Mental and behavioral health conditions among school-aged children, including substance use disorders and overall emotional well-being, are a public health concern in the United States. Timely data on seasonal patterns in child and adolescent conditions can guide optimal timing of prevention and intervention strategies. CDC examined emergency department (ED) visit data from the National Syndromic Surveillance Program for 25 distinct conditions during January 2018-June 2023 among U.S. children and adolescents aged 5-17 years, stratified by age group. Each year, during 2018-2023, among persons aged 10-14 and 15-17 years, the number and proportion of weekly ED visits for eight conditions increased in the fall school semester and remained elevated throughout the spring semester; ED visits were up to twice as high during school semesters compared with the summer period. Among children aged 5-9 years, the number and proportion of visits increased for five mental and behavioral health conditions. Seasonal increases in ED visits for some conditions among school-aged children warrant enhanced awareness about mental distress symptoms and the challenges and stressors in the school environment. Systemic changes that prioritize protective factors (e.g., physical activity; nutrition; sleep; social, community, or faith-based support; and inclusive school and community environments) and incorporate preparedness for increases in conditions during back-to-school planning might improve child and adolescent mental health.

OBJECTIVES: The rate of severe maternal morbidity in the United States increased approximately 200% during 1993-2014. Few studies have reported on the health of the entire pregnant population, including women at low risk for maternal morbidity. This information might be useful for interventions aimed at primary prevention of pregnancy complications. To better understand this, we sought to describe the distribution of comorbid risk among all delivery hospitalizations in Massachusetts and its association with the distribution of severe maternal morbidity. METHODS: Using an existing algorithm, we assigned an obstetric comorbidity index (OCI) score to delivery hospitalizations contained in the Massachusetts pregnancy to early life longitudinal (PELL) data system during 1998-2013. We identified which hospitalizations included severe maternal morbidity and calculated the rate and frequency of these hospitalizations by OCI score. RESULTS: During 1998-2013, PELL contained 1,185,182 delivery hospitalizations; of these 5325 included severe maternal morbidity. Fifty-eight percent of delivery hospitalizations had an OCI score of zero. The mean OCI score increased from 0.60 in 1998 to 0.82 in 2013. Hospitalizations with an OCI score of zero comprised approximately one-third of all deliveries complicated by severe maternal morbidity, but had the lowest rate of severe maternal morbidity (22.8/10,000 delivery hospitalizations). CONCLUSIONS: The mean OCI score increased during the study period, suggesting that an overall increase in risk factors has occurred in the pregnant population in Massachusetts. Interventions that can make small decreases to the mean OCI score could have a substantial impact on the number of deliveries complicated by severe maternal morbidity. Additionally, all delivery facilities should be prepared for severe complications during low-risk deliveries.

Over the past 10 years, the available evidence on the treatment of malaria during pregnancy has increased substantially. Owing to their relative ease of use, good sensitivity and specificity, histidine rich protein 2 based rapid diagnostic tests are appropriate for symptomatic pregnant women; however, such tests are less appropriate for systematic screening because they will not detect an important proportion of infections among asymptomatic women. The effect of pregnancy on the pharmacokinetics of antimalarial drugs varies greatly between studies and class of antimalarial drugs, emphasising the need for prospective studies in pregnant and non-pregnant women. For the treatment of malaria during the first trimester, international guidelines are being reviewed by WHO. For the second and third trimester of pregnancy, results from several trials have confirmed that artemisinin-based combination treatments are safe and efficacious, although tolerability and efficacy might vary by treatment. It is now essential to translate such evidence into policies and clinical practice that benefit pregnant women in countries where malaria is endemic. Access to parasitological diagnosis or appropriate antimalarial treatment remains low in many countries and regions. Therefore, there is a pressing need for research to identify quality improvement interventions targeting pregnant women and health providers. In addition, efficient and practical systems for pharmacovigilance are needed to further expand knowledge on the safety of antimalarial drugs, particularly in the first trimester of pregnancy.

Malaria remains one of the most preventable causes of adverse birth outcomes. Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine is used to prevent malaria, but resistance to this drug combination has decreased its efficacy and new alternatives are needed. In Africa, a meta-analysis showed three-course or monthly IPTp with sulfadoxine-pyrimethamine to be safe and more effective than the original two-course sulfadoxine-pyrimethamine strategy, prompting WHO to update its policy in 2012. Although resistance to sulfadoxine-pyrimethamine reduces the parasitological efficacy of IPTp, this drug combination remains associated with reduced incidence of low birthweight in areas where prevalence of parasites with quintuple Plasmodium falciparum dihydrofolate reductase (Pfdhfr) and dihydropteroate synthetase (Pfdhps) mutations is greater than 90%. Nevertheless, its effectiveness is compromised in women infected with sextuple mutant parasites. Six trials of IPTp showed that neither amodiaquine, mefloquine, nor chloroquine-azithromycin are suitable replacements for sulfadoxine-pyrimethamine because of poor tolerability. Furthermore, four trials showed that intermittent screening and treatment with the current generation of malaria rapid diagnostic tests was not a suitable alternative strategy to IPTp with sulfadoxine-pyrimethamine, even in areas with high prevalence of quintuple mutations. Two trials showed that IPTp with dihydroartemisinin-piperaquine was well tolerated, effective, and acceptable for IPTp, with monthly regimens being the most effective. Coverage of IPTp and insecticide-treated nets continues to lag behind targets. The key barriers to uptake are well documented, and many are open to intervention. Outside of Africa, a single trial suggests a potential role for integrated approaches that combine sulfadoxine-pyrimethamine with azithromycin for IPTp in areas of Papua New Guinea where malaria transmission is high. Modelling analysis suggests the importance of the prevention of malaria early in pregnancy and the need to protect pregnant women declines more slowly than the rate at which transmission declines. Improved funding has led to an increase in the number of prevention trials in the past decade, showing the value of more sustained protection with monthly IPTp regimens. There is a need for confirmatory trials of the safety, efficacy, and feasibility of IPTp with dihydroartemisinin-piperaquine, for studies of intermittent screening and treatment with more sensitive rapid diagnostic tests, for studies of integrated strategies for malaria and other co-infections, and for studies of prevention strategies for malaria in pregnant women who are HIV-positive and living outside of Africa. Additional research is required on how to improve uptake of WHO's updated policy on IPTp with sulfadoxine-pyrimethamine and insecticide-treated nets.

