LISA BODNAR, PHD, MPH, RD

CTSI recently sat down with Lisa Bodnar from the University of Pittsburgh School of Public Health’s Department of Epidemiology to discuss risk factors for pregnant women and how they can be reduced.

CTSI: Briefly describe the problem of infant mortality (defined as a baby’s death during the first year of life) in Allegheny County.
Dr. Bodnar: The disparity we see in infant mortality rates between African Americans and Whites in Allegheny County is striking. It’s far worse than in other counties in Pennsylvania, let alone in other parts of the country. Putting that in context, the infant mortality rates overall in the U.S. are much higher than in many other developed countries. So, the fact that the rates in the U.S. are high—and knowing that the rates in Allegheny County are very high, and the disparity in those rates is even higher—is staggering and tragic. We absolutely have to do something about it.
CTSI: Please give us an overview of your work with vitamin D and its possible connection with infant mortality.
We used to think vitamin D was only important for things like bone health. What researchers realized in the last 15 years or so is that low vitamin D levels are also related to a number of other diseases. Low vitamin D has been related to some cancers, cardiovascular disease, diabetes, asthma, autism, depression and other mental health illnesses. The reason researchers started exploring these outcomes is because we realized vitamin D does more in the body than keep bones healthy and help the body use calcium. In fact, all of our cells use vitamin D for some reason. So, when every single cell in the body uses vitamin D, we started thinking that it must be related to something other than just bones.    
We started looking at vitamin D in pregnancy because the placenta makes vitamin D and takes it to the unborn baby (the placenta feeds and nourishes the baby and gets rid of waste). Vitamin D helps regulate how the placenta works. Researchers wondered whether vitamin D is related to harmful pregnancy outcomes. We’re particularly concerned about this in Pittsburgh. Many people don’t get enough vitamin D here. This is especially true in the winter and spring months when we don’t see as much sunshine.
We get vitamin D through our food and from sunlight. People get most of their vitamin D just from being in the sunlight for a few minutes. Melanin, which makes people’s skin dark, absorbs vitamin D and acts as a natural sunscreen. It prevents sunlight from getting into the skin and being changed to vitamin D. So, we find that African Americans have a much harder time getting enough vitamin D from sunlight. They need maybe 5 times as much time in the sun as someone with lighter skin would need. You can imagine that getting this much sun can be hard when we spend so much of the winter months indoors. We also see high rates of vitamin D deficiency in Whites in Pittsburgh. But the difference we see between Blacks and Whites is similar to what we see for infant mortality in the county. We saw that vitamin D could be important for pregnancy outcomes. This insight started to make us question whether vitamin D could be adding to racial differences in infant mortality. The goal is to find out whether giving people extra vitamin D will reduce the inequality we see in the county.  
CTSI: Would taking prenatal vitamins help with vitamin D deficiency?
Prenatal vitamins contain about 600 international units (IU) of vitamin D. But there’s disagreement about whether that’s enough for most women. We have found that women who take prenatal vitamins about as much vitamin D deficiency as those who don’t. There are limitations with that research, though; we’re basing it on what people tell us. Vitamin D levels are a bit higher in women who take prenatal vitamins but not enough to make a dent in the disparity we see. It seems that higher doses, in the 1,000 to 2,000 IU range, might be what’s needed to raise vitamin D levels in most people and prevent deficiency.    
It’s hard because the definition of vitamin D deficiency in adults is controversial. It’s hard to say how much vitamin D women should be taking because we don’t know what the best level is. Some of the work I’m doing now is to relate levels of vitamin D with pregnancy outcomes to determine whether there’s a point at which we see a reduction in risk. If low levels and high levels aren’t good, is there a middle level that’s a sweet spot for most women? Because there hasn’t been much research done, we’re starting from scratch in pregnant women. Right now, it seems that a woman’s vitamin D level when she gets pregnant is most important.    
CTSI: Tell us about your pregnancy weight gain research.
It’s similar to the vitamin D work. There are clear racial inequalities in the amount of weight women gain in pregnancy and the weight at which they start pregnancy. African American women have much higher levels of obesity when they start pregnancy. They also tend to gain less weight during pregnancy. In all body-mass index (BMI) groups, it looks as if Black women on average gain less weight than White women. Gaining less weight than is recommended is associated with babies being born too early or too small. These are factors related to infant mortality. Changing a woman’s weight before she gets pregnant is very hard to do. If a woman gets prenatal care, she is getting routine medical contact. She may be more likely at that point to make lifestyle changes because it’s not just for her health—it’s also for her baby’s health. If we could help women gain the appropriate amount of weight, it might reduce some of that disparity in infant mortality.    
Starting a pregnancy at too high or too low a BMI is unhealthy. Gaining too little or too much weight is also unhealthy. The reason we’re trying to target weight gain in pregnancy is that once we see women who are pregnant, it’s too late to change their prepregnancy weight. The only thing we can help with at that point is their weight gain during pregnancy. Scientists agree that a woman’s BMI is more important that how much weight she gains in pregnancy. We should be doing more to promote weight loss in women before pregnancy, but that’s proved to be a difficult task. Fifty percent of pregnancies are unplanned, so women usually aren’t thinking about their weight with regard to getting pregnant.    
We’re looking at how weight gain may explain infant mortality disparities. Among obese, overweight, normal weight or underweight women, is weight gain adding to infant mortality?  
CTSI: How do other things, such as the environment or people’s culture, affect pregnancy weight gain?
So many things can interfere with people having a healthy weight. They include personal choices, as well as the environments and cultures in which we live, how much money we have and how much people know about what’s healthy and what’s not. There are a tremendous numbers of barriers.    
Pregnancy could be a time when we can provide resources to women about their weight. It may be a time when we can help stop a weight-gain cycle. In women, we tend to see them gain too much weight in pregnancy, not lose it all after having the baby and then start their next pregnancy at a higher weight. Then, women maybe gain too much weight in another pregnancy and don’t lose it. This cycle puts babies at a higher risk for problems at birth. A woman may start her first pregnancy at a decent weight, but after having three children, she ends up overweight or obese. If we can help her gain an appropriate amount of weight during pregnancy, that may help stop the cycle. That’s what we want to try to do.  
CTSI: What kind of practical advice can you give to women who are concerned about vitamin D or pregnancy weight gain?
Taking a supplement of 1,000 units of vitamin D is safe and won’t hurt most people. If women have easy access to health care, they can ask to have their vitamin D levels checked. It’s safer than spending time out in the sun because we don’t know the amount of sun that is safe.
To control weight gain, women should try eating more fruits and vegetables—fresh, canned, frozen, cooked, whatever—and drink fewer sugary drinks and eat fewer sweets. This would go a long way in promoting health, even without seeing a doctor or getting on a diet plan. Eating fruits and vegetables is better than eating processed food.    
Vitamin D is certainly about more than just bones. It can affect pregnancy outcomes in many ways, and we don’t know yet which is most important. So, let’s focus on the things we can control—healthy behaviors and getting the right nutrients.    
If you are worried about infant mortality and your risk factors, talk to a health care professional.
Dr. Lisa Bodnar, Ph.D., M.P.H., R.D., is an assistant professor in the University of Pittsburgh School of Public Health’s Department of Epidemiology. She was recently awarded the Young Professional Achievement Award, given by the National Coalition for Excellence in Maternal and Child Health Epidemiology

