot-preeclampsia-preemie-risk-weeks-pregnancy-study-finds.html

Collaboration + Laboratory = Collaboratory

A creative partnership model brings teams of experts together to solve complex public health problems.

 

“We have to abandon the conceit that isolated personal actions are going to solve this crisis,” former Vice President Al Gore has said of climate change. Whether a problem is as monumental as global warming, or more emerging, such as the relatively sudden worldwide use of an insecticide whose effects are not fully understood, solutions will rarely arise from a single person or even a single laboratory. Rather, such difficult problems necessitate collabora­tions that span disciplines and organizations, challenge accepted methods, and even push established lexicons to shift.

This is the founding principle behind the Iowa Institute of Public Health Research and Policy’s collaboratory initiative. Two inaugural collaboratory teams just completed their first year of work via this new funding source available to teams anchored in the College of Public Health but extending beyond it. One team is focused on better understanding neonicotinoids, a relatively new class of insecticides. The other team is invested in creating data that can be leveraged by providers and public health professionals to improve the health outcomes of children born in Iowa.

 

THE TEAMS INCLUDE research scien­tists, physicians, public policy experts, epidemiologists, engineers, geologists, chemists, and others. This rich array of expertise and the fertile network of knowledge and contacts that members bring with them is what makes this model so ripe with possibility.

Vickie Miene, interim director of the Iowa Institute of Public Health Research and Policy (IIPHRP), says that in addition to spanning a spectrum of disciplines, the new program is intended to encourage team-building strategies. It is one part of the burgeoning institute’s work, which is focused on fostering new relationships within and outside of the University of Iowa.

Funded by a gift from Dale and Linda Baker and supplemented by the Roy J. Carver Charitable Trust, the collabo­ratory program is intended to create teams that are ready to respond rapidly to opportunities.

“In today’s funding world, you get maybe 60 days to respond to a call for a new grant or contract, and most of the time they’re looking for existing partnerships that are multidisciplinary,” says Miene.

Ideally, a successful collaboratory will lead to a sustainable research initiative that bolsters and builds upon the college’s three areas of excellence: rural health, comparative effectiveness research, and community engagement. Finding the kinds of complex topics that call for this approach isn’t difficult, but locating faculty leaders who appreciate the necessity and utility in an approach that can take many people out of their comfort zones is another matter. Miene is impressed by the success of the initial two collaboratories, both in the depth of their work and in their willingness to embrace the team-building aspects of the process.

“People have to be willing to get their hands dirty in learning collaboration,” says Miene. “They are the content experts, and our role at IIPHRP is to support them in their efforts.” To do so, the institute helps the teams to develop memorandums of understanding, create a team process, and make a plan for disseminating their work.

According to Miene, the institute could not have chosen better directors for the inaugural collaboratories. CPH Professors Kelli Ryckman and R. William Field, she says, “have been all in and completely willing to learn.”

 

Photo of William Field
William Field

FIELD LEADS THE TEAM “Human Exposure and Heath Risks from Neonicotinoid Insecticides,” which grew out of his graduate student Darrin Thompson’s strong interest in the occurrence and potential health effects of these emerging chemicals as a dissertation topic.

“Neonicotinoids have only been around for about 20 years,” explains Thompson, “but they are already the most widely used class of insecticides in the world.”

Although they were developed as a safer alternative to other insecticides, there is already substantive evidence that neonicotinoids are playing a role in the decline of honey bee popula­tions. Beyond initial laboratory tests done by the manufacturers, there has been little research on human health effects of this insecticide, which is used by farmers, gardeners, and the timber industry, among others. According to Thompson, laboratory tests simply cannot take into account the myriad of variables that exist when these chem­icals interact with environmental factors and other chemicals.

Field says the topic is especially pertinent to the state “since neonicotinoids are used as a seed coating for the majority of corn and soybean seeds in Iowa.” In the long-term, the collaboratory intends to study the potential health risk, if any, posed by chronic exposure to low concentrations. In the shorter term, the central research is that of Thompson’s dissertation, which includes measuring the levels in groundwater and in the urine of people who apply the pesticide. The team now comprises more than 15 active members and includes researchers from the UI College of Engineering, the Iowa Geological and Water Survey, the State Hygienic Laboratory, the U.S. Geological Survey, the Center for Health Effects of Environmental Contamination, and the National Cancer Institute. The collaboratory is ready to publish a paper that will open a whole new portfolio of research, Miene says.