BACKGROUND: In endemic regions of sub-Saharan Africa, malaria during pregnancy (MiP) is a major preventable cause of maternal and infant morbidity and mortality. Current recommended MiP prevention and control includes intermittent preventive treatment (IPTp), distribution of insecticide-treated bed nets (ITNs) and appropriate case management. This article explores the social and cultural context to the uptake of these interventions at four sites across Africa. METHODS: A comparative qualitative study was conducted at four sites in three countries: Ghana, Malawi and Kenya. Individual and group interviews were conducted with pregnant women, their relatives, opinion leaders, other community members and health providers. Observations, which focused on behaviours linked to MiP prevention and treatment, were also undertaken at health facilities and in local communities. RESULTS: ITNs were generally recognized as important for malaria prevention. However, their availability and use differed across the sites. In Malawi and Kenya, ITNs were sought-after items, but there were complaints about availability. In central Ghana, women saved ITNs until the birth of the child and they were used seasonally in northern Ghana. In Kenya and central Ghana, pregnant women did not associate IPTp with malaria, whereas, in Malawi and northern Ghana, IPTp was linked to malaria, but not always with prevention. Although IPTp adherence was common at all sites, whether delivered with directly observed treatment or not, a few women did not comply with IPTp often citing previous side effects. Although generally viewed as positive, experiences of malaria testing varied across the four sites: treatment was sometimes administered in spite of a negative diagnosis in Ghana (observed) and Malawi (reported). Despite generally following the advice of healthcare staff, particularly in Kenya, personal experience, and the availability and accessibility of medication--including anti-malarials--influenced MiP treatment. CONCLUSION: Although ITNs were valued as malaria prevention, health messages could address issues that reduce their use during pregnancy in particular contexts. The impact of previous side effects on adherence to IPTp and anti-malarial treatment regimens during pregnancy also requires attention. Overtreatment of MiP highlights the need to monitor the implementation of MiP case management guidelines.

BACKGROUND: Antenatal care (ANC) is a key strategy to improve maternal and infant health. However, survey data from sub-Saharan Africa indicate that women often only initiate ANC after the first trimester and do not achieve the recommended number of ANC visits. Drawing on qualitative data, this article comparatively explores the factors that influence ANC attendance across four sub-Saharan African sites in three countries (Ghana, Kenya and Malawi) with varying levels of ANC attendance. METHODS: Data were collected as part of a programme of qualitative research investigating the social and cultural context of malaria in pregnancy. A range of methods was employed interviews, focus groups with diverse respondents and observations in local communities and health facilities. RESULTS: Across the sites, women attended ANC at least once. However, their descriptions of ANC were often vague. General ideas about pregnancy care - checking the foetus' position or monitoring its progress - motivated women to attend ANC; as did, especially in Kenya, obtaining the ANC card to avoid reprimands from health workers. Women's timing of ANC initiation was influenced by reproductive concerns and pregnancy uncertainties, particularly during the first trimester, and how ANC services responded to this uncertainty; age, parity and the associated implications for pregnancy disclosure; interactions with healthcare workers, particularly messages about timing of ANC; and the cost of ANC, including charges levied for ANC procedures - in spite of policies of free ANC - combined with ideas about the compulsory nature of follow-up appointments. CONCLUSION: In these socially and culturally diverse sites, the findings suggest that 'supply' side factors have an important influence on ANC attendance: the design of ANC and particularly how ANC deals with the needs and concerns of women during the first trimester has implications for timing of initiation.

BACKGROUND: Sickle cell disease (SCD) is a severe hematologic condition that presents unique complications among affected pregnant women. Many studies of adverse perinatal outcomes associated with SCD are limited by small samples or fail to consider important risk factors. PURPOSE: This study compared perinatal outcomes among women of African ancestry with and without SCD in a large, population-based sample. METHODS: Data from the Massachusetts Pregnancy to Early Life Longitudinal (PELL) Data System were analyzed during June-August 2009 to identify in-state deliveries to resident women of African descent. Logistic regression analyses compared perinatal outcomes for deliveries among women with and without SCD, adjusted for maternal age, education, parity, plurality, insurance status, adequacy of prenatal care, smoking during pregnancy, and infant gender. RESULTS: During 1998-2006, there were 116,076 deliveries to 84,561 women; SCD prevalence was 0.6%. Adjusted odds of fetal death among deliveries to women with SCD were 2.2 times those among women without SCD (95% CI=1.2, 4.2). Compared to women without SCD, the odds of preterm delivery, low birth weight, and having babies small for gestational age (SGA) among women with SCD were 1.5 (95% CI=1.2, 1.8); 1.7 (95% CI=1.1, 2.6); and 1.3 (95% CI=1.0, 1.7), respectively. Sickle cell disease was positively associated with cesarean delivery and inductions. CONCLUSIONS: Population-based linked data systems are useful for assessing risks of adverse health outcomes among women with specific medical conditions, such as SCD. Women with SCD should seek preconception care to identify and modify risk behaviors and receive counseling regarding potential adverse sequelae associated with pregnancy-related morbidity and preterm delivery.