Birth outcomes depend on a healthy lifestyle before and during pregnancy. By the time a woman knows she is pregnant and goes to her doctor for prenatal care, it may be too late to make changes that increase the likelihood that the birth will result in a healthy baby. For this reason, the Allegheny County Health Department Child Death Review Team and UPMC McKeesport, Shadyside and St. Margaret Family Health Centers have joined other family health centers from the northeastern United States to develop strategies for improving birth outcomes. Their newest strategy is the Inter-Conception Care (ICC) project.
The inter-conception period refers to the time between pregnancies—after the birth of one child and before the birth of another child. During this time, new mothers are busy. They may feel like they don’t have time to get regular check-ups. This means that new mothers may not be getting the health care they need.
Although new mothers may not seek health care for themselves, they do take their babies to the doctor for regular check-ups. The ICC project uses the baby’s check-up to make sure that both the mother and baby are healthy. Doctors involved in the ICC project take time at the baby’s check-up to screen mothers for specific health risks. These risks include smoking, depression, birth spacing, taking a daily multivitamin that contains folic acid and practicing safe-baby sleep habits.
These five health risks were included in the ICC project because research shows that these risks can negatively affect families and future pregnancies. By identifying and addressing these risks, doctors hope to improve family health and reduce prematurity and low birth weight in future pregnancies. Also, doctors can assess mothers for these health risks quickly—the screening usually takes less than two minutes.
As mothers return to their children’s doctor, the doctors re-screen the mothers for these health risks. This happens each time a mother takes her child to check-ups, from the time the child is born until the child is 2 years old. This check-up allows doctors to monitor a mother’s health risks and get her the care she needs to lead a healthy life.
The ICC project began at UPMC Family Health Centers in 2012. As of December 2012, the three health centers were collecting data on almost 130 mothers. Throughout the next several years, UPMC Family Health Centers and their partners will collect and analyze data about the project. The findings will help determine how well the ICC project identifies and addresses these health risks in mothers. The health centers plan to use this information to refine and improve the project over time.
The goal of UPMC Family Health Centers and their partners, including the Allegheny County Health Department, is to develop a brief model of maternal care that can be used in other primary care clinics. For more information about the ICC project in Pittsburgh, please contact the project principal investigator, Lisa Schlar, MD, UPMC Shadyside Family Health Center, at This email address is being protected from spambots. You need JavaScript enabled to view it. or 412-623-2287.

