Diana Montoya-Williams

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Breastfeeding is increasingly recognized as a powerful biologic intervention associated with positive infant and maternal health outcomes. Emerging evidence continues to expand our understanding of the mechanisms through which human milk promotes health, including via immune system development and modulation of antimicrobial resistance. Yet despite the robust scientific evidence supporting breastfeeding as critical to public health, many families in the US face structural barriers to achieving their breastfeeding goals. In the US, paid family leave has been strongly associated with both the initiation of breastfeeding and its duration. Paid family leave has also been associated with improved maternal and infant health, including reduced infant mortality. These findings suggest that paid family leave should be viewed not solely as a labor policy, but as a maternal-child health policy. The US remains one of the few high-income nations without a federal paid family leave program, relying instead on a fragmented patchwork of state policies. State experiences demonstrate that paid family leave can be implemented without major labor market disruption, while public support for a national program remains high. As breastfeeding science continues to advance, federal paid family leave represents overdue public health infrastructure necessary to translate evidence into population-level health improvements. Impact: Paid family leave is one of the most effective and well-supported policy mechanisms for promoting breastfeeding success and improving maternal and infant health. This article synthesizes emerging breastfeeding science, including new evidence regarding human milk’s influence on neonatal immunity and antimicrobial resistance. We then link breastfeeding research with research on the policy that most supports widespread breastfeeding at a population level: paid family leave. Translating the benefits of breastfeeding into improved public health will require national policies that enable families to achieve breastfeeding goals. Federal paid family leave is among the most evidence-based policy strategies to achieve such goals.

Objective: Determine the association of infant mortality (IM) and gentrification, a composite measure of rising neighborhood income, education, and housing costs. Study design: Retrospective cohort analysis of 672,432 infants born 2010–2019 across metropolitan Michigan. Multilevel multivariable regression models examined the association of gentrification and IM. Gentrification components were evaluated in separate models. Results: Gentrification was not associated with IM, but some of its components were. Living in a census tract with an above median rise in income or education attainment was associated with lower odds of IM, compared to below median change (Income: aOR=0.88; 95% CI: 0.82–0.95; Education: aOR=0.93; 95% CI: 0.86–0.997). Rent increases above the median were linked to higher IM among term infants and lower IM among infants <32 weeks’ gestation. The association of IM with rising home values varied by maternal insurance status. Conclusions: Indicators of increasing community affluence, often combined to define gentrification, have opposing relationships with IM.

Importance Neonatal clinical trials frequently encounter low enrolment rates, challenges obtaining consent and biased research populations. Alternative approaches to consent have been proposed to address these concerns but introduce complex ethical trade-offs. Objective Using a modified Delphi approach with diverse stakeholders, we aimed to create recommendations for the use of alternative methods of consent in neonatal clinical trials. Findings Our process resulted in 21 recommendations within three categories. In ‘deciding whether to use alternative methods of consent’, we present five statements to guide whether alternative methods are appropriate. For example, heightened justification may be required for early phase research or allocation arms that are highly preference-sensitive for families. In ‘preallocation information and ability to opt-out’, we present 11 statements related to information sharing with families of potential participants. These include guidance on researcher communication and guidance for passive information sharing such as via flyers. In ‘postallocation information and decision to continue participation’, we present five statements to guide later information sharing. These focus on best practices for researcher communication postallocation. For two items, our Working Group could not reach consensus. These items were not included in our recommendations. Conclusions and relevance Our recommendations may guide researchers, clinicians, regulators and funders in the consideration and conduct of alternative methods of consent for neonatal clinical trials. Future work must evaluate these recommendations within neonatal clinical trials and the areas of lack of consensus among our Working Group.

Importance: US territory nativity and/or residence may be associated with health because it affects environmental exposures, insurance coverage, prenatal care, and other factors. Investigations of preterm birth in the US territories are limited. Objective: To assess the association between maternal territory status and preterm birth, as well as whether insurance type modified associations. Design, Setting, and Participants: Cross-sectional study of restricted-use birth certificates of in-hospital, singleton births in the US and territories from 2014 to 2023. Exposures: Maternal territory status was defined for births in territories where data were available (Guam, Northern Mariana Islands, Puerto Rico, and Virgin Islands) for the following groups: (1) those with territory nativity and residence; (2) those with territory nativity and mainland residence; (3) those with mainland nativity and territory residence; and (4) those with mainland nativity and residence (reference group). Insurance type (private, Medicaid, or other) was evaluated as well. Main Outcomes and Measures: Preterm birth (live birth before 37 weeks’ gestation). Results: Among 28 627 700 births, 465 291 (1.6%) had any maternal territory status (nativity or residence). This group had a mean (SD) age of 27.1 (6.0) years, and 297 593 (64.0%) had Medicaid insurance. The highest preterm birth rate was among those with territory nativity and residence (10.5%; 95% CI, 10.4%-10.7%); the lowest was among those with mainland nativity and residence (8.4%; 95% CI, 8.4%-8.5%). Individuals with territory nativity and residence had an adjusted relative risk (aRR) of 1.30 (95% CI, 1.29-1.32) for preterm birth compared with the reference group. There was significant interaction between territory residence and insurance. Compared with individuals with mainland residence and private insurance, those with territory residence and Medicaid had the highest preterm birth risk (aRR, 1.57; 95% CI, 1.55-1.59), followed by territory residence and private insurance (aRR, 1.42; 95% CI, 1.39-1.45). Conclusions and relevance: In this cross-sectional study, maternal territory nativity and residence were associated with preterm birth. Territory residence was associated with a higher risk of preterm birth, regardless of insurance type. Privately insured-individuals in US territories had a higher risk of preterm birth than Medicaid-insured individuals in the mainland. Given differential access to health care, health insurance, and other social exposures between territory and mainland populations, future work should explore causal effects and related policies that may improve birth outcomes in US territories.

This article reviews the psychological distress experienced by NICU families, including anxiety, postpartum depression (PPD), and post-traumatic stress disorder (PTSD), in addition to providing recommendations for clinicians at the individual, institutional, and national level. Currently, mental health screenings, specialized evaluations, and treatment options are not routinely offered to NICU families and are frequently under-utilized when offered. Here we provide expert opinion recommendations to address challenges in supporting universal screening, offering bedside interventions, including trained mental health professionals in care plans, updating neonatology training competencies, and advocating for policies that support the mental health of NICU families. We advocate that mental health of NICU families be incorporated into the standard of care.