Health Care for Women International, 36:108–120, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2013.862796
Maternal Fair/Poor Self-Rated Health and Adverse Infant Birth Outcomes DAC A. TEOLI and KEITH J. ZULLIG Department of Social and Behavioral Sciences, School of Public Health, West Virginia University, Morgantown, West Virginia, USA
MICHAEL S. HENDRYX Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana, USA
We conducted a cross-sectional, correlational analysis of the West Virginia Birth Score Program database examining the relationship between maternal self-rated health (SRH) and infant low birth weight (LBW), preterm birth, and small for gestational age (SGA). We found that, after controlling for covariates, mothers reporting fair/poor SRH were more likely to deliver an LBW infant (OR = 1.35, 95% CI = 1.14, 1.59), to deliver preterm (OR = 1.38, 95% CI = 1.17, 1.63), and to deliver an SGA infant (OR = 1.20, 95% CI = 1.05, 1.38). Given these results, further research is warranted to analyze maternal SRH during pregnancy, thereby exploring its potential predictive ability in regards to adverse birth outcomes. Women’s self-rated health (SRH) has been a major international focal point for researchers in recent years (Abdulrahim & El Asmar, 2012; Ahmad, Ryan, Maziak, Pless-Mulloli, & White, 2013; Erlandsson, Bj¨orkelund, Lissner, & ˚ Hakansson, 2010; Lamarca, Leal, Sheiham, & Vettore, 2013; Mart´ın-L´opez et al., 2011; Sampaio, Sampaio, Yamada, Ogita, & Arai, 2013). Of particular relevance to this study are investigations on maternal SRH, pre- and postdelivery. Researchers have addressed such postdelivery issues as what SRH does (and does not) capture 1 year after childbirth (Schytt, Waldenstr¨om, & Olsson, 2009), and the risk factors for developing poor self-rated health
Received 4 January 2013; accepted 24 October 2013. Address correspondence to Keith J. Zullig, Department of Social and Behavioral Sciences, School of Public Health, West Virginia University, P.O. Box 9190, Morgantown, WV 26506, USA. E-mail: [email protected] 108
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after delivery (Schytt & Waldenstr¨om, 2007). Furthermore, investigators have shown a number of select maternal traits and states that bear a predictive power in regards to birth outcomes, including the presence of anxiety (Hosseini et al., 2009) and stress (Martini, Knappe, Beesdo-Baum, Lieb, & Wittchen, 2010). The importance placed on the call for further study is internationally warranted, given that it is known that, regardless of a woman’s nationality, a newborn’s physical attributes present at birth play vital roles in growth, morbidity risk, quality of life, and overall survival (Rosenzweig & Schult, 1982). To expand upon current knowledge, we directly investigated whether maternal SRH was associated with three universal adverse birth outcomes (birth weight, gestational age, and small for gestational age [SGA]). Suchman, Phillips, and Streib (1958) were the first to posit that an underlying difference exists between an individual’s self-rating of health (regarded as “subjective” or “perceived” ratings) and the ratings procured by physicians (considered as “objective” or “actual”). SRH is theorized to be such a powerful indicator of overall health status because it spans past, present, and future predictions of health (Sehulster, 1994). Although SRH is influenced by both mental and physical functioning, a meta-analysis of 12 chronic disease studies concluded that SRH is more strongly associated with physical functioning than mental health functioning among adults (Smith, Avis, & Assmann, 1999). Since the 1950s, SRH has been among the most frequently utilized measures of an individual’s health perception and is used frequently on the international scale in population-based health questionnaires owing to its relationship to mortality (e.g., Mossey & Shapiro, 1982; Singer, Garfinkel, Cohen, & Srole, 1976). A wide selection of more contemporary researchers has offered support for SRH’s ties to both morbidity and mortality (Benjamins, Hummer, Eberstein, & Nam, 2004; Benyamini, Leventhal, & Leventhal, 1999; Ferraro & Kelley-Moore, 2001; Idler, Kasi, & Lemke, 1990; Idler, Leventhal, McLaughlin, & Leventhal, 2004; Kaplan & Camacho, 1983; Knauper & Turner, 2003). For instance, when asked, “All in all, would you say your health is” (or a variation thereof), a significant association has been established not only with life expectancy and mortality in adults, but also with risk behaviors such as smoking, exercise, sleep, weight, and alcohol consumption (Segovia, Bartlett, & Edwards, 1989). Moreover, after reviewing 27 studies that examined SRH and mortality, Idler and Benyamini (1997) concluded that SRH status proved to be a more powerful predictor of morbidity and mortality than other objective, physician-assessed, health indicators making it a universal and “irreplaceable dimension of health status.” One hypothesis for the observed connection is that individuals who are truly in good health instinctively rate their health better than those suffering from physical ailments (Benyamini, Blumstein, Lusky, & Modan, 2003). This notion is supported by researchers who suggest that SRH tends to decline with age (Roberts, 1999) as health generally declines. Nevertheless, SRH