ESTHER BUSH

This month’s issue on infant mortality is a continuation of the monthly series started last year focusing on health disparities in the Pittsburgh region. The series is a partnership among the New Pittsburgh Courier, Community PARTners (a core service of the University of Pittsburgh’s Clinical and Translational Science Institute—CTSI) and the Urban League of Greater Pittsburgh. Jessica Griffin Burke, PhD, MHS, associate professor of behavioral and community health sciences at Pitt, sat down with Esther L. Bush, president and CEO of the Urban League, to talk about this month’s topic.
by Jessica Griffin Burke, PhD, MHS
JGB:  Ms. Bush, I know from working with you that issues related to infant and child health are very important to you. What are your thoughts about the topic this month?
EB: The numbers about the scope of the disparities in infant mortality in Allegheny County are staggering, overwhelming and, frankly, unacceptable. I’ve been in Pittsburgh for a long time; and, unfortunately, the entire time that I’ve been in this wonderful city those numbers have been the same. It’s time for us to work together, as a community, to do something to improve maternal health and to reduce poor pregnancy outcomes.
JGB: What can or should we do differently now to deal with this issue?
EB: As I said, we need to work together. That means that researchers need to work with community members to better understand the roots causes of these stark disparities. Dr. Dara Mendez’s work exploring how neighborhood context matters for health is very important. Where you live can definitely affect your health. Dr. Mendez’s work with the Birth Circle doulas and women gives us some clue about where to begin addressing issues related to how a neighborhood may contribute to low birth weight and preterm birth. The answer to reducing disparities in infant mortality likely lies in our ability to think creatively and to explore options that have not been considered until now.