Describing one of their meetings, Miene adds, “I was in awe of the expertise around the table. There were geologists, engineers, epidemiologists, and a major scientist calling in from California. It’s really impressive how they are thinking about sustainability and the intricacies of the conversation.”

Field agrees. “It sort of reminds me—in a real sense rather than an imaginary one—of The Field of Dreams: If you start the collaborative, researchers with a shared interest and vision will come, and with each addition, the collaborative expertise expands.”

 

Portrait of Kelli Ryckman, professor in the Department of Epidemiology at the University of Iowa College of Public Health.
Kelli Ryckman

RYCKMAN HAS HAD A similar experience as her team, the Iowa Perinatal Health Research Collaborative, has grown since its inception. Ryckman’s biggest challenge wasn’t finding researchers, but rather creating a team committed to sharing research. “There has had to be some breaking down of barriers of what is mine and what is ours,” says Ryckman, a genetic epidemiologist.

“This first year has really been about creating shared resources and a similar language,” she observes. “There were already many projects out there related to this topic, but instead of us each doing our own siloed thing, we were challenged to consider if we could create some synergy to share and collect data. Is there a way to connect initia­tives so that we can all benefit?”

The perinatal collaboratory has 12 regular members, including UI researchers from obstetrics and gynecology, neonatology, and pediatric neurodevelopment; as well as partners from the Iowa March of Dimes, the Iowa Department of Public Health, and the State Hygienic Laboratory.

Miene says that how to do research better is a key part of Ryckman’s project: “They are building and testing a database that will allow them to answer a lot of questions about outcomes of children born in Iowa, particularly those born preterm or low birth weight. They are gaining crucial understanding of how kids born under these circumstances are doing in multiple ways.”

It’s such an important issue, Miene adds, that the team has already received generous gifts from donors Dale and Linda Baker and Dr. Roger Williamson to help continue its work.

Traditionally, research comes with a strong sense of turf since success leads to future funding. There is under­standable concern for who gets credit and what department or unit “owns” the grant funding around a project. As she’s created and nurtured her team, Ryckman simply wasn’t accepting that model.

As though summing up the modus operandi of the collaboratory and why the College of Public Health initiated it, Ryckman says, “Everything I have is ours—that’s my stance, and you have to give me the same buy-in. That’s the difference between simply collabo­rating versus really creating something beneficial to the broader research community and to the public.”

This story originally appeared in the spring 2018 issue of Insight magazine.

Speaker to address maternal mental health disparities

Maternal Mental Health Disparities and Patient Engagement in Research

Karen Tabb Dina, PhD
Assistant Professor
University of Illinois School of Social Work

Thursday, April 12
3:30-4:30 pm
C217 CPHB

Abstract: Women’s mental health during the perinatal period is critically important.  Currently there are no best practices for screening for depression and addressing mental health needs in public health clinics. Clinic staff are often responsible for performing depression screening, however, few studies examine staff perceptions on feasibility and acceptability of using perinatal screening for mood disorders in ethnically diverse public health clinics. We conducted focus group interviews with public health staff (n=25) to learn how a multidisciplinary clinical staff addresses mental health in their clinic. Most participants identified multiple barriers to universal depression screening in a public health clinic, but at the same time found value in the practice of screening low-income women for depression. The findings from the focus group study established the foundation for a university-community partnership to improve maternal health outcomes at the county level in Illinois. The partnership has grown into a local initiative and is now in the early stages of developing a patient centered outcomes research community.

Sponsored by the Iowa Institute of Public Health Research and Policy and the Iowa Perinatal Health Research Collaborative

Individuals with disabilities are encouraged to attend all University of Iowa-sponsored events. If you are a person with a disability who requires a reasonable accommodation in order to participate in this program, please contact the College of Public Health in advance at 319-384-1500.