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is largely stable during middle adulthood (between 20 and 50 years) where adults report generally high levels of SRH (McCullough & Laurenceau, 2004), and the female sex seems to be especially protective against SRH decline (Verropoulou, 2012). For example, while it has been established that women experience substantial changes in their actual health status during and after pregnancy (notably in regards to physical function and vitality), women report significantly smaller changes in their level of SRH prior to, during, and after pregnancy compared with objective, physician assessments (Haas et al., 2004). This is consistent with researchers who suggest that individuals can “bracket” health problems when rating their health (Idler, 1993). In this case, while women may account for (not ignore) the emotional and physical pain associated with childbirth, they are able to effectively deny its importance when determining their overall health rating. Therefore, we adopt the premise that the experience of pregnancy and delivery does not alter the mothers’ overall perception of health. For our investigative purposes, birth outcomes are categorized through three frequently and internationally measured characteristics that have been validated as risks for neonatal mortality: birth weight, gestational age, and SGA (Goldenberg, Culhane, Iams, & Romero, 2008; Kristensen et al., 2007; McCormick, 1985). Through this present investigation, we directly explored whether maternal SRH was associated with these three adverse birth outcomes. While researchers in a prior study conducted in Pakistan have suggested that poor SRH is associated with low birth weight (LBW) in a mother’s offspring, additional international research is necessary as the relationship of maternal SRH with adverse birth outcomes was not the primary focus of their study (Janjua et al., 2009). These investigators stated that future research is required to directly measure SRH and its association with birth outcomes (including LBW), given that their study sample was small and derived exclusively from a Middle Eastern population. For this current investigation, we hypothesized that maternal SRH would bear an association with adverse birth outcomes in a large, North American-based female population. Specifically, mothers who report “fair” or “poor” SRH were hypothesized to show a higher risk of experiencing adverse birth outcomes.
METHOD Data The data for this investigation were obtained by the researchers from the West Virginia Birth Score-Developmental Risk Screen and Newborn Hearing Screen (WVBSDRS). The WVBSDRS was constructed in 1984 and was originally developed to identify West Virginia infants at risk for Sudden Infant Death Syndrome (SIDS) during the first year of life (Mullett, Britton, John, & Hamilton, 2010). State regulators require all birthing hospitals and
Maternal Fair/Poor Self-Rated Health
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facilities to complete the WVBSDRS at time of birth for all children born in West Virginia (Mullett et al., 2010). The form includes demographic (e.g., age) maternal behavior (e.g., smoking and alcohol use during pregnancy) and child variables (e.g., birth weight, weeks gestation). The WVBSDRS data are sent to three entities: (a) the birth score office; (b) medical records; and (c) the parent or guardian of the newborn. Completed forms are scanned as an image directly into the Birth Score Program database for documentary and research purposes.
Design Our study is a cross-sectional, correlational analysis of the Birth Score Program database. We examined the relationship between maternal SRH and infant LBW, preterm birth, and SGA before and after controlling for covariates.
Participants In January of 2010, the WVBSDRS was modified to include the single measure of SRH. Therefore, data for this study included observations only from January 2010 to July 2011 (N = 16,091). Of those original screens, 1,792 (11%) were excluded due to missing or erroneous values, resulting in a final sample of 14,298 participants who delivered a live singleton infant. Respondents are all female and gave birth in a hospital located within West Virginia. The mean age of the respondents was 25 years (SD = 6 years).
