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.

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.

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.

by Dr. Mark Burhenne

(CNN) -- We all know about the importance of sleep, and we know we should be getting more of it. When we wake up exhausted, drag ourselves to work or hit that afternoon slump, we blame ourselves: "Should have gotten more sleep last night."

You can't ask yourself how well you're sleeping without considering sleep apnea. Sleep apnea is a condition that affects an estimated one in 15 Americans but often goes undetected.

Most people who suffer from sleep apnea don't know it -- they often seek out a diagnosis only if their partner can't sleep through the snoring. Since sleep apnea ranges from mild to severe, lots of cases of sleep apnea aren't noticed by sleeping partners, and people live their whole lives undiagnosed.

Sleep apnea can't usually be detected by doctors during routine office visits, but a screening from your dentist may help.

Recent studies have shown that teeth grinding, also called bruxism, is a major indicator for obstructive sleep apnea. The simple dental health screening that can improve the quality of your sleep and -- because almost everything boils down to a good night's sleep -- even save your life, begins with asking your dentist, "Do I grind my teeth?"

Q: What is obstructive sleep apnea?

A: The most common type of sleep apnea is obstructive sleep apnea. The key word is "obstructive" -- the thing "obstructing" the airway being the jaw, which falls back as the brain approaches the deepest stages of sleep and the muscles of the airway fully relax.

When the airway collapses like this, breathing becomes compromised. This is where you get snoring, which is just the sound that's made when air is getting forced through a partially obstructed airway.

Once the brain senses that breathing is dangerously compromised, it gets out of the deepest stage of sleep to regain control of the jaw muscles and reopen the airway, and keep you alive and breathing. These sleep apnea cycles can occur from five to up to 70 times per hour while you sleep -- preventing you from entering the deepest stages of sleep where the brain and body tissues can repair themselves from the wear and tear of the day.

Sufferers of sleep apnea never get the benefits of the deepest stages of sleep, which is what reverses the aging process and repairs tissue damage. After just one night of the lack of deep sleep that the body craves, you awake in a damaged state. Cumulative damage could lead to expression of the Alzheimer's gene, high blood pressure, depression, mood disorders, suppression of the immune system, diabetes, cancer and weight gain.

Q: What are the symptoms of untreated sleep apnea?

A: You feel sleepy or tired during waking hours. For every sleep apnea cycle, or apneic episode, the body goes into fight-or-flight mode with an adrenaline response to "wake up" the brain to reopen the airway. That response evolved to keep humans alive in the short term, but on a nightly basis puts extraordinary wear and tear on the body.

You're anxious or stressed during the day. What's missing from the sleep apnea discussion is the emotional toll of going into fight-or-flight mode several times each night. This stress manifests itself not only physically but also emotionally -- the exhaustion that sufferers of severe sleep apnea feel during the day is partially due to emotional stress at night as they struggle to breathe.

You grind your teeth. One of the ways the brain tries to reopen the airway in an unconscious state is by grinding and clenching the teeth. People who grind their teeth at night often have sore or clicking jaws or flat, worn-down teeth. Many times, symptoms of teeth grinding can be far less obvious -- such as earaches or sensitive teeth.

Snoring. The key here is that not everyone who has sleep apnea snores and not everyone who snores has sleep apnea. Snoring can go undetected if you don't have a bed partner or if you have a bed partner who is a heavy sleeper. Everyone, however, can ask their dentist if they grind their teeth at their next checkup.

Q: I might have sleep apnea. What should I do?

A: See your dentist. Get screened at your next dental checkup for teeth grinding. Your dentist can tell you definitively if you grind your teeth at night or not. Teeth grinding is a major indicator that you are struggling to keep your airway open at night and might suffer from obstructive sleep apnea.

Also, see a medical sleep specialist. These specialists are the only ones who can officially diagnose sleep apnea. Make sure to discuss all of your options and let your doctor know if you're grinding your teeth.

"Sleep disorders such as sleep apnea can lead to many secondary health conditions," said Dr. Kalpalatha Guntupalli, president of the American College of Chest Physicians. "When treating sleep apnea, clinicians must also recognize and address secondary health conditions, such as bruxism, in order to fully manage a patient's sleep disorder."

People who are diagnosed and treated for sleep apnea often report that the process has "given them their life back." Quality of sleep affects most of the things that help us enjoy life: appearance, well-being, outlook on life, energy level, patience, ability to cope with stress and how we interact with loved ones.

Many of us tolerate this anxiety and exhaustion every day of our lives and never get the chance to repair our bodies with the deepest stages of sleep. Asking your dentist if you grind your teeth will hopefully make the sleep apnea diagnosis a little less daunting for the millions of people who suffer from it.

Editor's note: Mark Burhenne is a practicing family and cosmetic dentist of 25 years and founder of AsktheDentist.com. He is dedicated to empowering people to take control of their dental health, stop managing symptoms and prevent chronic illnesses in the mouth. Follow him on Facebook or Twitter.