JGB:  It seems as if Dr. Lisa Bodnar’s work also falls into the category of issues that haven’t been well investigated yet. What do you think of her work suggesting that vitamin D may be contributing to the disparities in infant mortality we see here in Pittsburgh?
EB:  Well, I do know that it’s cold and gray here in the winter months and that we don’t see the sun much! I didn’t know about the potential connection between vitamin D deficiency and poor pregnancy outcomes. While I understand that she is still conducting necessary research, it’s possible that a vitamin D supplement could help. I look forward to learning more as her research continues.
JGB:  Let’s go back to what you were saying about making progress in our efforts to reduce infant mortality and, specifically, the disparities that exist. How does that progress happen?
EB: I think progress can occur through creative, collaborative approaches. I was really encouraged to read about the Inter-Conception Care (ICC) project, involving the Allegheny County Health Department Child Death Review Team and UPMC Family Health Centers. The ICC model makes sense. We need to work to make sure that all mothers, children and families are healthy in their homes and neighborhoods. Then they can care for themselves and their children and will be ready and healthy for future pregnancies. This approach should extend beyond the clinic. In the end, I believe we’ll be able to successfully improve birth outcomes in Allegheny County if we remember to think about moms as women who need help facing challenges. Also, we must engage with health care providers and policy makers to make positive changes.  
JGB:  I absolutely agree. We can do it. What makes Allegheny County different is that it’s a smaller area than other urban areas. The dynamic is different, and I think we can do some things here because of our size that you can’t do in larger cities. I look forward to our continued collaboration.
EB: I want to encourage others to learn more, ask questions and get involved in research. People can call the Community PARTners Core for more information about participating in research at 412-624-8139. They can also call the contacts listed in this month’s segment to learn how to participate in the highlighted studies.

According to the Centers for Disease Control and Prevention (CDC), more than 25,000 infants die each year in the United States. Infant mortality is defined as the death of an infant before one year of age. Infant mortality rates refer to the number of infant deaths for every 1,000 live births. The infant mortality rate in the U.S. is six deaths per 1,000 live births and is worse than that of many other industrialized countries (CDC, 2013).
Infant mortality rates vary by the race of the mother. Sadly, the racial disparities seen in infant mortality rates between African Americans and Whites in Allegheny County are striking (Figure 1). In Allegheny County in 2009, there were 16 deaths per 1,000 live births among African Americans, while the rate among whites was 5.6 deaths per 1,000 births. The Allegheny County numbers for African Americans are considerably higher than both the state (14.4 deaths per 1,000 births) and national rates (11.6 deaths per 1,000 births). Disparities are also seen between African Americans and Whites on low birth weight (infants born weighing less than 5.5 pounds) and preterm birth (birth before 37 weeks of pregnancy). These are two of the major predictors of infant mortality.
The racial disparities in infant mortality rates are puzzling. It’s not clear what factors contribute to the differences. For example, take the complex problem of preterm birth. Differences in maternal characteristics, such as socioeconomic status, prenatal care, infection and nutrition, are known to contribute to disparities in preterm birth. But, in the U.S., African American women with advanced schooling are more likely to have an infant die in the first year than are White women who did not finish high school. The reasons for this disparity are not clear. Could other factors (like neighborhood environment) be contributing to the differences? Research is now focusing on the role of stress as one key contributing factor.  
The Community Child Health Network (CCHN) is a large, federally funded research project currently underway to help understand how communities and families create a context that influences pregnancy and infant and child health. The goals of this research include looking at how community, family and individual stressors can influence and affect pregnancy health. Researchers are also studying whether these factors might result in health disparities in pregnancy outcomes and infant mortality. Although the CCHN study does not include Pittsburgh, the results from this research will provide valuable insights into ways to reduce infant mortality rates and to effectively address racial disparities in pregnancy outcomes. More information about the CCHN project can be found at http://www.communitychildhealthnetwork.com/index.html.
Researchers are now interested in interventions are being planned that adopt a holistic (consideration of the complete person, physically and psychologically) approach and focus on health across the entire lifespan, not just when a woman is pregnant. Reducing disparities in infant mortality and improving birth outcomes will require an increase in efforts to better understand the reality of African American women’s lives, both during pregnancy and overall.