Measures Self-rated health (SRH). Each mother was asked, in person, by a hospital employee to self-report her own health at the time of her infant’s birth. The question was written as follows: “All in all, would you say your health is . . .” Response options were in a 4-point rating scale and listed in a descending order, specifically as “excellent,” “good,” “fair,” and “poor.” We assigned this variable as the study’s dependent variable. Birth weight (grams). During the 1970s, the World Health Organization designated “normal birth weight” as above 2,500 grams, LBW as between 1,500 and 2,500 grams, and “very low birth weight” (VLBW) as below 1,500 grams (Kramer, 1987). At these designations, being LBW or VLBW is internationally validated as a factor that plays a major detrimental role in an infant’s health and well-being (Kramer, 1987). Our categorizations have been adapted from the values given above. Birth weight in grams was recorded as a single item on the WVBSDRS. The birthing hospital employee recorded birth weight on a 5-point scale: “3000.” Birth weights of “3000” indicate normal birth weight. For this study, we combined both VLBW and LBW into a single low birth weight category (
Maternal Fair/Poor Self-Rated Health and Adverse Infant Birth Outcomes DAC A. TEOLI and KEITH J. ZULLIG Department of Social and Behavioral Sciences, School of Public Health, West Virginia University, Morgantown, West Virginia, USA
MICHAEL S. HENDRYX Department of Applied Health Science, School of Public Health, Indiana University, Bloomington, Indiana, USA
We conducted a cross-sectional, correlational analysis of the West Virginia Birth Score Program database examining the relationship between maternal self-rated health (SRH) and infant low birth weight (LBW), preterm birth, and small for gestational age (SGA). We found that, after controlling for covariates, mothers reporting fair/poor SRH were more likely to deliver an LBW infant (OR = 1.35, 95% CI = 1.14, 1.59), to deliver preterm (OR = 1.38, 95% CI = 1.17, 1.63), and to deliver an SGA infant (OR = 1.20, 95% CI = 1.05, 1.38). Given these results, further research is warranted to analyze maternal SRH during pregnancy, thereby exploring its potential predictive ability in regards to adverse birth outcomes. Women’s self-rated health (SRH) has been a major international focal point for researchers in recent years (Abdulrahim & El Asmar, 2012; Ahmad, Ryan, Maziak, Pless-Mulloli, & White, 2013; Erlandsson, Bj¨orkelund, Lissner, & ˚ Hakansson, 2010; Lamarca, Leal, Sheiham, & Vettore, 2013; Mart´ın-L´opez et al., 2011; Sampaio, Sampaio, Yamada, Ogita, & Arai, 2013). Of particular relevance to this study are investigations on maternal SRH, pre- and postdelivery. Researchers have addressed such postdelivery issues as what SRH does (and does not) capture 1 year after childbirth (Schytt, Waldenstr¨om, & Olsson, 2009), and the risk factors for developing poor self-rated health
Received 4 January 2013; accepted 24 October 2013. Address correspondence to Keith J. Zullig, Department of Social and Behavioral Sciences, School of Public Health, West Virginia University, P.O. Box 9190, Morgantown, WV 26506, USA. E-mail: [email protected] 108
Maternal Fair/Poor Self-Rated Health
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after delivery (Schytt & Waldenstr¨om, 2007). Furthermore, investigators have shown a number of select maternal traits and states that bear a predictive power in regards to birth outcomes, including the presence of anxiety (Hosseini et al., 2009) and stress (Martini, Knappe, Beesdo-Baum, Lieb, & Wittchen, 2010). The importance placed on the call for further study is internationally warranted, given that it is known that, regardless of a woman’s nationality, a newborn’s physical attributes present at birth play vital roles in growth, morbidity risk, quality of life, and overall survival (Rosenzweig & Schult, 1982). To expand upon current knowledge, we directly investigated whether maternal SRH was associated with three universal adverse birth outcomes (birth weight, gestational age, and small for gestational age [SGA]). Suchman, Phillips, and Streib (1958) were the first to posit that an underlying difference exists between an individual’s self-rating of health (regarded as “subjective” or “perceived” ratings) and the ratings procured by physicians (considered as “objective” or “actual”). SRH is theorized to be such a powerful indicator of overall health status because it spans past, present, and future predictions of health (Sehulster, 1994). Although SRH is influenced by both mental and physical functioning, a meta-analysis of 12 chronic disease studies concluded that SRH is more strongly associated with physical functioning than mental health functioning among adults (Smith, Avis, & Assmann, 1999). Since the 1950s, SRH has been among the most frequently utilized measures of an individual’s health perception and is used frequently on the international scale in population-based health questionnaires owing to its relationship to mortality (e.g., Mossey & Shapiro, 1982; Singer, Garfinkel, Cohen, & Srole, 1976). A wide selection of more contemporary researchers has offered support for SRH’s ties to both morbidity and mortality (Benjamins, Hummer, Eberstein, & Nam, 2004; Benyamini, Leventhal, & Leventhal, 1999; Ferraro & Kelley-Moore, 2001; Idler, Kasi, & Lemke, 1990; Idler, Leventhal, McLaughlin, & Leventhal, 2004; Kaplan & Camacho, 1983; Knauper & Turner, 2003). For instance, when asked, “All in all, would you say your health is” (or a variation thereof), a significant association has been established not only with life expectancy and mortality in adults, but also with risk behaviors such as smoking, exercise, sleep, weight, and alcohol consumption (Segovia, Bartlett, & Edwards, 1989). Moreover, after reviewing 27 studies that examined SRH and mortality, Idler and Benyamini (1997) concluded that SRH status proved to be a more powerful predictor of morbidity and mortality than other objective, physician-assessed, health indicators making it a universal and “irreplaceable dimension of health status.” One hypothesis for the observed connection is that individuals who are truly in good health instinctively rate their health better than those suffering from physical ailments (Benyamini, Blumstein, Lusky, & Modan, 2003). This notion is supported by researchers who suggest that SRH tends to decline with age (Roberts, 1999) as health generally declines. Nevertheless, SRH
110
D. A. Teoli et al.
is largely stable during middle adulthood (between 20 and 50 years) where adults report generally high levels of SRH (McCullough & Laurenceau, 2004), and the female sex seems to be especially protective against SRH decline (Verropoulou, 2012). For example, while it has been established that women experience substantial changes in their actual health status during and after pregnancy (notably in regards to physical function and vitality), women report significantly smaller changes in their level of SRH prior to, during, and after pregnancy compared with objective, physician assessments (Haas et al., 2004). This is consistent with researchers who suggest that individuals can “bracket” health problems when rating their health (Idler, 1993). In this case, while women may account for (not ignore) the emotional and physical pain associated with childbirth, they are able to effectively deny its importance when determining their overall health rating. Therefore, we adopt the premise that the experience of pregnancy and delivery does not alter the mothers’ overall perception of health. For our investigative purposes, birth outcomes are categorized through three frequently and internationally measured characteristics that have been validated as risks for neonatal mortality: birth weight, gestational age, and SGA (Goldenberg, Culhane, Iams, & Romero, 2008; Kristensen et al., 2007; McCormick, 1985). Through this present investigation, we directly explored whether maternal SRH was associated with these three adverse birth outcomes. While researchers in a prior study conducted in Pakistan have suggested that poor SRH is associated with low birth weight (LBW) in a mother’s offspring, additional international research is necessary as the relationship of maternal SRH with adverse birth outcomes was not the primary focus of their study (Janjua et al., 2009). These investigators stated that future research is required to directly measure SRH and its association with birth outcomes (including LBW), given that their study sample was small and derived exclusively from a Middle Eastern population. For this current investigation, we hypothesized that maternal SRH would bear an association with adverse birth outcomes in a large, North American-based female population. Specifically, mothers who report “fair” or “poor” SRH were hypothesized to show a higher risk of experiencing adverse birth outcomes.
METHOD Data The data for this investigation were obtained by the researchers from the West Virginia Birth Score-Developmental Risk Screen and Newborn Hearing Screen (WVBSDRS). The WVBSDRS was constructed in 1984 and was originally developed to identify West Virginia infants at risk for Sudden Infant Death Syndrome (SIDS) during the first year of life (Mullett, Britton, John, & Hamilton, 2010). State regulators require all birthing hospitals and
Maternal Fair/Poor Self-Rated Health
111
facilities to complete the WVBSDRS at time of birth for all children born in West Virginia (Mullett et al., 2010). The form includes demographic (e.g., age) maternal behavior (e.g., smoking and alcohol use during pregnancy) and child variables (e.g., birth weight, weeks gestation). The WVBSDRS data are sent to three entities: (a) the birth score office; (b) medical records; and (c) the parent or guardian of the newborn. Completed forms are scanned as an image directly into the Birth Score Program database for documentary and research purposes.
Design Our study is a cross-sectional, correlational analysis of the Birth Score Program database. We examined the relationship between maternal SRH and infant LBW, preterm birth, and SGA before and after controlling for covariates.
Participants In January of 2010, the WVBSDRS was modified to include the single measure of SRH. Therefore, data for this study included observations only from January 2010 to July 2011 (N = 16,091). Of those original screens, 1,792 (11%) were excluded due to missing or erroneous values, resulting in a final sample of 14,298 participants who delivered a live singleton infant. Respondents are all female and gave birth in a hospital located within West Virginia. The mean age of the respondents was 25 years (SD = 6 years).
Measures Self-rated health (SRH). Each mother was asked, in person, by a hospital employee to self-report her own health at the time of her infant’s birth. The question was written as follows: “All in all, would you say your health is . . .” Response options were in a 4-point rating scale and listed in a descending order, specifically as “excellent,” “good,” “fair,” and “poor.” We assigned this variable as the study’s dependent variable. Birth weight (grams). During the 1970s, the World Health Organization designated “normal birth weight” as above 2,500 grams, LBW as between 1,500 and 2,500 grams, and “very low birth weight” (VLBW) as below 1,500 grams (Kramer, 1987). At these designations, being LBW or VLBW is internationally validated as a factor that plays a major detrimental role in an infant’s health and well-being (Kramer, 1987). Our categorizations have been adapted from the values given above. Birth weight in grams was recorded as a single item on the WVBSDRS. The birthing hospital employee recorded birth weight on a 5-point scale: “3000.” Birth weights of “3000” indicate normal birth weight. For this study, we combined both VLBW and LBW into a single low birth weight category (
